Pediatric Foot Fractures

Talus Fractures

Fractures of the talus are extremely rare in children.  Most fractures involve the neck of the talus.  The mechanism of injury is the forced dorsiflexion of the foot from a fall or a motor vehicle accident. Fractures of the dome and talar body are extremely rare. 

The patients usually have pain when trying to walk on the foot.  The range of motion of the ankle is painful and there is swelling of the hindfoot.  A neurovascular examination should be done as these may be injured. X-rays of the front side and mortise views of the ankle can show most fractures.  Sometimes a CT can be done to plan surgical intervention and an MRI exam can identify occult injuries to the talus. 

Treatment can be without surgery if the fracture is undisplaced.  A long leg cast with a flexed knee is recommended for 6-8 weeks with a walking cast used after that for another 2-3 weeks.  Surgery is recommended for displaced fractures unless they are minimally displaced.  Surgery involves placement of Kirschner wires to hold the fracture ends together.  A short leg cast is used for 6-8 weeks after that. 

Complications include osteonecrosis (bone cell death) that tends to occur within six months of injury. 

Calcaneus Fracture

This is a rare injury usually occurring in older kids and adolescents.  Most do not involve the joint.  A third of these injuries are associated with other injuries, including lower extremity and lumbar fractures.  The mechanism of injury is a fall from a great height.  Open fractures are seen in lawnmower injuries. 

Patients usually cannot walk on the leg.  There is pain, swelling, and tenderness at the site of the injury.  The leg and the lumbar spine should be assessed for secondary injuries.  The injury can be missed in 44-55 percent of cases. 

X-rays can show these types of fractures in most cases.  Comparison views with the other foot can help identify disruptions in certain measured angles.  Technetium bone scans can show occult fractures not seen on routine x-ray. CT scanning can help define the fracture better, especially if they are intra-articular. 

Nonoperative treatment with cast immobilization can be done in fractures that are not displaced and that do not involve the joint.  Surgery is recommended for displaced fractures involving the joint surface.  It is important to restore the joint surface; this is usually down by placing a lag screw in to hold the fracture fragments together.

Complications include post traumatic arthritis, heel widening, nonunion and compartment syndrome. 

Tarsometatarsal Fractures

This is extremely uncommon in young children and more common in older children.  This involves the joints between the tarsus and the metatarsals that together form the arch of the foot. The mechanism of injury includes direct injuries in which a heavy object is dropped onto the foot which squashes the arch.  Indirect injuries are more common and involve violent abduction and forced flexion of the foot along with twisting of the forefoot. 

The patient often has swelling on the top of the foot with an inability to ambulate or painful ambulation.  There may be a deformity due to spontaneous reduction of the ligaments.  Tenderness over the tarsometatarsal joint can be found.  Twenty percent of these fractures are initially missed. X-ray can show these fractures, especially if oblique views are made.  

Treatment can be without surgery if the displacement is minimal. When swelling goes down, a short leg cast is applied for 5-6 weeks or until asymptomatic.  A cast boot can be used after that until the patient ambulated well.  If the fracture is displaced, closed reduction can take place under general anesthesia. 

Surgery is necessary if reduction can’t be done using external means.  Percutaneous Kirschner wires are used to maintain reduction.  They are left protruding from the skin so that they can be removed later.  A short leg cast is then placed for four weeks.  The wires are then removed and the cast discontinued.  Complications include ongoing pain and an angular deformity of the joint.

Metatarsals

Sixty percent of pediatric foot fractures involve the metatarsals.  Stress fractures are uncommon but still possible.  The mechanism of injury is direct when it involves dropping a heavy object onto the foot.  Indirect fractures are more common and result from axial loading to the foot with the force transmitted through the plantar flexed ankle or from torsion on the foot. A “bunk bed fracture” occurs when a child jumps from a bunk bed landing on a plantar flexed foot.  Stress fractures can happen with long distance runners.

Patients with these fracture have pain when attempting to walk on the foot.  There may be minimal swelling if the fracture is nondisplaced.  Compartment syndrome and neurovascular compromise are possible.  X-rays of the foot usually show the fracture but bone scanning can help if fractures are suspected but are not seen on x-ray. 

Treatment is usually done without surgery.  Splinting is done first, followed by a short leg cast.  In nondisplaced fractures, a short leg cast can be placed for 3-6 weeks until the x-ray shows healing.  Fifth metatarsal fractures may need an intramedullary screw to hold the fracture together because these do not heal as well as the other metatarsals.  Stress fractures are treated with a short leg walking cast for two weeks or until walking is painless. 

Surgery is necessary if there is compartment syndrome.  There are nine compartments in the foot and fasciotomy should be done to release the pressure in all nine compartments.  Unstable fractures require percutaneous pinning with Kirschner wires.  Remodeling is likely in kids so that some degree of angulation and displacement is acceptable.  Open reduction and pinning are used when closed reduction is not possible.  After surgery, a short leg cast for three weeks is needed with removal of pins after that. Then a walking cast is used for 2-4 weeks. Complications include malunion of the fracture and compartment syndrome. 

Phalanges Fractures

These are uncommon fractures in kids.  The mechanism of injury is direct trauma to the toes from a heavy object dropped on the foot.  Indirect injuries can happen with rotational forces on the toes.  The patient usually presents with guarding of the forefoot.  There is bruising and swelling of the affected toes.  A neurovascular injury is possible and must be assessed.  The toe should be examined for open fractures.  X-rays of the toe usually identify the fracture with x-rays of the unaffected side done for comparison. 

Treatment is almost always nonoperative.  Traction can correct shortening and angulation of the toe.  The toe can be buddy-taped with gauze placed between the toes to prevent skin breakdown of the toes.  There should be no kicking or running in sports for 2-3 weeks. 

Surgery is reserved for fractures that can’t be reduced externally.  Some rotational injuries need surgery to correct.  Intramedullary Kirschner wire placement can hold the fracture together easily. If the nailbed is injured, it should be repaired.  The Kirschner wires are removed after three weeks.  After surgery, a firm supportive orthosis should be placed for about 3 weeks.  Complications include malunion of the toes, especially with proximal phalanx fractures. 

I’m Ed Smith, an injury lawyer in Sacramento who has handled many foot fracture cases and aware of the dangerous aftereffects they can have. Feel free to call me anytime for free, friendly advice at 916-921-6400 or 800-404-5400.

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