Keys To Managing Common Pediatric Foot Fractures
The treatment of foot fractures presents specific challenges in pediatric patients. Accordingly, this author presents a comprehensive guide to diagnosing and treating calcaneal fractures, stress fractures, metatarsal fractures and other common injuries in this patient population.
Physicians must handle fractures in children uniquely because the physiologic and biomechanical responses are different than what one would see in a mature skeleton. With the increase in activity and organized sport participation of children today, the incidence and complexity of foot trauma in this population have increased.
Most fractures in children require only immobilization for treatment, which is often the stated guiding principle for the management of foot trauma in children.1 Closed reduction should be the starting point for treatment of all extra-epiphyseal fractures in children. Severe displacement in the non-articular, extra-epiphyseal fracture is the rare indication for open reduction in a child. Anatomic reduction is an important goal.
There are fundamental differences in the child’s foot in comparison with that of the adult. Ogden noted that there is a greater percentage of cartilage with increased elasticity associated with growing cartilage and bone in children.2 This allows for dissipation of significant amounts of applied energy across the foot, producing different types of injuries in the pediatric patient. In this population, one must consider the potential for long lasting, growth-related damage to the child with a fracture and the possibility of early degenerative joint changes.
In recent years, some have advocated a more aggressive surgical approach to certain injuries such as calcaneal fractures in children, most notably in the German literature.3
Further advances in imaging allowing easier identification of subtle changes such as soft tissue swelling, cartilaginous disruptions and subchondral bone bruising have also changed the assessment and management of these conditions.
Salter-Harris injuries to the growth plate constitute a large topic. As these injuries are frequently covered in various publications, I will not discuss those injuries in this particular article.
Pertinent Insights On Treating Talar Fractures
Fractures of the talus are relatively rare in children and the reported incidence is 0.01 to 0.08 percent.4 Talar fractures in children generally have minimal displacement and cast immobilization is usually sufficient to allow healing. This is particularly true for children under the age of 8 when the talar anlage offers enhanced healing potential. In a child over the age of 10, the course of healing is more similar to that present in adults.
The location of talar fractures often signals the mechanism of fracture. A talar neck fracture is most often associated with a fall from a height. A crush injury is more likely to produce a fracture in the talar body. In the case of a lawnmower injury, a resultant open fracture is more likely.
Note that talar fractures often occur in conjunction with other injuries. This is in part because a force as high as twice that needed to fracture a calcaneus or navicular is needed to fracture a talus.5 In 64 percent of adults with talar fractures, Hawkins noted there was an associated musculoskeletal injury as well so clinicians should have a high index of suspicion for other trauma in the presence of talar fractures.6