Chapter 33: Fractures and Dislocations of the Foot

Haemish Crawford

Chapter Outline

Introduction to Fractures and Dislocations of the Foot

Trauma to the pediatric foot was traditionally treated nonoperatively by orthopedic surgeons.16,141 The dogma existed that the bones of the foot were predominantly cartilaginous and would remodel as the child matures. Few, if any, long-term studies exist to measure the outcomes of these treatments. 
Children are now involved in sports and activities of greater physical intensity that lead to more complex fractures and dislocations.4,40,44,136 It is not uncommon for young children to be competing in motocross, extreme skiing, and rock climbing.4,164 Professional sport has brought about more intense training and greater expectations from the child, the parent, and the coach. Injuries need to be treated “quicker” and rehabilitation time decreased to allow early return to the sport. These expectations should not get in the way of treating the child's foot injury in the best possible way. 
As the child grows into a young adult, the largely cartilaginous foot becomes ossified and fracture and dislocation patterns change. Ogden124 showed that the cartilaginous bones were elastic and absorbed the energy from the trauma and dissipated it differently from the adult foot. This resulted in different fracture patterns.124 The management algorithms for the adolescent foot are therefore quite different from the infant's foot; however, the exact age at which this occurs needs to be individualized for each patient. The amount of fracture angulation and joint line displacement to accept is one of the real challenges in treating the skeletally immature foot. Some complex fractures of the talus and calcaneus in adolescents are in fact best internally fixed according to the principles used to treat adult trauma. 
An in-depth knowledge of the anatomy of the growing foot is helpful as the variable ossification centers, apophyses, and physes make fracture recognition difficult. Most of the papers quoted in this chapter are level IV (uncontrolled case series) or level V (expert consensus). One of the problems with pediatric foot and ankle research is that long follow-up intervals are necessary to validate treatments. There are no pediatric outcome scores for children's foot trauma, so prediction of outcome is dependent on orthopedic first principles of anatomic reduction, union, and effective rehabilitation. Long-term retrospective studies also have the difficulty of locating children treated decades earlier and, therefore, the follow-up rate is low. 

Anatomy of the Growing Foot

The child's foot is different from the adult foot in that the bones are largely cartilaginous until adolescence. Although the mechanisms of injury are similar, the resulting fracture is usually less severe in the child as the energy of the injury is dissipated by the elasticity of the cartilage. The cartilage also makes interpretation of imaging more difficult and fractures may not be appreciated on plain radiograph. Computed tomography (CT) and magnetic resonance imaging (MRI) scans assist in clarification of anatomy and identification of fractures. The remodeling potential of cartilage allows some displacement and angulation of fractures to be accepted in children, whereas in adults it may be unacceptable. 
Secondary areas of ossification, accessory bones, and growth plates also make fracture recognition more difficult. The appearance of the ossification centers are summarized in Figure 33-1.5 The calcaneus and talus are usually ossified at birth and the cuboid ossification center usually becomes evident shortly after.157 The navicular does not develop its primary ossification center until the child is around 3 years of age. Figure 33-2 shows the accessory ossicles and sesamoid bones in the foot which can also be confused with fractures especially if they are bipartite or if the accessory bones are closely adhered. It is useful clinically to radiograph the opposite foot if any doubt exists as to what may be normal or pathologic. 
Figure 33-1
(From 


Aitken JT,

Joseph J,

Causey G
, et al. A Manual of Human Anatomy. 2nd ed. London: E & S Livingstone; 1966:80, with permission).
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Figure 33-1
Appearance and fusion times of foot ossification centers, with figures in parentheses indicating the time of fusion of the primary and secondary ossification centers (y., years; m.i.u., months in utero).
(From Aitken JT, Joseph J, Causey G, et al. A Manual of Human Anatomy. 2nd ed. London: E & S Livingstone; 1966:80, with permission).
(From 


Aitken JT,

Joseph J,

Causey G
, et al. A Manual of Human Anatomy. 2nd ed. London: E & S Livingstone; 1966:80, with permission).
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Figure 33-2
Diagrammatic representation of accessory ossicles and sesamoid bones about the foot and ankle.
 
Note that the sesamoid bones can be bipartite and that accessory ossicles can be multicentric.
 
(From Traughber PD. Imaging of the foot and ankle. In Coughlin MJ, Mann RA. Surgery of the Foot and Ankle. 7th ed. St. Louis, MO: Mosby, 1999.)
Note that the sesamoid bones can be bipartite and that accessory ossicles can be multicentric.
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Figure 33-2
Diagrammatic representation of accessory ossicles and sesamoid bones about the foot and ankle.
Note that the sesamoid bones can be bipartite and that accessory ossicles can be multicentric.
(From Traughber PD. Imaging of the foot and ankle. In Coughlin MJ, Mann RA. Surgery of the Foot and Ankle. 7th ed. St. Louis, MO: Mosby, 1999.)
Note that the sesamoid bones can be bipartite and that accessory ossicles can be multicentric.
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History and Examination of Fractures and Dislocations of the Foot

The history is not always accurate in childhood trauma; however, every attempt should be made to ascertain the mechanism of injury. Often, other children or adults who witnessed the accident can give a more accurate account than the patient. The degree of force, the speed and height of the fall, and the way the foot is twisted all help predict the degree of displacement or severity of the injury. In more subtle injuries, the ability to weight bear, degree of instability, and the location of the pain are vital parts of the history. 
Careful examination of the foot will guide the surgeon to the site of injury. The child often complains of the whole foot “hurting”; however, systematic palpation helps localize the most painful site. Appropriate radiographs can then be taken. Bruising and swelling will also help predict the injury pattern. Isolated bruising on the sole of the midfoot often overlies a subtle Lisfranc injury whereas excessive dorsal swelling may predict a more severe fracture-dislocation.145 In a soft tissue injury such as a crush injury, the possibility of increased compartment pressures should be considered. 
Multiple trauma must also be ruled out. A complete secondary survey should be undertaken to exclude other injuries. For example, bilateral calcaneus fractures following a fall may be associated with a tibial fracture or spinal column injury. 

Talar Fractures

Management of Talar Fractures

Fractures of the talus are very rare in children and adolescents.37,124 Talus fractures most commonly occur through the neck and occasionally the body. Although rare, talus fractures are important to recognize because of the possible complication of avascular necrosis (AVN). This can occur because of the precarious blood supply and fracture patterns. In children, AVN seems more prevalent in innocuous fractures when compared to adults with similar injuries.140 The majority of talus fractures in children can be treated with cast immobilization whereas displaced fractures in adolescents need to be treated operatively similar to an adult fracture. 

Mechanism of Injury

A fall from a height is the predominant mechanism of injury causing talar fractures.79,98,111 The foot is forcibly dorsiflexed and the neck of the talus impinges against the anterior lip of the distal tibia. This shear force usually results in a vertical or slightly oblique fracture line at the junction of the body and neck of the talus. When the dorsiflexion is combined with supination of the foot, the impingement occurs more medially and the medial malleolus may be fractured as well. With displaced fractures, the subtalar joint may become subluxed. The force required to fracture a child's talus is almost twice that required to fracture the other ankle and tarsal bones.131 One must be thorough in looking for other injuries that may coexist as a result of the severe trauma. The talus can also be fractured with crushing injuries, and open fractures are well described in lawnmower accidents.124 Fractures of the lateral process of the talus have been described recently in snowboarding accidents where the mechanism appears to be forced dorsiflexion and inversion of the ankle.95 

Signs and Symptoms of Talar Fractures

The history of forced dorsiflexion of the ankle especially associated with a fall from a height should lead to a suspicion of a talus fracture. The same mechanism of injury can cause other foot fractures and dislocations as well. The ankle and foot are extremely swollen and the foot is usually held plantarflexed. Because of this soft tissue swelling, the foot needs to be examined closely for increased compartment pressure. As with all fractures, the soft tissues need to be inspected for any puncture wounds, abrasions, or fracture blisters as these are important in determining the management of the patient. 
In these patients, there may be less swelling so careful palpation around the talus is needed to detect the source of the pain. Once the foot has been clinically assessed, the appropriate radiographic investigations can be performed. 

Associated Injuries with Talar Fractures

Because of the level of force that is often required to fracture a talus, other injuries often coexist.131 A number of studies have found fractures of the calcaneus, malleoli, tibia, and lumbar spine in the presence of a talus fracture.20,26,65,127,128 Hawkins,65 in his study, on adult talus fractures found 64% of the patients had an associated musculoskeletal injury. 

Imaging Evaluation of Talar Fractures

The routine radiographs for a fractured talus include an anteroposterior (AP), lateral, and oblique views. Canale and Kelly26 have described a pronated oblique view of the talus which may demonstrate the fracture more clearly. The fractures are not always easy to see in young children, as the talus is largely cartilaginous until the second decade.111 The cartilage anlage often leads to an underestimation of fracture displacement. Some authors have even suggested the use of MRI to show the morphology better in children less than 10 years old.124,173 
Once the fracture is identified, a CT scan is useful in assessing the fracture plane, comminution, degree of displacement, and any other associated foot or ankle fractures. This is particularly useful preoperatively when pain prohibits the full range of radiographs mentioned above to be taken. If an open reduction is planned, the CT scan will also aid in the preoperative planning of the size and placement of the screws. Hawkins65 described an x-ray classification to define the different types of fractures of the talar neck and used it to predict the risk of AVN (Fig. 33-3): 
Figure 33-3
Hawkins classification of talar neck fractures (see text for details).
 
A: Type I, nondisplaced fracture of the talar neck. B: Type II, displaced talar neck fracture with subluxation or dislocation of the subtalar joint. C: Type III, displaced talar neck fracture with associated dislocation of the talar body from both the subtalar and tibiotalar joints. D: Type IV, as suggested by Canale and Kelly, displaced talar neck fracture with an associated dislocation of the talar body from subtalar and tibiotalar joints and dislocation of the head and neck fragment from the talonavicular joint.
 
(From Canale ST, Kelly FB Jr. Fractures of the neck of the talus: Long-term evaluation of seventy-one cases. J Bone Joint Surg Am. 1978; 60:143–156.)
A: Type I, nondisplaced fracture of the talar neck. B: Type II, displaced talar neck fracture with subluxation or dislocation of the subtalar joint. C: Type III, displaced talar neck fracture with associated dislocation of the talar body from both the subtalar and tibiotalar joints. D: Type IV, as suggested by Canale and Kelly, displaced talar neck fracture with an associated dislocation of the talar body from subtalar and tibiotalar joints and dislocation of the head and neck fragment from the talonavicular joint.
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Figure 33-3
Hawkins classification of talar neck fractures (see text for details).
A: Type I, nondisplaced fracture of the talar neck. B: Type II, displaced talar neck fracture with subluxation or dislocation of the subtalar joint. C: Type III, displaced talar neck fracture with associated dislocation of the talar body from both the subtalar and tibiotalar joints. D: Type IV, as suggested by Canale and Kelly, displaced talar neck fracture with an associated dislocation of the talar body from subtalar and tibiotalar joints and dislocation of the head and neck fragment from the talonavicular joint.
(From Canale ST, Kelly FB Jr. Fractures of the neck of the talus: Long-term evaluation of seventy-one cases. J Bone Joint Surg Am. 1978; 60:143–156.)
A: Type I, nondisplaced fracture of the talar neck. B: Type II, displaced talar neck fracture with subluxation or dislocation of the subtalar joint. C: Type III, displaced talar neck fracture with associated dislocation of the talar body from both the subtalar and tibiotalar joints. D: Type IV, as suggested by Canale and Kelly, displaced talar neck fracture with an associated dislocation of the talar body from subtalar and tibiotalar joints and dislocation of the head and neck fragment from the talonavicular joint.
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Type I fracture: Undisplaced talar neck fracture 
Type II fracture: Displaced talar neck fracture with subtalar subluxation or dislocation 
Type III fracture: Displaced fracture of the talar neck with dislocation of both the subtalar and ankle joints 
Hawkins65 also described a subchondral lucent line, the “Hawkins sign,” that indicates normal blood flow to the talar body. The absence of this lucency may indicate the development of osteonecrosis (see complications of talar fractures). 

Diagnosis and Classification of Talar Fractures

Fractures of the talus can be classified as occurring either in the body or the neck. Some authors suggest classifying talar fractures based on the age of the patient as children less than 6 years of age generally have a better prognosis.111 

Fractures of the Talar Neck

The majority of talar fractures in children are of the talar neck. Hawkins65 has classified these into three different types depending on whether the fracture is displaced and the degree of subluxation of the subtalar and ankle joints (Fig. 33-3). This classification was developed so it could be used to predict if the talus would become avascular because of the disruption of the tenuous blood supply. Canale and Kelly26 later modified the classification (Fig. 33-3) to include a type IV injury in which there is subluxation or dislocation of the ankle, subtalar, and talonavicular joints. In the adult literature, the majority of talar fractures are type II and III.26,65 This classification of talus fractures can help predict the type of treatment required and the outcome one can expect (Table 33-1). 
 
Table 33-1
Hawkins Classification of Talar Neck Fractures
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Table 33-1
Hawkins Classification of Talar Neck Fractures
Type Description Treatment Affect on Blood Supplya Osteonecrosis Rate
Type I Stable, undisplaced vertical fracture through talar neck. 8 weeks in cast, 4 weeks in CAM cast. Theoretical damage to only one vessel entering talar neck. 0–10%
Type II Displaced fracture with subtalar joint subluxation or dislocation; normal ankle joint. Immediate closed reduction.b A near anatomic reduction delays surgical treatment. Two of three blood supply vessels lost: Neck vessel and one entering the tarsal canal. 20–50%
Type III Same as type II but with subluxation or dislocation of both the ankle and subtalar joint. Direct to operating room for combined anteromedial and anterolateral surgical approach (see text). All three sources of blood affected. 80–100%
Type IV Very rare; basically a type III with talonavicular joint displacement. Same as type III. Not related to blood supply. 100%
 

CAM, controlled active motion.

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Treatment of Talar Neck Fractures

The treatment of talar fractures is based on the severity of the fracture and the age of the child. The Hawkins classification system is useful in directing the treatment. In a child less than 8 years of age, a less than perfect reduction of the fracture can be accepted because of the remodeling potential.79,98,111 Adolescent fractures should be treated the same way as an adult injury. 

Hawkins Type I Fractures

Undisplaced fractures of the talar neck can be treated for 6 to 8 weeks non–weight-bearing in a below-knee cast. The child can then start taking full weight if the fracture has healed radiographically. Canale and Kelly26 accepted 5 mm of displacement and 5 degrees of angulation of the talar neck in their series. 

Hawkins Type II Fractures

A displaced or severely angulated talar neck fracture usually presents with significant soft tissue swelling and pain. This makes management more difficult than type I injuries. Achieving adequate radiographs to assess the degree of displacement is difficult without sedation. The distal fragment of the neck is usually displaced dorsally and medially. 
The fracture and subluxation of the subtalar joint should be reduced under general anesthesia, most often by gentle plantarflexion and pronation of the foot. If a stable reduction is achieved, a well-molded below-knee cast can be applied with the foot in plantarflexion. This initial cast is changed to a more neutral position at 4 weeks and then removed 8 weeks following fracture reduction. Postoperative serial radiographs or a CT scan should be performed as the fracture position may be lost when the soft tissue swelling subsides. If the fracture is unstable after reduction, percutaneous Kirschner wire (K-wire) fixation is useful to hold the fracture. Two K-wires can be passed through a small dorsomedial incision and across the fracture. The incision should be on the medial side of extensor hallucis longus to avoid damage to the tibial vessels. Although the amount of residual displacement or angulation acceptable is not clearly defined, it may be better to accept a few millimeters of offset and up to 10 degrees of angulation rather than perform an open reduction and risk devascularizing the talus further. 

Hawkins Type III Fractures

These fractures are a result of a serious injury and require urgent surgery to openly reduce and internally fix the talus. 

Surgical Approaches

There are three surgical approaches to the fractured talus: 
  1.  
    Posterolateral
  2.  
    Anteromedial
  3.  
    Anterolateral
The decision on the approach depends on the condition of the soft tissues and the familiarity of the approach by the surgeon. Occasionally, more than one approach is required if adequate reduction cannot be achieved. It is preferable to use the posterolateral approach as this causes less potential disruption to the blood supply; however, direct visualization of the talar neck is not possible. The timing of the open reduction of these fractures is somewhat controversial. With such a tenuous blood supply, one would think that urgent reduction and internal fixation is indicated. Lindvall et al.102 compared the results of surgery within 6 hours to delayed surgery in 26 fractures of the talus in adult patients and found no significant difference in outcome. Kellam et al.,84 in another similar study, concluded that the severity of the injury, the quality of the reduction, and the surgical outcomes had a bigger influence on long-term outcome than if the surgery was fixed emergently or delayed (greater than 12 hours). 
Posterolateral Approach
This approach is commonly used to internally fix fractures of the talar neck once it has been reduced. The patient is positioned supine so the other approaches can be utilized if necessary. The incision is made just lateral to the Achilles tendon. Blunt dissection is then carried out down to the joint capsule avoiding damage to the sural nerve. The posterior joint capsule can then be opened if not already torn by the injury and the posterior process of the talus can be identified. If possible, two partially threaded cannulated 4.5- or 6.5-mm screws can be used to provide compression across the fracture. It is preferable to use titanium screws which are MRI compatible to allow investigation of AVN during fracture healing if necessary. If only one screw is used, a separate K-wire should also be passed across the fracture for rotational stability. These posterior screws are more stable biomechanically than anterior screws (Fig. 33-4).166 
Figure 33-4
Posterolateral approach to the talus.
 
Incision is based lateral to the Achilles tendon. The Achilles tendon and flexor hallucis longus are reflected medially. The posterolateral talar tubercle is the starting point for the guide pin. Right: Screws are directed in line with the long axis of the neck of the talus in a plantar-medial direction such that the distal threads of the screw are all in the distal fragment (talar head), beyond the fracture line to allow for compression. Combinations of two screws or one screw and one smooth pin are determined by size and anatomy.
 
(From Adelaar RS. Complex fractures of the talus. Instr Course Lect. 1997; 46:328, with permission.)
Incision is based lateral to the Achilles tendon. The Achilles tendon and flexor hallucis longus are reflected medially. The posterolateral talar tubercle is the starting point for the guide pin. Right: Screws are directed in line with the long axis of the neck of the talus in a plantar-medial direction such that the distal threads of the screw are all in the distal fragment (talar head), beyond the fracture line to allow for compression. Combinations of two screws or one screw and one smooth pin are determined by size and anatomy.
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Figure 33-4
Posterolateral approach to the talus.
Incision is based lateral to the Achilles tendon. The Achilles tendon and flexor hallucis longus are reflected medially. The posterolateral talar tubercle is the starting point for the guide pin. Right: Screws are directed in line with the long axis of the neck of the talus in a plantar-medial direction such that the distal threads of the screw are all in the distal fragment (talar head), beyond the fracture line to allow for compression. Combinations of two screws or one screw and one smooth pin are determined by size and anatomy.
(From Adelaar RS. Complex fractures of the talus. Instr Course Lect. 1997; 46:328, with permission.)
Incision is based lateral to the Achilles tendon. The Achilles tendon and flexor hallucis longus are reflected medially. The posterolateral talar tubercle is the starting point for the guide pin. Right: Screws are directed in line with the long axis of the neck of the talus in a plantar-medial direction such that the distal threads of the screw are all in the distal fragment (talar head), beyond the fracture line to allow for compression. Combinations of two screws or one screw and one smooth pin are determined by size and anatomy.
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Anteromedial Approach
This approach is useful to visualize the talar neck and directly reduce the fracture. Often, there is comminution of the medial wall of the neck which makes restoring length difficult. With the patient supine, the incision is made from just anterior to the medial malleolus and directly distally down the midfoot. Deeper dissection is carried out medial to the tibialis anterior and the extensor hallucis longus tendons. The dissection down to the capsule is in the interval between the tibialis anterior and tibialis posterior tendons. This approach avoids damage to the deltoid branch of the posterior tibial artery and the medial branches of the anterior tibial artery. This approach is potentially less harmful to the blood supply of the talus when compared to the anterolateral approach.3 
Anterolateral Approach
One advantage of this approach is that it permits excellent exposure of the lateral talar neck which is not usually comminuted allowing anatomic reduction. The approach also gives good access to the subtalar joint. The disadvantage to this approach is that it may disrupt the blood supply more than the other approaches. The incision starts at the tip of the lateral malleolus and extends to the base of the fourth metatarsal. Care must be taken to avoid damaging the sural nerve with deeper dissection. In the base of the incision is the artery of the sinus tarsi which should be visualized if possible. 
Following open reduction and internal fixation of talar neck fractures, the foot is placed in a non–weight-bearing below-knee cast for 6 to 8 weeks. Radiographs are then taken to assess fracture healing and the presence or absence of the Hawkins sign. If the subchondral lucent line is present, one can assume there is adequate blood supply to the body of the talus and osteonecrosis is unlikely to occur. If the fracture has also healed, the child can start progressive weight bearing as tolerated. The absence of a subchondral lucency during healing should alert the surgeon to the possible development of osteonecrosis (Fig. 33-5). The patient should continue to be non–weight-bearing until the lucency is present. If it is still not present 3 months postinjury, an MRI scan should be performed which will assess the vascularity more accurately.67 The use of titanium screws in the open reduction makes this possible. The decision on the amount of weight bearing in the presence of altered blood supply to the talus is not clear. AVN of the talus often takes 18 months to 2 years to revascularize so it would be impractical, if not impossible, to keep a child non–weight-bearing for this period in the hope it will prevent premature collapse of the body. 
Figure 33-5
A 14-year-old girl with a talar neck fracture and a positive Hawkins sign.
 
Disuse osteoporosis leads to halo-like image of the talus on the AP view denoting adequate talar dome vascularization; if there had been no blood supply, there would be no blood flow to loose calcium. If this happens, the dome of the talus would become denser and more radio-opaque than the surrounding bones that are undergoing diffuse osteoporosis.
Disuse osteoporosis leads to halo-like image of the talus on the AP view denoting adequate talar dome vascularization; if there had been no blood supply, there would be no blood flow to loose calcium. If this happens, the dome of the talus would become denser and more radio-opaque than the surrounding bones that are undergoing diffuse osteoporosis.
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Figure 33-5
A 14-year-old girl with a talar neck fracture and a positive Hawkins sign.
Disuse osteoporosis leads to halo-like image of the talus on the AP view denoting adequate talar dome vascularization; if there had been no blood supply, there would be no blood flow to loose calcium. If this happens, the dome of the talus would become denser and more radio-opaque than the surrounding bones that are undergoing diffuse osteoporosis.
Disuse osteoporosis leads to halo-like image of the talus on the AP view denoting adequate talar dome vascularization; if there had been no blood supply, there would be no blood flow to loose calcium. If this happens, the dome of the talus would become denser and more radio-opaque than the surrounding bones that are undergoing diffuse osteoporosis.
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Surgical and Applied Anatomy of Talar Neck Fractures

The talus is comprised of three parts: A body, neck, and head. Ossification starts from one center that appears in the sixth intrauterine month. The talus ossification process starts in the head and neck and proceeds in a retrograde direction toward the subchondral bone of the body. Approximately two-thirds of the talar body is articular cartilage with just a small area of bare bone on the neck where the bone receives its nutrient blood supply. There are no tendon insertions into the talus. The stability is provided by the capsular and ligamentous attachments to the surrounding bones. 
The superior articular surface of the talus is wider anteriorly than it is posteriorly. Traditional teaching suggests the foot should generally be immobilized in neutral dorsiflexion so this widest part of the talus is engaged in the ankle mortise to help prevent an equinus contracture. This is of less importance in younger children who are less likely to develop equinus contractures. The lateral wall of the superior articular surface curves posteriorly whereas the medial wall is straight. The two walls converge posteriorly to form the posterior tubercle of the talus. Often, there is a separate ossification centre (os trigonum) that appears here on radiographs at 11 to 13 years of age in boys and 8 to 10 years of age in girls. It usually fuses to the talus 1 year after it appears (Fig. 33-6).113 
Figure 33-6
Anatomic details of the talus are important when correlating high-definition imaging, such as CT scans, with normal anatomy for the purposes of fracture management decision making.
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The short neck of the talus is medially deviated approximately 10 to 44 degrees and plantarflexed between 5 and 50 degrees in relation to the axis of the body.56 Beneath the talar neck is the tarsal canal, a funnel-shaped area that contains the anastomotic ring formed between the artery of the tarsal canal and the artery of the tarsal sinus.118 The broad interosseous ligament joining the calcaneus and talus is also within the canal. 
The tarsal canal is conical in shape and runs from posteromedial (apex) to anterolateral where the base of the cone is known as the sinus tarsi (Fig. 33-7). 
Figure 33-7
Subtalar joint opened such that the medial borders of the joint face each other.
 
A: Plantar surface of the talus, which articulates with the dorsal surface of the calcaneus. Note the extensive area of the talus that is articular cartilage. B: Dorsal surface of the calcaneus with the articular facets occupying the anterior half of the calcaneus.
 
(From Sammarco GJ. Anatomy. In: Helal B, Rowley D, Cracchiolo AC, et al, eds. Surgery of Disorders of the Foot and Ankle. Philadelphia, PA: Lippincott-Raven, 1996.)
A: Plantar surface of the talus, which articulates with the dorsal surface of the calcaneus. Note the extensive area of the talus that is articular cartilage. B: Dorsal surface of the calcaneus with the articular facets occupying the anterior half of the calcaneus.
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Figure 33-7
Subtalar joint opened such that the medial borders of the joint face each other.
A: Plantar surface of the talus, which articulates with the dorsal surface of the calcaneus. Note the extensive area of the talus that is articular cartilage. B: Dorsal surface of the calcaneus with the articular facets occupying the anterior half of the calcaneus.
(From Sammarco GJ. Anatomy. In: Helal B, Rowley D, Cracchiolo AC, et al, eds. Surgery of Disorders of the Foot and Ankle. Philadelphia, PA: Lippincott-Raven, 1996.)
A: Plantar surface of the talus, which articulates with the dorsal surface of the calcaneus. Note the extensive area of the talus that is articular cartilage. B: Dorsal surface of the calcaneus with the articular facets occupying the anterior half of the calcaneus.
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The lateral process of the talus is a large wedge-shaped process that is covered in articular cartilage. It articulates with the fibular superiorly and laterally and with the subtalar joint inferiorly. The lateral talocalcaneal ligament is attached to the most distal part of the process.64,66 
The head of the talus is entirely cartilaginous, convex, and articulates with the concave surface of the navicular. The undersurface of the talus is comprised of three articulating surfaces for the calcaneus: The posterior, middle, and anterior facet. Between the posterior and middle facets is a transverse groove which forms the roof of the tarsal canal. 

Blood Supply

The blood supply of the talus has been extensively studied.9,62,118 The nutrient arteries are derived from the three major vessels that cross the ankle joint: Posterior tibial artery, tibialis anterior artery, and peroneal artery (Fig. 33-8). Branches of these three vessels perforate circumferentially the short talar neck which is the only part of the talus denude of articular cartilage. A fracture in this area can disrupt this intricate anastomosis of vessels and lead to AVN of the body of the talus. 
Figure 33-8
Arterial blood supply to the talus.
 
Medial blood supply (A) and lateral blood supply (B). Dorsal view with sagittal cut through length (a) of talus and transverse cut through neck of talus (b).
 
(From Gelberman RH, Mortensen WW. The arterial anatomy of the talus. Foot Ankle. 1983; 4:64–72.)
Medial blood supply (A) and lateral blood supply (B). Dorsal view with sagittal cut through length (a) of talus and transverse cut through neck of talus (b).
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Figure 33-8
Arterial blood supply to the talus.
Medial blood supply (A) and lateral blood supply (B). Dorsal view with sagittal cut through length (a) of talus and transverse cut through neck of talus (b).
(From Gelberman RH, Mortensen WW. The arterial anatomy of the talus. Foot Ankle. 1983; 4:64–72.)
Medial blood supply (A) and lateral blood supply (B). Dorsal view with sagittal cut through length (a) of talus and transverse cut through neck of talus (b).
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The main blood supply to the talus is through the artery of the tarsal canal. This artery branches off the posterior tibial artery approximately 1 cm proximal to the origin of the medial and lateral plantar arteries. It passes between flexor digitorum longus and flexor hallucis longus before entering the tarsal canal where it anastomoses with the artery of the tarsal sinus. Before entering the canal, the artery of the tarsal canal gives off a deltoid branch that penetrates the deltoid ligament and supplies the medial third of the talar body.57 A dorsal vessel of the deltoid branch anastomoses with the medial branch of the dorsalis pedis artery to enter the talar neck. 
The second source of blood supply is from the anterior tibial artery and its terminal extension, the dorsalis pedis artery. Multiple vessels from these arteries penetrate the dorsal neck of the talus. The third source of blood supply is from the peroneal artery. Small branches supply the posterior process of the talus and a larger branch forms the artery of the sinus tarsi to supply the lateral aspect of the talus. 
Within the capsular and ligamentous attachments to the talus there are small vessels that also contribute to the blood supply.130 

Fractures of the Talar Body and Dome

Fractures of the talar body are less common than of the neck. In 1977, Sneppen et al.163 described a classification system based on the anatomic position of the fracture in the talus. This was later modified by DeLee42 and the result is a five-part classification. 
Fractures of the talar body are rare in adults and children (Table 33-2). In a long-term follow-up of 14 talus fractures in children Jensen et al.79 found only four (29%) were fractures through the body. Undisplaced fractures can be treated in a non–weight-bearing below-knee cast for 6 to 8 weeks until the fracture is healed and the outcome is excellent. Undisplaced intra-articular fractures can be treated in the same way; however, serial radiographs must be taken to confirm displacement does not occur. Anatomic reduction of displaced fractures has been recommended because residual displacement of the articular surfaces leads to degenerative osteoarthritis.97 
 
Table 33-2
Sneppen Classification System of Talar Body Fractures
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Table 33-2
Sneppen Classification System of Talar Body Fractures
Sneppen Grade Fracture Type
1 Transchondral/osteochondral
2 Coronal, sagittal, or horizontal shear
3 Posterior tubercle
4 Lateral process
5 Crush fracture
X

Fractures of the Lateral Process of the Talar Body

Fractures of the lateral process of the talus are rare in adults and children, and a high level of suspicion is required if the diagnosis is to be made. The lateral process is a wedge-shaped prominence that forms almost the whole lateral wall of the talus. It is covered entirely in articular cartilage and is the articulating surface of the talus with the fibular. The talocalcaneal ligament inserts into the tip of the lateral process. The mechanism of injury is a forced dorsiflexion injury with inversion of the foot.64 The talocalcaneal ligament may avulse the lateral process. 
Isolated fractures of the lateral process of the talus are often not recognized on the initial radiographs.64,66,112 Leibner et al.95 suggested that this may occur in 46% of the cases. The lateral process is best visualized on the mortise view so the fibula is not overlying it. On the lateral radiograph, the lateral process is seen just superior to the angle of Gissane.66 This is the angle between a line drawn along the lateral border of posterior facet and a line drawn along the anterior process (Fig. 33-9). If there is persistent pain laterally around the ankle following an inversion ankle injury, one should have a high suspicion for a lateral process fracture or an osteochondral injury. If not clearly seen on the plain films, a CT scan should be performed to assess the talus and rule out any other coexisting fractures.87,123 
Figure 33-9
 
Diagrammatic depictions of the crucial angle of Gissane (A) and the Bohler angle (B). The Bohler angle is more frequently used for decision making regarding fracture management. For measuring the Bohler angle, the landmarks on the lateral radiograph of the calcaneus are the anterior and posterior facets and the superior margin of the calcaneal tuberosity.
Diagrammatic depictions of the crucial angle of Gissane (A) and the Bohler angle (B). The Bohler angle is more frequently used for decision making regarding fracture management. For measuring the Bohler angle, the landmarks on the lateral radiograph of the calcaneus are the anterior and posterior facets and the superior margin of the calcaneal tuberosity.
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Figure 33-9
Diagrammatic depictions of the crucial angle of Gissane (A) and the Bohler angle (B). The Bohler angle is more frequently used for decision making regarding fracture management. For measuring the Bohler angle, the landmarks on the lateral radiograph of the calcaneus are the anterior and posterior facets and the superior margin of the calcaneal tuberosity.
Diagrammatic depictions of the crucial angle of Gissane (A) and the Bohler angle (B). The Bohler angle is more frequently used for decision making regarding fracture management. For measuring the Bohler angle, the landmarks on the lateral radiograph of the calcaneus are the anterior and posterior facets and the superior margin of the calcaneal tuberosity.
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The incidence of this rare injury is increasing because of the increased popularity of snowboarding.87,95,122 Kirkpatrick et al.87 reviewed 3,213 snowboarding injuries and found an unusually high incidence of lateral process fractures. They comprised 34% of all ankle fractures.87 
The treatment of nondisplaced fractures of the lateral process is with a non–weight-bearing cast for 6 to 8 weeks. Displaced fractures are best treated with open reduction and internal fixation; however, the degree of displacement that is acceptable in a child is not clearly defined. What may be more important is the congruity of the joint surface of the talus. A step or gap in the articular surface of more than 2 to 3 mm may be useful criteria as to when to open reduce the fracture. The fracture can be held with one 3.5-mm partially threaded cancellous screw inserted from lateral to medial perpendicular to the fracture line. A below-knee cast is then worn for 6 weeks.64,66,95,172 

Fractures of the Osteochondral Surface of the Talus

Damage to the osteochondral surface of the talus can be caused by direct trauma or may be caused by an underlying osteochondral lesion (osteochondritis dissecans [OCD]) that may have been present for some time and has been made symptomatic by the injury. The pathogenesis and etiology of OCD are controversial; however, most authors report preceding trauma as a cause of the defects (Canale and Bedding25 80%, Letts et al.97 79%, Higuera et al.69 63%, and Perumal et al.129 47%). The medial lesion is usually deeper and cup-shaped compared to the thinner “wafer” type lateral lesion. The lateral lesion is more often associated with trauma and more symptomatic than the medial lesions. It is postulated that the medial lesions may be because of more repetitive microtrauma.25,26 Berndt and Harty,12 in 1959, used freshly amputated legs to biomechanically reproduce injuries to the ankle and observe the injuries inflicted. They showed that the anterolateral talus hits the medial aspect of the fibula with dorsiflexion and inversion and that plantarflexion and inversion caused posteromedial osteochondral lesions (Fig. 33-10). 
Figure 33-10
Typical positions of osteochondral lesions of the talus.
 
Berndt and Harty12 found that of 201 osteochondral lesions in adults 56% were on the medial side and 44% on the lateral side. Letts et al. found medial lesions in 79% of 24 children, lateral lesions in 21%, and central lesions in 1%.
 
(From Letts M, Davidson D, Ahmer A. Osteochondritis dissecans of the talus in children. J Pediatr Orthop. 2003; 23:617–625, with permission.)
Berndt and Harty12 found that of 201 osteochondral lesions in adults 56% were on the medial side and 44% on the lateral side. Letts et al. found medial lesions in 79% of 24 children, lateral lesions in 21%, and central lesions in 1%.
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Figure 33-10
Typical positions of osteochondral lesions of the talus.
Berndt and Harty12 found that of 201 osteochondral lesions in adults 56% were on the medial side and 44% on the lateral side. Letts et al. found medial lesions in 79% of 24 children, lateral lesions in 21%, and central lesions in 1%.
(From Letts M, Davidson D, Ahmer A. Osteochondritis dissecans of the talus in children. J Pediatr Orthop. 2003; 23:617–625, with permission.)
Berndt and Harty12 found that of 201 osteochondral lesions in adults 56% were on the medial side and 44% on the lateral side. Letts et al. found medial lesions in 79% of 24 children, lateral lesions in 21%, and central lesions in 1%.
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The initial radiographs following an ankle injury in a child should be closely assessed for an osteochondral injury. If pain and swelling persist for over 2 months after an “ankle sprain,” then further investigations should be carried out to look for an osteochondral lesion. This will initially be a further radiograph series; however, an MRI scan is often more useful at this stage to look for an osteochondral lesion as a small percentage are purely cartilaginous. Some consider an MRI arthrogram useful in further determining whether the fragment is detached or not as occasionally the arthrographic contrast can be seen deep to the osteochondral lesion. The bone scan has largely been superseded by the MRI scan in the diagnosis and assessment of these lesions. The bone scan is useful, however, when it is not clear if the pain in the child's ankle is coming from the osteochondral lesion or some other pathology. A normal bone scan in the presence of a stage I or II osteochondral lesion may indicate a soft tissue lesion as being a source of the pain. 
Mechanical symptoms of locking and catching are not as common as one would think but can occur with these lesions if the loose fragment becomes trapped within the joint. The pain seems to be related to the synovitis and effusion that develops secondary to the uneven articular surface. On examination, the ankle is slightly swollen and can be painful on passive movement as the loose fragment passes under the tibia. With plantarflexion of the foot, the anterolateral talus can be palpated directly and a lesion here can be painful on direct pressure. 

Classification of Osteochondral Fractures

Berndt and Harty12 classified osteochondral fractures of the talar dome into four stages based on radiographic criteria (Fig. 33-11): 
Figure 33-11
Adaptation of the Berndt and Harty12 (1959) classification of osteochondral injuries of the talus by Anderson et al.8
 
Stage I is identified only by MRI scanning, which demonstrates trabecular compression of subchondral bone; stage II lesions have incomplete separation of the osteochondral fragment from the talus. If a subchondral cyst also is present, the lesion is designated stage IIa. Stage III lesions occur when the fragment is no longer attached to the talus but is undisplaced. Stage IV indicates both complete detachment and displacement.
 
(From Alexander IF, Chrichton KI, Grattan-Smith Y, et al. Osteochondral fractures of the dome of the talus. J Bone Joint Surg Am. 1989; 71:1143, with permission.)
Stage I is identified only by MRI scanning, which demonstrates trabecular compression of subchondral bone; stage II lesions have incomplete separation of the osteochondral fragment from the talus. If a subchondral cyst also is present, the lesion is designated stage IIa. Stage III lesions occur when the fragment is no longer attached to the talus but is undisplaced. Stage IV indicates both complete detachment and displacement.
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Figure 33-11
Adaptation of the Berndt and Harty12 (1959) classification of osteochondral injuries of the talus by Anderson et al.8
Stage I is identified only by MRI scanning, which demonstrates trabecular compression of subchondral bone; stage II lesions have incomplete separation of the osteochondral fragment from the talus. If a subchondral cyst also is present, the lesion is designated stage IIa. Stage III lesions occur when the fragment is no longer attached to the talus but is undisplaced. Stage IV indicates both complete detachment and displacement.
(From Alexander IF, Chrichton KI, Grattan-Smith Y, et al. Osteochondral fractures of the dome of the talus. J Bone Joint Surg Am. 1989; 71:1143, with permission.)
Stage I is identified only by MRI scanning, which demonstrates trabecular compression of subchondral bone; stage II lesions have incomplete separation of the osteochondral fragment from the talus. If a subchondral cyst also is present, the lesion is designated stage IIa. Stage III lesions occur when the fragment is no longer attached to the talus but is undisplaced. Stage IV indicates both complete detachment and displacement.
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Stage I: Subchondral trabecular compression fracture (not seen radiographically) 
Stage II: Incomplete separation of an osteochondral fragment 
Stage III: The osteochondral fragment is unattached but undisplaced 
Stage IV: A displaced osteochondral fragment 
Anderson et al.8 modified this classification after correlating clinical findings with radiographs and MRI scans. They described the stage I lesion as not visible on plain radiographs but visible on an MRI scan. They also introduced a stage IIa lesion, which is an undisplaced osteochondral lesion with a subchondral cyst adjacent to the floor of the lesion. Anderson et al.8 felt a stage IIa lesion should be treated surgically whereas a stage II lesion can initially be treated nonoperatively (Fig. 33-12). 
Figure 33-12
This would be classified by Anderson et al.8 as a stage IIa lesion.
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Figure 33-12
This CT scan clearly shows a well-circumscribed cyst at the base of a stage II osteochondral lesion.
This would be classified by Anderson et al.8 as a stage IIa lesion.
This would be classified by Anderson et al.8 as a stage IIa lesion.
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A further classification was proposed by Pritsch et al.135 in 1986 based on the arthroscopic appearance of the articular cartilage at the time of surgery. The quality of the articular cartilage was placed into one of three grades: 
Grade I: Intact, firm, and shiny articular cartilage 
Grade II: Intact but soft articular cartilage 
Grade III: Frayed articular cartilage 
They used this classification to determine which lesions should be treated with activity modification (grade I), who should have arthroscopic drilling (grade II), and finally which patients require arthroscopic curettage and microfracture (grade III). 

Treatment of Osteochondral Fractures

The treatment of osteochondral lesions of the talus in children is challenging. Only a few papers purely address this condition in children,69,97,129 and the rest of the literature is a combination of adult and childhood lesions. It is important to distinguish between an acute osteochondral fracture and a chronic osteochondral lesion as the two may require different treatment strategies. 
To enable thorough assessment, these patients need to be followed up for a minimum of 2 years as it takes this long for the lesion to become radiographically healed despite the child often being clinically normal.129 

Nonoperative Management

Most authors agree that the primary treatment of stage I and stage II lesions is nonoperative.12,69,97,129 The symptomatic patient can be immobilized for 6 weeks in a below-knee walking cast or a Cam walker (Fig. 33-13). This usually relieves the acute symptoms; over the next 6 weeks, the patient has activity modification maintaining a pain-free range of movement. This allows the fracture to heal before returning to active sport. Higuera et al.69 treated their stage III lesions nonoperatively as well and all seven patients had good outcomes. 
Figure 33-13
 
A: Anterolateral stage III osteochondral lesion that was treated by arthroscopic excision and microfracture. B: Posteromedial stage II osteochondral lesion that was treated successfully nonoperatively.
A: Anterolateral stage III osteochondral lesion that was treated by arthroscopic excision and microfracture. B: Posteromedial stage II osteochondral lesion that was treated successfully nonoperatively.
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Figure 33-13
A: Anterolateral stage III osteochondral lesion that was treated by arthroscopic excision and microfracture. B: Posteromedial stage II osteochondral lesion that was treated successfully nonoperatively.
A: Anterolateral stage III osteochondral lesion that was treated by arthroscopic excision and microfracture. B: Posteromedial stage II osteochondral lesion that was treated successfully nonoperatively.
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Surgical Treatment

The outcomes of surgery for osteochondral fractures of the talus are controversial. It is hard to compare results between authors as they have often used different outcome measures. Some authors use pain as their primary outcome97 whereas others also consider radiologic healing. The long-term outcome of an asymptomatic subchondral lucency in the talar body is unknown. In some series, the patients have had arthrotomies97 whereas others had arthroscopic debridement.129 The staging of the lesions are also subject to interobserver variability.97 Letts et al.95 performed surgery in 24 patients with osteochondral lesions. They used arthroscopy in three patients only and two of those patients required arthrotomy as well.95 With modern ankle arthroscopy equipment and newer surgical techniques, ankle arthroscopy has become the primary surgical treatment for both medial and lateral lesions of the talar dome. The anterolateral lesions are more accessible; however, with good ankle distraction and different portal placement posteromedial lesions are accessible. 
Recently, Perumal et al.129 reviewed 31 patients with juvenile OCD with a minimum of 6-month follow-up. They recommended nonoperative treatment with an ankle brace and activity modification in most cases for 6 months. Only 16% of the lesions healed radiographically in that timeframe. If pain continues after this time and the lesion is still present, further immobilization and activity modification is recommended. They recommend arthroscopic surgery for patients with type II lesions who are not prepared to modify their activities longer than 6 months and patients with type III lateral lesions and all stage IV lesions. Thirteen of the 31 patients were treated surgically. 
Arthroscopic treatment options include: 
  1.  
    Drilling the lesion (antegrade or retrograde)88
  2.  
    Curettage and microfracture
  3.  
    Internal fixation with bioabsorbable nails
  4.  
    Bone grafting and internal fixation
In stage II lesions with intact articular cartilage, Kumai et al.56 showed excellent results drilling through the lesion into the subchondral bone. They also found that in skeletally immature patients, there may be an increased tendency for the lesion to heal when compared to the adult patients. Retrograde drilling can be performed using specific tip directed instrumentation.168 This avoids damage to the articular cartilage and may prevent fragmentation of a small lesion. Access to a posteromedial lesion can be difficult. One approach is to use a transmalleolar portal after drilling a 3.5-mm drill through the medial malleolus or to use a posteromedial portal taking care to avoid damaging the neurovascular bundle. 
Curettage and microfracture is a very effective, relatively straightforward procedure. It is particularly useful in small stage III and stage IV lesions where the fragment is too small to internally fix or there is no subchondral bone on the lesion for healing. The articular cartilage is debrided back to stable tissue and the subchondral bone is curettaged until bleeding occurs. Either a microfracture pick or 2-mm drill is then used in the subchondral bone. Anderson et al.8 would suggest this treatment for all stage IIa lesions where a subchondral cyst is present. 
Internal fixation with or without bone grafting is a difficult procedure for the inexperienced arthroscopist. It is preferable to use absorbable pegs or nails rather than metallic implants. In large stage III and IV acute osteochondral lesions, this is probably the treatment of choice rather than excising the fragment. 

Author's Preferred Treatment

For simple undisplaced fractures, a below-knee nonwalking cast is applied for 6 weeks. 
Displaced lateral process fractures need to be anatomically reduced especially if they are intra-articular and there is 2 to 3 mm of incongruity in the joint surface. A lateral approach is used and a single compression screw inserted across the fracture. The foot is immobilized in a below-knee cast for 6 weeks. 
Displaced talar neck fractures should be operated on as soon as possible. If the fracture can be reduced closed, the author prefers a posterolateral approach to insert the compression screws as this helps preserve the tenuous blood supply (Fig. 33-4). These screws are best inserted through this open approach so an accurate starting point can be found and neurovascular structures protected. The author has no hesitation to use an anteromedial approach as well to help with fracture reduction before inserting the screws. Through this approach, the neck fragment can be stabilized while the screws are being compressed and anatomic fracture reduction can be seen. Usually, two 4.5-mm partially threaded titanium screws are used depending on the size of the talus and degree of fragmentation. The titanium screws allow MRI postoperatively if osteonecrosis is suspected. 
Acute osteochondral injuries need to be recognized and distinguished from OCD lesions. Acute lesions should be repaired after assessing the amount of bone present on the lesion. This can be initially assessed arthrocopically but is repaired through an arthrotomy depending on the position on the talus. The author prefers to repair the lesion with dissolvable nails. 
The author treats types I to III OCD lesions nonoperatively for 6 months. Initially, the child or adolescent wears a Cam walker for 4 to 6 weeks to help the symptoms settle and then an elastic ankle support and activity modification. If symptoms persist, the author performs a repeat MRI scan and, if the staging has worsened, proceeds to an arthroscopic debridement and microfracture or stabilization. For patients with displaced fragments on presentation (stage IV), the author recommends arthroscopic removal and microfracture or repair if possible. 

Complications

Osteonecrosis of the Talus

Osteonecrosis of the talus is the most serious complication of talus fractures. This has been reported in a number of large series of predominantly adult patients.26,65 Osteonecrosis of the body of the talus occurs when the blood supply has been disrupted by a fracture of the talar neck. The result is necrosis of the talar dome and possible collapse of the articular surface. It appears that this process of necrosis can start as early as the first month following the fracture. Hawkins65 described the presence of a subchondral lucent line, the “Hawkins sign,” as prognostic of a good outcome as it indicates adequate blood flow to the talar body. The absence of the sign on a 6- to 8-week radiograph implies there is inadequate blood supply and osteonecrosis may evolve. 
In adults, the incidence of osteonecrosis seems directly related to the degree of displacement of the femoral neck fracture. Hawkins65 showed that type I fractures had a 0% to 10% AVN rate, type II fractures a 20% to 50% AVN rate, type III an 80% to 100% AVN rate, and all type IV fractures develop AVN. Canale and Kelly26 had similar long-term results. 
Osteonecrosis has also been seen in pediatric talus fractures; however, it does not seem to be as predictable as the adult literature suggests. The Hawkins sign was described in adults, and Ogden124 suggests this sign may not be as reliable in the cartilaginous talar dome of a child. Mazel et al.111 reported on seven complete fractures of the talar neck in children over 6 years of age and two developed AVN. Similarly, Letts and Gibeault98 had three children with AVN after talus fractures. Interestingly, two of these patients had undisplaced fractures of the talus at the time of their injury that were not initially picked up. Subsequent radiographs revealed the AVN.98 Rammelt et al.140 also reported on a 5-year-old whose undisplaced talar neck fracture was missed who went on to develop AVN. In a literature search, they found a 16% incidence of AVN of the talus in undisplaced talar fractures in children. They suggest that the pediatric talus is more susceptible to AVN than the adult counterpart.140 Jensen et al.,79 on the other hand, had no cases of AVN in 14 children with talus fractures. 
The dilemma for the treating surgeon is what to advise the patient regarding weight bearing when the Hawkins sign is not present by 8 weeks. Some of the above series report AVN occurring 6 months after the injury and not resolving for many years. There does not appear to be any series comparing outcomes in patients who bear weight over this period and those who do not. If the Hawkins sign is not present, it is advisable to perform an MRI scan at 3 months to establish if AVN is present or not.67,170 If present, it may be advisable to encourage the child to avoid impact activities to prevent collapse rather than have a prolonged period of non–weight-bearing. 

Calcaneal Fractures

Epidemiology of Calcaneal Fractures

Fractures of the calcaneus are rare in children with an incidence of only 1 in 100,000 fractures.181 The treatment of these fractures has historically been nonoperative, relying on the largely cartilaginous bone to remodel with time. The majority of fractures in children less than 14 years old are extra-articular whereas in older children the fracture pattern resembles those in adults. Children appear to have more coexisting lower limb fractures than adults but fewer fractures of the axial skeleton.156 
Calcaneal fractures in young children are often missed or are diagnosed late on radiographs or bone scan when the child is still limping long after the injury. At the other end of the spectrum, the adolescent patient has often had a major fall and has a displaced intra-articular fracture. This older age group should be treated like the adult population with open reduction and internal fixation restoring the joint congruity and calcaneal height and width. The challenge for the surgeon is at what age and what degree of displacement is this more aggressive treatment indicated in a group of patients traditionally treated nonoperatively. 

Management of Calcaneal Fractures

Mechanism of Injury

The most common mechanism of injury is a fall from a height. This axial load drives the talus into the calcaneus resulting in the fracture. The degree of comminution appears to be less in children even though they often fall from greater heights than adults.20 Wiley and Profitt181 found that in young children, the fall was usually less than 4 feet and in children older than 10 years the fall was greater than 14 feet. They noted that the minor falls in the younger children often resulted in undisplaced fractures that were diagnosed late. 
Schmidt and Weiner156 reviewed 56 children with calcaneal fractures of which 25 (45%) were caused by a fall from a height. They also found that children less than 14 years of age predominantly had extra-articular fractures, hypothesizing that the calcaneus in this age bracket absorbs the compression force rather than dissipating it through the joint. 
Vehicle-related injuries were the second biggest cause of calcaneal fractures in both Schmidt and Weiner156 and Wiley and Profitt's reviews.181 
Fractures of the calcaneus can also occur in major crush injuries when compartment syndrome may coexist and open fractures are common in lawnmower injuries. 

Signs and Symptoms of Calcaneal Fractures

Any child who has fallen from a height and landed on their feet should be examined carefully for a calcaneal fracture. Associated injuries should also be evaluated with a thorough secondary survey, especially of the lower limbs and spine. 
The foot will often be extremely swollen with bruising around the heel and dorsum of the foot. Symptoms and signs of compartment syndrome, including excessive pain, pallor, paresthesia, and pulselessness should be assessed. In more subtle injuries, careful palpation is necessary to elucidate areas of pain which may disclose an underlying undisplaced fracture. 
Many calcaneal fractures in children are initially missed and diagnosed late. Often, the fracture line is not evident on the initial radiographs. Inokuchi et al.75 reported that 44% of fractures in their series were initially missed, as were 55% of those reported by Schantz and Rasmussen154 and 44% of those reported by Wiley and Profitt.181 
A differential diagnosis must be kept in mind for other causes of heel pain in a child. These include Sever disease, osteomyelitis, a unicameral bone cyst, or a stress fracture.126 

Associated Injuries with Calcaneal Fractures

Schmidt and Weiner156 reviewed 59 children with 62 calcaneal fractures and found a number of associated injuries. These included fractures of the lumbar spine, lower limb fractures, a pelvic fracture, and upper extremity fractures. These other skeletal injuries were more frequent in children over 13 years of age. Associated lower limb fractures occurred twice as frequently as in adults; however, injuries to the axial skeleton occurred half as often as in adults. Wiley and Profitt,181 however, only had two patients with accompanying significant injuries in their series of 32 pediatric calcaneal fractures. 

Diagnosis and Classification of Calcaneal Fractures

Plain Radiographs

Calcaneal fractures in children often missed as the radiographic findings are usually more subtle than in adults.89,110,156,165,181 Subsequent radiographs at 10 to 14 days often show the fracture line. The majority of these missed fractures are extra-articular.156 
The standard views for a suspected calcaneal fracture are posteroanterior, lateral, and axial views. The posteroanterior view shows the calcaneocuboid and talonavicular joints well. The lateral view is excellent at showing the congruity of the posterior articular facet and allows calculation of Bohler angle (Fig. 33-9). The axial view demonstrates the tuberosity, the body, the sustenaculum tali, and the posterior facet of the calcaneus Oblique views are also useful and will show a fracture of the anterior process more clearly (Fig. 33-14).142 The oblique views also define the subtalar joint well so are very useful in intra-articular fractures. Broden views can also be taken that look at the posterior facet of the calcaneus. These are taken with the leg internally rotated 40 degrees and the x-ray beam angled between 15 to 40 degrees toward the head.18 This is a difficult radiograph for the technicians to master and almost the same information can be achieved by ordering a mortise view of the ankle and looking at the posterior facet of the subtalar joint. 
Flynn-ch033-image014.png
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Figure 33-14
Fracture of the anterior process of the talus.
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The lateral view is useful for measuring the Bohler angle. This is the angle between a line drawn from the highest point of the anterior process to the highest point of the posterior facet and a line drawn tangential to the highest point of the calcaneal tuberosity. The normal value in an adult is between 20 and 40 degrees. In a child, the angle is slightly less than in an adult and may be caused by the incomplete ossification of the calcaneus. It is advisable to perform a lateral radiograph of the contralateral calcaneus to use as a comparison rather than accept the absolute value of Bohler angle. The child's calcaneus does not resemble that of an adult until after 10 years of age.71,73,124,173 Another angle which is not so easy to measure is “the crucial angle of Gissane.” This is the angle formed by two strong cortical struts seen on the lateral radiograph. One runs along the lateral margin of the posterior facet and the other runs up to the anterior process of the calcaneus. The angle between them ranges from 95 to 105 degrees (Fig. 33-9).51 
When reviewing radiographs of children's feet, it is always important to be cognizant of the normally appearing ossification centers and accessory bones about the growing foot, which often are confused with fractures (Figs. 33-1 and 33-2).27 The os calcis is the earliest tarsal bone to ossify with the primary ossification center appearing in the third intrauterine month. The secondary ossification center appears around 6 to 8 years and is the crescentic epiphysis seen posteriorly that gives rise to Sever disease. This epiphysis fuses to the body of the calcaneus when the adolescent is 14 to 16 years old. 
The use of a technetium-labeled bone scan in diagnosing calcaneal fractures is uncommon with the ready availability of MRI scans. The bone scan is useful in evaluating a nonlocalized painful limp in a toddler and in this setting a calcaneal fracture may be diagnosed. Laliotis et al.89 used bone scans and identified five calcaneal fractures in seven toddlers less than 36 months of age who had no history of significant injury. Bone scanning is sensitive for bone pathology but not specific and will be positive when other conditions are present like infection, Sever disease, juvenile arthritis, and some neoplasms. A CT scan is a useful investigation to evaluate the positive bone scan. 

Computed Tomography Scanning

CT scanning has evolved as the best method to evaluate the fractured calcaneus. Not only does it clearly show the fracture lines and altered anatomy, but also reveals injuries to adjacent bones. Sanders et al.152 have used CT scans to develop a classification system that is particularly useful in the preoperative planning of open reduction of these fractures. The primary and secondary fracture lines are identified and the degree of comminution and position of the fragments is more accurately seen than in the radiographs. The primary fracture line usually runs obliquely from plantar medial to dorsolateral exiting the posterior facet. Secondary fracture lines that develop off this primary line are also seen and their pattern determines the classification of the fracture (Fig. 33-15). The CT scan also allows a three-dimensional reconstruction to be made which again is useful in visualizing the fracture lines for possible internal fixation. 
Figure 33-15
Sanders CT-based classification of intra-articular fractures of the calcaneus in adults.
 
(From Sanders R. Intraarticular fractures of the calcaneus: Present state of the art. J Orthop Trauma. 1992; 6:254, with permission.)
(From 


Sanders R
.
Intraarticular fractures of the calcaneus: Present state of the art.
J Orthop Trauma.
1992;
6:254, with permission.)
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Figure 33-15
Sanders CT-based classification of intra-articular fractures of the calcaneus in adults.
(From Sanders R. Intraarticular fractures of the calcaneus: Present state of the art. J Orthop Trauma. 1992; 6:254, with permission.)
(From 


Sanders R
.
Intraarticular fractures of the calcaneus: Present state of the art.
J Orthop Trauma.
1992;
6:254, with permission.)
View Original | Slide (.ppt)
X
Buckingham et al.20 and Ogden124 reviewed nine patients with 10 calcaneal fractures and performed CT scans on all of them. They found the fracture patterns in these adolescents (average 13.4 years old) to be very similar to those found in adults. They did find less comminution in children than in adults, even though the children reportedly had fallen from greater heights. 
The use of MRI scans is largely unnecessary for the majority of calcaneal fractures. They can be useful in young children when the calcaneus is still largely cartilaginous and a fracture is not seen on plain films or CT. 

Classification of Calcaneal Fractures

Children's calcaneal fractures were traditionally classified according to their adult counterparts using the Essex-Lopresti51 and Letournal96 classifications. Schmidt and Weiner156 reviewed 62 calcaneal fractures in children and compared them to the adult literature.147 They used the classification systems of Essex-Lopresti51 and Chapman and Galway32 and added a new fracture type (type VI) to develop a classification for pediatric calcaneal fractures which is in routine use today (Fig. 33-16). 
Figure 33-16
Schmidt and Weiner classification of calcaneal fracture patterns in children.
 
A: Extra-articular fractures. B: Intra-articular fractures. C: Type VI fracture pattern with significant bone loss, soft tissue injury, and loss of Achilles tendon insertion.
 
(From Schmidt TL, Weiner DS. Calcaneus fractures in children: An evaluation of the nature of injury in 56 children. Clin Orthop Relat Res. 1982; 171:150, with permission.)
A: Extra-articular fractures. B: Intra-articular fractures. C: Type VI fracture pattern with significant bone loss, soft tissue injury, and loss of Achilles tendon insertion.
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Figure 33-16
Schmidt and Weiner classification of calcaneal fracture patterns in children.
A: Extra-articular fractures. B: Intra-articular fractures. C: Type VI fracture pattern with significant bone loss, soft tissue injury, and loss of Achilles tendon insertion.
(From Schmidt TL, Weiner DS. Calcaneus fractures in children: An evaluation of the nature of injury in 56 children. Clin Orthop Relat Res. 1982; 171:150, with permission.)
A: Extra-articular fractures. B: Intra-articular fractures. C: Type VI fracture pattern with significant bone loss, soft tissue injury, and loss of Achilles tendon insertion.
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For adolescent fractures, it is probably more appropriate to use the Sanders classification.152 This is an adult classification system that was developed after reviewing the CT scans on 120 cases preoperatively and at minimum 1-year follow-up. The follow-up CT scans were correlated with the clinical outcome scores to help validate the classification system used. 

Surgical and Applied Anatomy of Calcaneal Fractures

The calcaneus is the largest tarsal bone and has quite an unusual shape. It has three articular facets (anterior, middle, and posterior) on the superior surface where it articulates with the talus to form the subtalar joint (Fig. 33-7) and anteriorly there is a saddle-shaped articular surface for the cuboid. The posterior facet is the largest facet and is slightly convex. The middle facet is anterior and medial to the posterior facet lying on the sustenaculum tali. It is concave like the anterior facet with which it is often contiguous. Between the middle and posterior facets lies the calcaneal groove, which forms the inferior wall of the sinus tarsi. Posteriorly, the tendoachilles inserts into the tuberosity of the calcaneus which is the whole area behind the posterior facet. On the lateral surface of the calcaneus are two shallow grooves with a small ridge in between (the peroneal trochlea). The peroneus longus and brevis run either side of this trochlea. The medial side is concave and is structurally stronger than the lateral side. The sustentaculum tali projects from the medial wall and supports the middle articular facet on its surface. The tendon of flexor hallucis longus runs on the undersurface of the sustenaculum. On the plantar surface are the medial and lateral processes for the origin of the abductor hallucis and abductor digiti minimi muscles, respectively (Fig. 33-17). 
Figure 33-17
 
Anatomic details of various angles of the calcaneus including lateral (A), medial (B), and coronal (C) views through the level of the sustentaculum tali, which correlate with the CT scan view important in reconstruction of the posterior facet.
Anatomic details of various angles of the calcaneus including lateral (A), medial (B), and coronal (C) views through the level of the sustentaculum tali, which correlate with the CT scan view important in reconstruction of the posterior facet.
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Figure 33-17
Anatomic details of various angles of the calcaneus including lateral (A), medial (B), and coronal (C) views through the level of the sustentaculum tali, which correlate with the CT scan view important in reconstruction of the posterior facet.
Anatomic details of various angles of the calcaneus including lateral (A), medial (B), and coronal (C) views through the level of the sustentaculum tali, which correlate with the CT scan view important in reconstruction of the posterior facet.
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Secondary ossification occurs in the calcaneal apophysis between the ages of 6 and 10 years. Inflammation in the apophysis around this age causes heel pain and is referred to as Sever disease. 
The use of CT scans has defined the surgical anatomy of the calcaneus to help make treatment decisions. The coronal views show the important posterior facet and the sustenaculum tali and the height and width of the heel. The position of the peroneal tendons and flexor hallucis tendon can also be seen. The sagittal views provide additional information about the posterior facet and also show the anterior process well. The axial views visualize the calcaneocuboid joint well, the anterior-inferior aspect of the posterior facet, and the sustenaculum tali. This information can then be used in planning the reconstruction of the calcaneus.149,150 

Current Treatment Options for Calcaneal Fractures

Calcaneal fractures in growing children are usually less severe than in the adult population and often do well without operative intervention. The adolescent, on the other hand, often has fracture patterns similar to adults and requires open reduction and internal fixation. The challenge to the orthopedic surgeon is to recognize the patient that requires this form of surgery. There is a degree of remodeling that will take place in the child and hence the amount of growth remaining, degree of ossification, and difference in morphology from the contralateral side all need to be considered in making the treatment decisions. 
Extra-articular fractures of the calcaneus are treated by cast immobilization for 6 weeks. The child can start weight bearing in this cast when comfortable and can be changed to a Cam walker for the final few weeks if necessary.19,75 
Tongue-type fractures can be treated nonoperatively if the posterior gap is less than 1 cm and the Achilles tendon has not been significantly shortened by bringing the fragment up proximally. Occasionally, the technique described by Essex-Lopresti51 for percutaneous reduction of tongue-type fractures (Fig. 33-18) is useful. 
Figure 33-18
Percutaneous reduction technique for tongue-type fractures of the calcaneus, as described by Essex-Lopresti51.
 
This technique remains an alternative to conservative treatment and open reduction with internal fixation of displaced, tongue-type fractures. A: A pin is inserted into the tongue fragment and used as a joystick to manipulate the fragment into better position, usually with a downward force on the pin and the forefoot (plantarflexion). B: After reduction, the pin is driven across the fracture to maintain reduction.
 
(From Tornetta A III. The Essex-Lopresti reduction for calcaneal fractures revisited. J Orthop Trauma. 1998; 12:471, with permission.)
This technique remains an alternative to conservative treatment and open reduction with internal fixation of displaced, tongue-type fractures. A: A pin is inserted into the tongue fragment and used as a joystick to manipulate the fragment into better position, usually with a downward force on the pin and the forefoot (plantarflexion). B: After reduction, the pin is driven across the fracture to maintain reduction.
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Figure 33-18
Percutaneous reduction technique for tongue-type fractures of the calcaneus, as described by Essex-Lopresti51.
This technique remains an alternative to conservative treatment and open reduction with internal fixation of displaced, tongue-type fractures. A: A pin is inserted into the tongue fragment and used as a joystick to manipulate the fragment into better position, usually with a downward force on the pin and the forefoot (plantarflexion). B: After reduction, the pin is driven across the fracture to maintain reduction.
(From Tornetta A III. The Essex-Lopresti reduction for calcaneal fractures revisited. J Orthop Trauma. 1998; 12:471, with permission.)
This technique remains an alternative to conservative treatment and open reduction with internal fixation of displaced, tongue-type fractures. A: A pin is inserted into the tongue fragment and used as a joystick to manipulate the fragment into better position, usually with a downward force on the pin and the forefoot (plantarflexion). B: After reduction, the pin is driven across the fracture to maintain reduction.
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Open reduction and internal fixation is reserved for the severe intra-articular fractures with displacement of the fragments and depression of the joint surfaces. These fractures occur almost exclusively in the adolescent patient where the ossification process is complete. The adult literature abounds with indications for internal fixation, surgical approaches, rehabilitation, complications, and outcome measures (Fig. 33-19).10,132,149152 These series only have a few adolescent fractures among them, and therefore it is difficult to draw any conclusions specifically about children's calcaneal fractures. The literature on the management of displaced intra-articular fractures in children is somewhat conflicting in the indications for surgery. Schantz and Rasmussen154 reported on the outcome of displaced intra-articular fractures in children less than 15 years old treated nonoperatively. The majority of the patients had a good outcome; however, four complained of pain an average of 12 years after injury.154,169 Brunet19 believes the outcome does not correlate to the severity of the fracture. This is most likely because of the remodeling potential of the calcaneus in this age group. This concept also was supported by Mora et al.,117 who concluded that open reduction may be suitable only for severely displaced fractures in adolescents. The difficulty is defining the age or maturity of the patient that may predict a poor outcome if the fracture is left unreduced. Using validated quality-of-life scales 2 to 8 years after surgery, Buckley et al.21 found that younger patients (adults under the age of 30 years) who had operative treatment had better gait satisfaction scores than those who did not have surgery. Allmacher et al.6 questioned whether short-term or intermediate results of displaced intra-articular calcaneal fractures can predict long-term functional outcome. Using validated outcome instruments, they studied adult patients treated nonoperatively and found that nonoperative treatment often led to pain and loss of function, which increased in the second decade after injury. 
Figure 33-19
 
A: Lateral L-shaped approach to displaced intra-articular calcaneal fractures. The incision (dashed line) is laterally based, with the proximal arm approximately half the distance from the fibula to the posterior border of the foot and the distal arm halfway from the tip of the fibula to the sole of the foot. The sural nerve is illustrated. A full-thickness, subperiosteal flap exposes the entire lateral calcaneus. B: Reduction maneuvers 1, 2, and 3 (densest arrow indicates greatest displacement) with a Schanz screw are used to pull the tuberosity down and allow access to disimpact the posterior facet (C) after the lateral wall of the calcaneus is levered open. The posterior facet is then reduced anatomically, held provisionally with K-wires, and then fixed with two partially threaded cancellous screws (outside of plate) into the sustentaculum tali. Lateral view (D) of reduced calcaneus and axial view (E) of reduced fracture with hardware.
 
(From Benirschke SK, Sangeorzan BJ. Extraarticular fractures of the foot: Surgical management of calcaneal fractures [Review]. Clin Orthop Relat Res. 1993; 292:128–134, with permission.)
A: Lateral L-shaped approach to displaced intra-articular calcaneal fractures. The incision (dashed line) is laterally based, with the proximal arm approximately half the distance from the fibula to the posterior border of the foot and the distal arm halfway from the tip of the fibula to the sole of the foot. The sural nerve is illustrated. A full-thickness, subperiosteal flap exposes the entire lateral calcaneus. B: Reduction maneuvers 1, 2, and 3 (densest arrow indicates greatest displacement) with a Schanz screw are used to pull the tuberosity down and allow access to disimpact the posterior facet (C) after the lateral wall of the calcaneus is levered open. The posterior facet is then reduced anatomically, held provisionally with K-wires, and then fixed with two partially threaded cancellous screws (outside of plate) into the sustentaculum tali. Lateral view (D) of reduced calcaneus and axial view (E) of reduced fracture with hardware.
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Figure 33-19
A: Lateral L-shaped approach to displaced intra-articular calcaneal fractures. The incision (dashed line) is laterally based, with the proximal arm approximately half the distance from the fibula to the posterior border of the foot and the distal arm halfway from the tip of the fibula to the sole of the foot. The sural nerve is illustrated. A full-thickness, subperiosteal flap exposes the entire lateral calcaneus. B: Reduction maneuvers 1, 2, and 3 (densest arrow indicates greatest displacement) with a Schanz screw are used to pull the tuberosity down and allow access to disimpact the posterior facet (C) after the lateral wall of the calcaneus is levered open. The posterior facet is then reduced anatomically, held provisionally with K-wires, and then fixed with two partially threaded cancellous screws (outside of plate) into the sustentaculum tali. Lateral view (D) of reduced calcaneus and axial view (E) of reduced fracture with hardware.
(From Benirschke SK, Sangeorzan BJ. Extraarticular fractures of the foot: Surgical management of calcaneal fractures [Review]. Clin Orthop Relat Res. 1993; 292:128–134, with permission.)
A: Lateral L-shaped approach to displaced intra-articular calcaneal fractures. The incision (dashed line) is laterally based, with the proximal arm approximately half the distance from the fibula to the posterior border of the foot and the distal arm halfway from the tip of the fibula to the sole of the foot. The sural nerve is illustrated. A full-thickness, subperiosteal flap exposes the entire lateral calcaneus. B: Reduction maneuvers 1, 2, and 3 (densest arrow indicates greatest displacement) with a Schanz screw are used to pull the tuberosity down and allow access to disimpact the posterior facet (C) after the lateral wall of the calcaneus is levered open. The posterior facet is then reduced anatomically, held provisionally with K-wires, and then fixed with two partially threaded cancellous screws (outside of plate) into the sustentaculum tali. Lateral view (D) of reduced calcaneus and axial view (E) of reduced fracture with hardware.
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Pickle et al.132 reviewed the results of open reduction with internal fixation of displaced intra-articular calcaneal fractures in six adolescent patients (average age, 13 years) and found good short-term results at an average of 30 months after injury. None of the six patients (seven calcaneal fractures) developed any of the serious complications reported in adults. Four of the seven feet were completely pain-free, and three had some minor pain with sports or hard floors. Ceccarelli28 found that adolescents with displaced intra-articular fractures had better clinical and radiologic outcomes if treated by open reduction rather than nonoperatively. Buckingham et al.20 reviewed 10 adolescent patients and reported good or excellent outcomes in eight patients. They had no wound complications and the range in motion was hardly affected in seven patients. They recommended the routine removal of the screws and plates after fracture healing as this had improved the symptoms in six of eight patients.20 
The surgery for these fractures is technically demanding, and if the treating surgeon is not experienced with the approach, the child is best referred to a colleague who is. 

Author's Preferred Treatment

The key decision in treating children's calcaneal fractures is which one requires surgical intervention and which one can be treated in a cast. Almost all closed fractures in children less than 10 years of age can be treated nonoperatively because of the remodeling potential. This includes intra-articular fractures that are displaced. 
Extra-articular fractures of the calcaneus can be treated by nonoperative means with a below-knee cast for 6 weeks. Weight bearing in the cast can start after 2 to 3 weeks as the patient becomes more comfortable. 
Undisplaced intra-articular fractures can also be treated in a below-knee cast. In this group of patients, it is advisable for them to be non–weight-bearing for 6 weeks or until the fracture is healed to prevent further displacement. 
Adolescent patients with displaced intra-articular fractures are best treated by open reduction and internal fixation (Figs. 33-19 and 33-20). Before embarking on this surgery, a thorough assessment of the skin needs to be performed. Surgery should be delayed to allow swelling to subside and fracture blisters to resolve. This will decrease some of the wound complications commonly seen after open fixation of adult calcaneal fractures. The key point in performing this surgery is to maintain thick skin flaps, restore joint congruity, use specialized calcaneal plates, and be prepared to bone graft the defect. An outline of the surgical technique is in Table 33-3
Figure 33-20
Intra-articular depressed fracture of the calcaneus in a 13-year-old boy.
 
A: Preoperative sagittal CT shows the depression of the posterior facet into the body of the calcaneus. B: Coronal CT shows the displacement of the fracture fragments. C: Postoperative CT scans are useful at checking the fracture reduction and length and position of the screws. D, E: Postoperative radiographs confirm restoration of the Bohler angle.
A: Preoperative sagittal CT shows the depression of the posterior facet into the body of the calcaneus. B: Coronal CT shows the displacement of the fracture fragments. C: Postoperative CT scans are useful at checking the fracture reduction and length and position of the screws. D, E: Postoperative radiographs confirm restoration of the Bohler angle.
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Figure 33-20
Intra-articular depressed fracture of the calcaneus in a 13-year-old boy.
A: Preoperative sagittal CT shows the depression of the posterior facet into the body of the calcaneus. B: Coronal CT shows the displacement of the fracture fragments. C: Postoperative CT scans are useful at checking the fracture reduction and length and position of the screws. D, E: Postoperative radiographs confirm restoration of the Bohler angle.
A: Preoperative sagittal CT shows the depression of the posterior facet into the body of the calcaneus. B: Coronal CT shows the displacement of the fracture fragments. C: Postoperative CT scans are useful at checking the fracture reduction and length and position of the screws. D, E: Postoperative radiographs confirm restoration of the Bohler angle.
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Table 33-3
Operative Planning for Open Reduction and Internal Fixation of Intra-Articular Calcaneal Fractures in Adolescents
Equipment Radiolucent table
Image Intensifier
K-wires with driver
Lambotte osteotomes
Periosteal elevators
AO modular foot set
Synthes calcaneal plates, 2.7-mm reconstruction plates, H cervical plates
Fixation
Closure
Contour 2.7-mm reconstruction plate or an AO calcaneal plate to the lateral wall of the os calcis and fix to anterior process and the posterior tuber
Maintain posterior facet reduction with two interfragmentary screws angled well inferiorly to avoid the inferiorly curved medial surface of the calcaneal posterior facet and to engage the sustenactulum
Positioning Lateral decubitus on contralateral side
Upper thigh pneumatic tourniquet
Hip flexed 45 degrees, knee flexed 90 degrees
Seattle cushions
Radiolucent operating table
Irrigation
Always drain
Two-layered closure
2-0 Vicryl to the subcutaneous tissues (Interrupted vertical. Place all sutures on clips, tie individually commencing at the apex of the incision)
Incision L-shaped incision (Letournel, Regazzoni, Bernirschke) Curved at apex
Proximal extent 3 cm cephalid to tip of fibula anterior to lateral border of Achilles tendon
Distal extent tip of base of fifth metatarsal
Skin closure with interrupted 3-0 Nylon Donati All-gower sutures (all placed on clips and then tied individually commencing at the apex moving symmetrically to the proximal and distal extent of the wound holding multiple sutures to maintain even tension)
Exposure Blunt dissection with scissors proximally to identify the short saphenous vein and sural nerve
Sharp dissection with no. 15 blade direct to lateral wall of os calcaneus Subperiosteal reflection with scalpel
Sharp dissection and reflection of peroneal tendons and attachment of calcaneofibular ligament dorsally
Keep dorsal to the muscle belly of abductor digiti minimi
Protect peroneal tendons with baby Hoffmann retractors when exposing the anterior process and calcaneocuboid joint
Elevate flap dorsally to expose the posterior facet of the talus and sinus tarsi
Maintain flap anteriorly with K-wires placed into the body and neck of the talus and the fibula
Deflate tourniquet when exposure complete
Dressings
Postoperative
Gelnet dressing
Well padded below knee popliteal joint back slab supporting toes
Elevation on two pillows
IV antibiotics
CT scan to check reduction and exclude screw malposition
Remove drain when drainage is less than 10 mL over an 8-hr period
Review wound for hematoma and skin viability within 48 hrs
Continue splintage, elevation, and restricted mobility non–weight-bearing until sutures removed 14–18 days postsurgery
Reduction Place Schanz pin in inferior aspect of posterior tuber
Reduce fracture by traction on the Schanz pin displacing posterior tuber inferiorly and thence medially
Reflect lateral wall laterally if necessary
Reduce anterior process first, then posterior facet, and finally restore alignment of the os calcis by confirming reduction and alignment of the crucial angle
Thus reduce anterior to posterior, medial to lateral, and dorsal to plantar
Provisional reduction maintained with multiple K-wires
Reduction and alignment confirmed by screening with image intensifier
 

Courtesy of Dr. ACL Campbell, FRACS, Adult Foot and Ankle Surgeon, Auckland City Hospital, New Zealand.

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Complications in Calcaneal Fractures

Wound Complications

Wound dehiscence is the most common complication following open reduction of adult calcaneal fractures.10,72,99,152 
Although reported to occur in up to 25% of adult fractures, the incidence is lower in children. Pickle et al.132 had no wound problems in the six adolescents (age range: 11 to 16 years) they treated with open reduction and internal fixation. All the patients were treated with an extensile lateral approach an average of 10.5 days from the time of injury. The lower incidence in children reflects fewer risk factors in this group when compared to the adult population. Smoking, obesity, and diabetes all contribute to wound problems. 
Wound dehiscence can be decreased by meticulous closure of the incision. In adults, it has been shown that a two-layer closure is preferable to a single layer of sutures.1,55 Wound dehiscence can occur from days to weeks after the surgery. The best initial treatment is immobilization of the foot and ankle to decrease any tension on the wound edges. This is best accomplished in a below-knee cast with a large window cut around the entire incision. This allows space for wound dressing changes and debridements as necessary. Oral antibiotics may be required if superficial infection is also present. Once the wound is healed, gradual mobilization can be reinstated. 
In serious deep wound infections, the patient will require rehospitalization, repeat surgical debridements, and intravenous antibiotics. Often, the use of a suction dressing (Vacuum-Assisted Closure [VAC], KCI, Inc., San Antonio, TX) is advisable in recalcitrant wounds. This VAC device has been shown to be safe and effective by Mooney et al.116 for traumatic wounds in pediatric patients of all ages. Skin closure is usually not possible following such radical debridement. It is very helpful to consult with plastic surgeons early in the course of treatment as the patient often requires tissue transfer to cover the exposed metalware. 

Complex Regional Pain Syndrome

This syndrome, previously known as reflex sympathetic dystrophy (RSD), is a devastating painful disorder that can occur following operative or nonoperative management of a calcaneal fracture or other trauma about the foot. The condition is usually diagnosed when there is severe pain present out of proportion to the severity of the injury following the acute phase of healing. The pain is difficult to control even with oral narcotics. The child will not bear weight or even allow the foot to be examined. Light touch even by water may stimulate an unusual pain response. The foot clinically demonstrates the signs of autonomic dysfunction. There is often a grayish discoloration, cold clammy skin, and decreased hair growth. Through disuse of the foot, the calf will atrophy. If radiographs are taken, the bones of the foot will show patchy disuse osteopenia. 
There is a marked preponderance of lower extremity cases in children compared to adults.177 Sarrail et al.153 reviewed RSD in 24 children and adolescents and found that 73% had foot or ankle injuries. Wilder et al.178 reviewed 70 children (average age, 12.5 years) with RSD and 87% had injuries to the lower limb. Eighty-four percent of their patients were girls, and on average the time from injury to a diagnosis of RSD was 12 months. Despite multidisciplinary treatments, 54% of patients still had persistent symptoms of RSD at 3 years after diagnosis. They emphasized that complex regional pain syndrome (CRPS) has a different disease course in children when compared with adults and needs to be treated appropriately. CRPS occurs most commonly in girls with the incidence peaking at or just before puberty.177 
Most tertiary children's hospitals now have multidisciplinary pain teams that treat CRPS. These comprise a physician (anesthetist or pediatrician), a psychiatrist or clinical psychologist, a physiotherapist, and sometimes an occupational therapist. The child initially undergoes a multidisciplinary assessment that involves both schooling and social circumstances. The physiotherapist carries out a thorough functional assessment. 
The treatment focuses on improving function and therefore extensive physiotherapy is performed initially. Analgesics need to be used to facilitate this and include anti-inflammatory drugs, amitriptyline, and gabapentin. In severe cases, regional blocks occasionally need to be used to control the pain. Children appear to respond to physiotherapy better than adults and they require less medication and invasive procedures. On the other hand, the recurrence rate of CRPS is higher in children; however, they respond well to the reinitiation of treatment.177 

Peroneal Tendonitis/Dislocation

Peroneal tendon pain can occur in both the operated and nonoperated foot. Pain in the peroneal tendons on movement or direct palpation may indicate prominent underlying metalware. Simply removing the offending screw or plate may help. Buckingham et al.20 recommended the routine removal of metalware in their series of adolescent calcaneal fractures as this resulted in resolution of pain in their patients. 
The extensile L-shaped lateral incision has largely prevented the peroneal tendon subluxation that used to occur with the Kocher incision. Care has to be taken at the proximal and distal ends of this incision as the sural nerve can be damaged and a painful neuroma develops. 
In patients with calcaneal fractures treated nonoperatively, a displaced lateral wall can sublux or even dislocate the peroneal tendons. Lateral impingement pain can also result from the fragment coming in direct contact with the fibula. 
Diagnostic local anesthetic injections have been useful in differentiating the cause of pain in the adult foot but its use in children is limited. It should, however, be considered in adolescents who are willing to cooperate. 

Subtalar Dislocation

Subtalar dislocations (peritalar dislocation) occur infrequently and are particularly uncommon in children. They occur most often in young adult males. There are no series published on this condition in children; however, Dimentberg and Rosman44 reported on five talonavicular dislocations. 
A medial dislocation is the most common type (85%) and results from a forced inversion injury to the foot. The talonavicular and talocalcaneal ligaments rupture whereas the calcaneonavicular ligament stays intact. The result is that all the bones of the foot dislocate medially whereas the talus remains in the ankle mortise (Fig. 33-21). The foot looks markedly deformed and the talar head can be palpated laterally. A lateral dislocation is caused by a forced eversion injury and results in a laterally displaced “flatfoot.” 
(Courtesy of Dr. Thomas Lee, MD.)
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Figure 33-21
Posterior view demonstrating cavovarus deformity of the left foot.
(Courtesy of Dr. Thomas Lee, MD.)
(Courtesy of Dr. Thomas Lee, MD.)
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Radiographs are difficult to interpret in this unusual injury (Figs. 33-22 and 33-23). The key is to look for the “empty navicular” where the talar head no longer articulates with it. A CT scan is useful to look for any associated fractures or osteochondral damage; however, it is probably more useful to perform this after a closed reduction to confirm anatomic alignment as well (Fig. 33-24). 
Figure 33-22
Lateral view showing subluxation of the subtalar joint.
 
There is incongruity of the calcaneocuboid joint.
 
(Courtesy of Dr. Thomas Lee, MD.)
There is incongruity of the calcaneocuboid joint.
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Figure 33-22
Lateral view showing subluxation of the subtalar joint.
There is incongruity of the calcaneocuboid joint.
(Courtesy of Dr. Thomas Lee, MD.)
There is incongruity of the calcaneocuboid joint.
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Figure 33-23
(Courtesy of Dr. Thomas Lee, MD.)
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Figure 33-23
AP view demonstrating translation of the transverse tarsal joint.
(Courtesy of Dr. Thomas Lee, MD.)
(Courtesy of Dr. Thomas Lee, MD.)
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Figure 33-24
CT scan axial view shows marked talar head uncoverage (“ball is not in cup”).
 
There is also significant incongruity of the subtalar joint.
 
(Courtesy of Dr. Thomas Lee, MD.)
There is also significant incongruity of the subtalar joint.
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Figure 33-24
CT scan axial view shows marked talar head uncoverage (“ball is not in cup”).
There is also significant incongruity of the subtalar joint.
(Courtesy of Dr. Thomas Lee, MD.)
There is also significant incongruity of the subtalar joint.
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The treatment for a closed subtalar dislocation is a reduction under general anesthesia. The knee should be flexed to relax the tendoachilles and then the deformity accentuated before a reduction is carried out by relocating the deformed foot. Usually, the reduction is stable and anatomic reduction can be confirmed by radiographs and CT scan. The foot is immobilized until the child is comfortable enough to start gentle mobilizations. K-wire stabilization and 6 weeks of immobilization are necessary for unstable dislocations. 
Occasionally, the subtalar dislocation is irreducible by closed means and has to be opened through an anteromedial approach. The bone or soft tissue (often the tibialis posterior tendon) is removed from the joint and the foot reduced. 

Midtarsal Injuries

Fractures and dislocations of the navicular, cuboid, and cuneiforms are rare pediatric foot injuries. The midtarsal region extends from the calcaneocuboid and talonavicular joints (Cho-part's joint) to the metatarsals. It includes the cuboid, navicular, and three cuneiform bones. These bones are interlinked by extremely strong ligaments especially on the plantar surface. The lateral side of the midfoot is more stable than the medial side. The shape of these small bones and strength of their ligaments help maintain the longitudinal and transverse arch of the foot. Disruption of this rigid anatomy therefore requires a large force especially in the cartilaginous bones of a child's foot. Isolated injuries to this area are rare and one needs to look for other associated fractures and dislocations. 
Midtarsal injuries have been classified in adults by Main and Jowett.106 This classification uses five broad categories based on the direction of the force causing the injury and the direction that the fragment is displaced. In parentheses are the percentages of this type of injury in Main and Jowett's106 review of 71 midtarsal injuries. 
Longitudinal stress (40%) 
Medial stress (30%) 
Lateral stress (17%) 
Plantar stress (7%) 
Crush injury (6%) 
Hosking and Hoffman70 reviewed four cases of midtarsal dislocations in children, and this is the only report in the literature of this injury in the pediatric age group. The children had an average age of 9.5 years, and the mechanism of injury was forced supination in three of the patients. They all had associated midtarsal injuries and presented with significant swelling. The key to making the diagnosis, which was delayed in three of the patients, was subluxation or dislocation of the calcaneocuboid joint on the lateral radiograph. The AP view only showed the dislocation in two patients and the oblique view showed it in only one patient. 
The dislocation can usually be reduced closed and held with percutaneous K-wires. If an anatomic reduction is not possible closed, then one must proceed to an open reduction. 
A CT scan should be performed to more clearly define the associated injuries to both the midtarsal bones and rest of the foot. One of the patients in Hosking and Hoffman's70 series had an ipsilateral tibial fracture so associated injuries may be present because of the amount of force required to cause a midfoot disruption in a child. 
Isolated fractures of the mid tarsal bones are rare. The navicular, cuboid, and cuneiforms are usually fractured in association with a Chopart joint (talonavicular and calcaneocuboid) dislocation or a serious Lisfranc injury. The navicular has a number of conditions that can mimic a fracture. Between the ages of 2 and 5 years, the navicular can become avascular (Kohler disease) and cause pain and limp whereas the changes seen on radiograph can look similar to a fracture (Fig. 33-25). Likewise, an accessory navicular may be present that may mimic an avulsion fracture of the navicular tuberosity. These can be differentiated from a fracture as they have smooth, rounded edges and are usually symmetrical when a radiograph is taken of the other foot. Stress fractures of the navicular are also becoming an increasingly common problem as children and adolescents train more aggressively for competitions (see stress fractures of the foot). These stress fractures usually run in the sagittal plane in the middle third of the bone. They are often difficult to see on plain radiographs but are more easily seen on bone scans, CT, and MRI. 
Figure 33-25
Kohler disease of the navicular that can occasionally be confused with a stress fracture.
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Cuboid Fractures

Cuboid fractures were considered a rare foot injury in children and were usually associated with other foot fractures. Recent literature, however, reveals that this fracture may occur more often than we thought and commonly in isolation. Senaran et al.158 reported on 28 consecutive cuboid fractures in preschool children from 1998 to 2004. They found most patients had an avoidance gait pattern and walked on the outside of their foot. They used the “nutcracker” maneuver to help diagnose the fracture. To perform this test, the heel is stabilized by the examiner and the forefoot is abducted. Pain in the lateral aspect of the foot usually confirms a fracture of the cuboid. The diagnosis was then confirmed on initial or subsequent radiographs. A below-knee cast or Cam walker was used for 2 to 3 weeks and all fractures healed without complications. Six patients had ipsilateral fractures in the tibia or foot. Interestingly, eight patients had an associated genetic or systemic abnormality.158 Cuboid fractures have been classified by Weber and Locher176 into distal impaction shear-type fractures (type 1) and burst fractures (type 2). 
Ceroni et al.30 reported on four female teenagers who had equestrian injuries and cuboid fractures. The mechanism of the injury in all cases was a crush to the foot when the horse fell and abduction of the forefoot while it was still in the stirrup. All four cuboid fractures were associated with multiple midfoot fractures and the authors recommend CT scans in all patients in this age group with a cuboid fracture. Two patients required surgical reconstruction. This was performed through a lateral incision from the tip of the fibula to the base of the fifth metatarsal. The interval is then developed between the peroneal tendons and the extensor digitorum brevis. The lateral column length is then restored using an allograft block.30 

Tarsometatarsal Injuries (Lisfranc Fracture-Dislocation)

Tarsometatarsal (TMT) injuries, more commonly referred to as a Lisfranc injury, are more common in adults than they are in children.182 The degree of injury varies from a subtle disruption of the Lisfranc ligament to an extensive fracture-dislocation of the forefoot. Subtle injury can be difficult to diagnose especially if it is not thought about and if left untreated can develop into a painful chronic problem. 
Although mostly described as isolated case reports,17,29,139 a series of 18 TMT joint injuries in children was reported by Wiley180 in 1981, and more recently Buoncristiani et al.22 described an additional eight such injuries in skeletally immature patients. 

Management of Tarsometatarsal Injuries

Mechanism of Injury

TMT injuries are either caused by a direct blow to the foot, usually secondary to a falling object, or indirect, where there is forced plantarflexion of the forefoot combined with a rotational force (Fig. 33-26).179,180 
Figure 33-26
Mechanism of Lisfranc injuries.
 
A: The most common mechanism of injury: Progression from the “tiptoe” position to complete collapse of the TMT joint. B: Plantarflexion injury: Direct heel-to-toe compression produces acute plantar flexion of the TMT joint. C: Backward fall with the forefoot pinned.
A: The most common mechanism of injury: Progression from the “tiptoe” position to complete collapse of the TMT joint. B: Plantarflexion injury: Direct heel-to-toe compression produces acute plantar flexion of the TMT joint. C: Backward fall with the forefoot pinned.
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Figure 33-26
Mechanism of Lisfranc injuries.
A: The most common mechanism of injury: Progression from the “tiptoe” position to complete collapse of the TMT joint. B: Plantarflexion injury: Direct heel-to-toe compression produces acute plantar flexion of the TMT joint. C: Backward fall with the forefoot pinned.
A: The most common mechanism of injury: Progression from the “tiptoe” position to complete collapse of the TMT joint. B: Plantarflexion injury: Direct heel-to-toe compression produces acute plantar flexion of the TMT joint. C: Backward fall with the forefoot pinned.
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Traumatic Impact in the Tiptoe Position
This is an indirect injury where a load is applied to the foot while it is in the tiptoe position. A common example of this injury is jumping to the ground and landing awkwardly on the toes, producing acute plantarflexion at the TMT joint. The result is a TMT joint dislocation and usually a fracture at the base of the second metatarsal. Another example would be by putting the foot down suddenly to reduce speed while riding a bike. 
Heel-to-Toe Compression
In this situation, the patient is in a kneeling position when the impact load strikes the heel. This is an example of a direct compression type injury and usually results in lateral dislocation of the lesser metatarsals and fracture of the base of the second metatarsal. 
The Fixed Forefoot
In this third mechanism, the child falls backward while the forefoot is fixed to the ground by a heavy weight. An example would be a fall backward while the foot was pinned under the wheel of a car. The patient's heel, which is resting on the ground, becomes the fulcrum for the forefoot injury. 
In Wiley's180 review of 18 patients with TMT joint injuries, 10 (56%) were a fall from a height in the “tiptoe” position, three (18%) suffered “heel-to-toe” compression, and four (22%) sustained a fall backward while their forefoot was pinned to the ground. One patient could not recall their mechanism of injury following a motorbike collision. 
Atypical Lisfranc injuries have recently been reported in mini scooter injuries where the foot is planted to break speed. The resulting dorsiflexion, axial loading, and abduction cause the metatarsals to be impacted laterally. The result is a fracture of the base of the second metatarsal and a crush fracture of the cuboid.13 

Signs and Symptoms of Tarsometatarsal Injuries

The diagnosis of these injuries may be difficult, and in adults as many as 20% of injuries are misdiagnosed or overlooked.23,144 Some of the injuries are subtle and will present with minor pain and swelling at the base of the first and second metatarsals. This can be accompanied by ecchymosis on the plantar aspect of the midfoot where the TMT ligaments have been torn (Fig. 33-27).145 This can be confirmed by gently abducting and pronating the forefoot while the hindfoot is held fixed with the other hand,120 though this would be quite painful acutely. Alternatively, the child can be asked to try and perform a single limb heel lift. Pain in the midfoot often implies a TMT joint injury. With significant trauma, there is greater ligamentous injury and the resulting swelling makes it difficult to recognize any bony anatomy. It is important to assess the foot for a compartment syndrome in such circumstances, particularly when the foot has been crushed as part of the mechanism of injury. 
Figure 33-27
Plantar ecchymosis sign.
 
Ecchymosis along the plantar aspect of the midfoot is an important clinical finding in subtle Lisfranc TMT injuries.
 
(From Ross G, Cronin R, Hauzenblas J, et.al. Plantar ecchymosis sign: A clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma. 1996; 10:120.)
Ecchymosis along the plantar aspect of the midfoot is an important clinical finding in subtle Lisfranc TMT injuries.
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Figure 33-27
Plantar ecchymosis sign.
Ecchymosis along the plantar aspect of the midfoot is an important clinical finding in subtle Lisfranc TMT injuries.
(From Ross G, Cronin R, Hauzenblas J, et.al. Plantar ecchymosis sign: A clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma. 1996; 10:120.)
Ecchymosis along the plantar aspect of the midfoot is an important clinical finding in subtle Lisfranc TMT injuries.
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The examiner of any child's foot following trauma needs to have a high level of suspicion for a Lisfranc injury as they are uncommon and difficult to diagnose but have a poor prognosis if left untreated. 

Classification of Tarsometatarsal Injuries

Hardcastle et al.63 developed a classification system based on the one developed by Queno and Kuss137 in 1909 (Fig. 33-28). The classification comprises three types upon which treatment can be based. 
Figure 33-28
Classification of TMT dislocations.
 
L, lateral; M, medial.
 
(From DeLee JC. Fractures and dislocations of the foot. In: Mann RA, Coughlin MJ. Surgery of the Foot and Ankle. 6th ed. St. Louis, MO: Mosby, 1993:1465–1703, with permission; From Hardcastle PH, Reschauer R, Kutscha-Lissberg E, et al. Injuries to the tarsometatarsal joint: Incidence, classification, and treatment. J Bone Joint Surg Br. 1982; 64:349–356.)
L, lateral; M, medial.
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Figure 33-28
Classification of TMT dislocations.
L, lateral; M, medial.
(From DeLee JC. Fractures and dislocations of the foot. In: Mann RA, Coughlin MJ. Surgery of the Foot and Ankle. 6th ed. St. Louis, MO: Mosby, 1993:1465–1703, with permission; From Hardcastle PH, Reschauer R, Kutscha-Lissberg E, et al. Injuries to the tarsometatarsal joint: Incidence, classification, and treatment. J Bone Joint Surg Br. 1982; 64:349–356.)
L, lateral; M, medial.
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Type A: Total incongruity. There is total incongruity of the entire metatarsal joint in a single plane. This can be either coronal or sagittal or combined. 
Type B: Partial incongruity. Only partial incongruity of the joint is seen involving either medial displacement of the first metatarsal or lateral displacement to the four lateral metatarsals. The medial dislocation involves displacement of the first metatarsal from the first cuneiform because of disruption of the Lisfranc ligament or fracture at the base of the metatarsal, which remains attached to the ligament. 
Type C: Divergent pattern. The first metatarsal is displaced medially; any combination of the lateral four metatarsals may be displaced laterally. This is associated with partial or total incongruity. 
This classification does not address the nondisplaced TMT joint injury which can often be overlooked on initial assessment. 
Most children's injuries are type B with minimal displacement, whereas types A and C are rare.63,137,180 

Imaging Evaluation of Tarsometatarsal Injuries

The initial x-ray evaluation includes AP, lateral, and oblique views of the foot. These should be performed weight bearing if possible to stress the joint complex. 
On the AP radiograph, the lateral border of the first metatarsal should be in line with the lateral border of the medial cuneiform and the medial border of the second metatarsal should line up with the medial border of the middle cuneiform. On the oblique radiograph, the medial border of the fourth metatarsal should be in line with the medial border of the cuboid. The examiner looks for a disruption in these lines or diastases of greater than 2 mm between the base of the first and second metatarsals. It is very useful to obtain a weight-bearing radiograph of the opposite foot for comparison (Fig. 33-29). When the radiographs appear normal or minimally displaced and a Lisfranc injury is still suspected, alternative imaging with CT or MRI scans is strongly recommended. The CT scan will often show a small avulsion fracture of the first TMT ligament and will show any other associated fractures in the foot.59,93,105 The MRI scan can accurately visualize a partial tear or complete rupture of the first TMT ligament.134 
Figure 33-29
Weight-bearing radiographs show a subtle Lisfranc injury to the right foot.
 
Weight-bearing radiographs are essential for diagnosis; using the opposite foot for comparison is also helpful.
Weight-bearing radiographs are essential for diagnosis; using the opposite foot for comparison is also helpful.
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Figure 33-29
Weight-bearing radiographs show a subtle Lisfranc injury to the right foot.
Weight-bearing radiographs are essential for diagnosis; using the opposite foot for comparison is also helpful.
Weight-bearing radiographs are essential for diagnosis; using the opposite foot for comparison is also helpful.
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A fracture of the base of the second metatarsal should alert the examiner to the possibility of a TMT dislocation because these injuries can spontaneously reduce. Likewise, a cuboid fracture in combination with a fracture of the base of the second metatarsal is highly suspicious for a Lisfranc injury (Fig. 33-30). 
Figure 33-30
 
A: Second metatarsal is the “keystone” of the locking mechanism. B: Fractures of the cuboid and second metatarsal are pathognomonic signs of disruption of the TMT joints.
A: Second metatarsal is the “keystone” of the locking mechanism. B: Fractures of the cuboid and second metatarsal are pathognomonic signs of disruption of the TMT joints.
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Figure 33-30
A: Second metatarsal is the “keystone” of the locking mechanism. B: Fractures of the cuboid and second metatarsal are pathognomonic signs of disruption of the TMT joints.
A: Second metatarsal is the “keystone” of the locking mechanism. B: Fractures of the cuboid and second metatarsal are pathognomonic signs of disruption of the TMT joints.
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If weight-bearing radiographs are not possible, an abduction stress view can be obtained; however, in children these are difficult to obtain without general anesthesia. Bone scans may be helpful in the diagnosis of this injury when radiographs are normal, although they are not specific for the severity of the injury61 and less useful than MRI or CT. 

Surgical and Applied Anatomy of Tarsometatarsal Injuries

The TMT joint complex comprises the TMT joints, the intertarsal joints, and the intermetatarsal joints. The area represents the apex of the longitudinal and transverse arches of the foot and therefore its structural integrity is crucial in maintaining normal foot function. At the same time, there needs to be enough motion between the joints to allow the transfer of weight evenly from the hindfoot to the forefoot during the walking cycle. This intricate relationship is achieved by the anatomy of the tarsal and metatarsal bones and the arrangement of the ligaments. These midfoot bones are trapezoidal in cross section with their base dorsal. This creates a “Roman arch” effect, which is structurally very strong and helps maintain the transverse arch in the midfoot. The TMT joint complex can be divided up into a medial column and a lateral column. The medial column is a continuation of the talus and navicular and includes the cuneiforms and the medial three metatarsals. The lateral column is a continuation of the calcaneus and comprises the cuboid and the fourth and fifth metatarsals which articulate with it. The medial column has far less mobility than the lateral column, reflecting the increased need for stability on the medial side of the foot to maintain the longitudinal arch. This stability is also provided by the second metatarsal which is “keyed” into the step formed by the cuneiforms. This explains why the second metatarsal is usually fractured when a dislocation occurs across the TMT joint. The ligaments also play a big role in maintaining stability medially and movement laterally. The plantar ligaments are extremely strong compared to the weaker dorsal ligaments. The intermetatarsal ligaments help bind the lateral four metatarsals together but are absent between the first and second metatarsals. Instead, the second metatarsal is connected to the medial cuneiform by Lisfranc ligament (medial interosseous ligament) and an avulsion fracture of this strong ligament can sometimes be seen on radiograph (Fig. 33-31).180 
Figure 33-31
The ligamentous attachments at the TMT joints.
 
There is only a flimsy connection between the bases of the first and second metatarsals (not illustrated). The second metatarsal is recessed and firmly anchored.
 
(From Wiley JJ. The mechanism of tarsometatarsal joint injuries. J Bone Joint Surg Br. 1971; 53:474, with permission.)
There is only a flimsy connection between the bases of the first and second metatarsals (not illustrated). The second metatarsal is recessed and firmly anchored.
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Figure 33-31
The ligamentous attachments at the TMT joints.
There is only a flimsy connection between the bases of the first and second metatarsals (not illustrated). The second metatarsal is recessed and firmly anchored.
(From Wiley JJ. The mechanism of tarsometatarsal joint injuries. J Bone Joint Surg Br. 1971; 53:474, with permission.)
There is only a flimsy connection between the bases of the first and second metatarsals (not illustrated). The second metatarsal is recessed and firmly anchored.
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The dorsalis pedis artery crosses the cuneiforms before it courses between the first and second metatarsals to form the plantar arterial branch. The deep peroneal nerve travels beside the artery but continues on to supply sensation to the first web space. This neurovascular bundle can be damaged by the injury and care must be taken protect these structures when internally fixing these fracture-dislocations. The tibialis anterior tendon inserts into the base of the first metatarsal and medial cuneiform. The peroneous longus tendon inserts into the plantar surface of the base of the first metatarsal and acts as a flexor of this bone. Together, these two muscles and their tendon insertions give added stability to the medial column of the foot. 

Treatment Options for Tarsometatarsal Injuries

The key to treating these TMT injuries is to recognize the extent of the injury and the degree of instability. Once this is established, the appropriate treatment can be instigated. In all these injuries, a weight-bearing radiograph at the end of treatment should confirm anatomic congruency of the TMT joint complex. 
When a clinical diagnosis of a “sprain” is made, the foot should be immobilized in a below-knee cast for 6 weeks. The MRI scan may confirm a partial tear of the first TMT ligament, but regardless this painful injury takes time to heal and immobilization is the best treatment. In young adult athletes, these injuries can take a long time to heal.114 When there is complete intraligamentous rupture or an avulsion fracture of the first TMT ligament and no displacement of the joint surfaces, a below-knee cast for 6 weeks is advised. Whether the patient should be weight bearing or not for the entire 6 weeks is debatable. Wiley180 treated the children with undisplaced TMT joint injuries in his series with 3 to 4 weeks of immobilization with good results. 
Displaced fractures of the TMT joint need to be anatomically reduced and stabilized. Meyerson et al.120 found that following a closed reduction greater than 2-mm displacement or a talometatarsal angle of greater than 15 degrees would lead to a poor outcome. A closed reduction is best carried out under a general anesthetic when the acute swelling has subsided. “Finger traps” can help with traction on the toes while the displaced metatarsals are manipulated into place. If a stable anatomic reduction is achieved clinically and this is confirmed radiologically, a well-molded below-knee cast can be applied. Radiographs in the cast should also be taken while the patient is under anesthesia to confirm the reduction has been held. The non–weight-bearing cast is worn for 6 weeks with radiographs taken at 1 and 2 weeks to confirm the fracture-dislocation has remained reduced. 
If the closed reduction results in an anatomic reduction but the fragments are unstable, then K-wire fixation is used to hold the alignment of the foot. Stout 0.062-in smooth K-wires should be used. Their placement is determined by the direction of displacement of the metatarsals and how many are involved. The most important wire is used to stabilize the second metatarsal to the medial cuneiform. Additional wires can be used between the first metatarsal and the medial cuneiform, and between the lesser metatarsals and their corresponding tarsal bones. A useful wire can also be passed from the first metatarsal to the second metatarsal. These K-wires are left bent over outside of the skin and are removed at 4 to 6 weeks when mobilization is initiated if the radiographs confirm healing. Again, full weight-bearing radiographs are necessary when comfort allows and after K-wire removal to confirm adequate stability. Wiley180 used K-wire fixation in four patients. He removed these at 3 to 4 weeks and the alignment was maintained in all the children. There were some joint incongruities from intra-articular fractures that were not surgically addressed but they did not seem to alter the clinical outcome. 
Open reduction and internal fixation is rarely required for these fractures. It is indicated if there is greater than 1 to 2 mm of joint displacement. The impediments to reduction are 
  1.  
    Tibialis anterior tendon
  2.  
    Interposition of fracture fragments in the second metatarsal-middle cuneiform joint.
  3.  
    Incongruity of the first metatarsal-medial cuneiform articulation15
The entire TMT joint complex can be visualized using two longitudinal incisions.155 One is made over the first second metatarsal space and the second in line with the fourth metatarsal. The medial incision allows identification of the neurovascular bundle and access to the first and second metatarsal cuneiform joints. The lateral incision allows the joints of the lesser TMT joints to be clearly seen. After anatomic reduction, the joints can held reduced with K-wires or internally fixed with 3.5-mm screws (Fig. 33-32). Small chondral defects can be excised and larger ones repaired. Care must be taken to avoid the proximal growth plate of the first metatarsal if screw fixation is used. The adult literature supports the use of K-wire stabilization of the lesser metatarsals rather than screws as it is important to maintain the mobility in these joints long-term.47 Debate exists as to when to remove the screws across these weight-bearing joints. In a child, it would seem appropriate to remove the screws once pain free weight bearing is established as the ligaments and bone would have healed by this stage and further displacement is unlikely. Leaving the screws in for longer than 3 months risks damage to the joint and possible screw breakage. 
Figure 33-32
Sequence of repair for reduction and stabilization of TMT fracture-dislocations.
 
A: Stabilization of the first ray by alignment of the metatarsal, medial cuneiform, and navicular. B: Stabilization of the Lisfranc ligament by accurate alignment of the second metatarsal to the medial cuneiform, as well as the medial and middle cuneiforms. C: Alignment and stabilization of the third through fifth metatarsal rays. Cannulated screws can be used instead of pins as needed for stability and compression.
 
(From Trevino SG, Kodros S. Controversies in tarsometatarsal injuries. Orthop Clin North Am. 1995; 26:229–238, with permission.)
A: Stabilization of the first ray by alignment of the metatarsal, medial cuneiform, and navicular. B: Stabilization of the Lisfranc ligament by accurate alignment of the second metatarsal to the medial cuneiform, as well as the medial and middle cuneiforms. C: Alignment and stabilization of the third through fifth metatarsal rays. Cannulated screws can be used instead of pins as needed for stability and compression.
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Figure 33-32
Sequence of repair for reduction and stabilization of TMT fracture-dislocations.
A: Stabilization of the first ray by alignment of the metatarsal, medial cuneiform, and navicular. B: Stabilization of the Lisfranc ligament by accurate alignment of the second metatarsal to the medial cuneiform, as well as the medial and middle cuneiforms. C: Alignment and stabilization of the third through fifth metatarsal rays. Cannulated screws can be used instead of pins as needed for stability and compression.
(From Trevino SG, Kodros S. Controversies in tarsometatarsal injuries. Orthop Clin North Am. 1995; 26:229–238, with permission.)
A: Stabilization of the first ray by alignment of the metatarsal, medial cuneiform, and navicular. B: Stabilization of the Lisfranc ligament by accurate alignment of the second metatarsal to the medial cuneiform, as well as the medial and middle cuneiforms. C: Alignment and stabilization of the third through fifth metatarsal rays. Cannulated screws can be used instead of pins as needed for stability and compression.
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Author's Preferred Treatment

The majority of children have a type B TMT dislocation with minimal displacement. The most important step in treating these patients is confirming this diagnosis accurately and treating them until the joint is stable. If any doubt in the diagnosis exists, the author takes a comparable radiograph of the other foot. The author routinely orders a CT scan of the midfoot to assess the extent of the injury and to look for any associated injuries. 
An injury with less than 1 to 2 mm of displacement is treated in a below-knee non–weight-bearing cast for 6 weeks. Weight-bearing radiographs are taken on removal of the cast to assess stability. These radiographs are repeated 6 weeks later once pain free weight bearing is achieved to confirm no further displacement. 
If the TMT joint is displaced greater than 1 to 2 mm, then the author performs a closed reduction and routinely uses percutaneous K-wire fixation with image intensifier control. Although these injuries can be held with cast immobilization, the author prefers the assurance of knowing the fracture-dislocation is being held internally. This is especially useful when the foot is very swollen and repeated assessments are necessary to rule out compartment syndrome. In the rare circumstance of an open reduction, the author prefers to use temporary screw fixation. These injuries are usually far more severe than a type B dislocation and the TMT joints are very unstable. After open reduction through two longitudinal incisions, 3.5-mm cortical screws are used to hold the reduction taking care to avoid the proximal growth plate of the first metatarsal. These screws are removed usually within a month of cast removal. 
Regardless of the way the fracture-dislocation is treated, all these patients must be investigated at outpatient appointments with weight-bearing radiographs to confirm that the ligaments have healed and there is no residual subluxation. 

Complications of Tarsometatarsal Injuries

The most common complication following TMT injuries is posttraumatic arthritis. This can often occur because the injury is “missed” and the subtle fracture-dislocation remains displaced. Another cause is a loss of reduction. Lastly, the trauma itself can damage the articular cartilage and, despite an anatomic reduction, arthritis can develop. 
Hardcastle et al.63 showed that the outcomes are poor if the diagnosis is made more than 6 weeks after the injury. Curtis et al.38 found similar results in athletes who had a delayed diagnosis. This reinforces the importance of making the diagnosis early and treating appropriately. 
Posttraumatic arthritis is known to occur after TMT injuries in a significant percentage of adults, and this is best prevented by achieving an anatomic reduction.120 Wiss et al.183 performed gait analysis on 11 adult patients with TMT joint fracture-dislocations and found that no patient walked normally after a displaced TMT fracture-dislocation. In Wiley's180 series of 18 children, none of whom required open reduction, 14 patients were asymptomatic 3 to 8 months postinjury. Four patients had persisting pain of minor severity at the TMT joint 1 year following injury. Two of these patients had residual angulation at the injury site. One patient had an unrecognized dislocation and had not been treated; the other had not had an anatomic reduction because of extensive intra-articular fractures. One 16-year-old patient developed asymptomatic osteonecrosis of the second metatarsal head, and this was attributed to a possible compromise of the blood supply at the time of injury as the nutrient vessel to this area is a terminal branch of the dorsalis pedis. Buoncristiani et al.22 followed eight children (3 to 10 years old) with indirect TMT joint injuries treated in a below-knee cast and found seven were asymptomatic at an average follow-up of 32 months. The one patient who had midfoot pain had developed early degenerative changes on the plain radiographs. 
The treatment for painful TMT joint arthritis is arthrodesis if conservative care has failed. In children this would be extremely unusual. An arthrodesis often requires extensive soft tissue release to allow anatomic reduction of the joint and then rigid internal fixation with screws. It is important not to fuse the lesser TMT joints as mobility here is important for the long-term function of the foot. 

Metatarsal Fractures

Fractures of the metatarsals are the most common fractures of the foot in children, accounting for up to 60% of all pediatric foot fractures.37,38,125,161 Owen et al.125 showed in an epidemiologic study that in children younger than 5 years of age, 73% of metatarsal fractures involve the first metatarsal, whereas in children older than 10 years these fractures accounted for only 12%. The most common metatarsal fracture for all 60 patients was a fracture of the fifth metatarsal (45%). Six and a half percent of all the fractures and 20% of first metatarsal fractures were not diagnosed at the initial consultation in their series. 

Management of Metatarsal Fractures

Mechanism of Injury

Metatarsal fractures result from either a direct or indirect injury. Direct injuries are usually caused by a heavy load falling on the forefoot or a crush injury (i.e., the foot being run over by a car). The metatarsals can be fractured anywhere along the shaft but typically they are fractured middiaphyseal. Indirect injuries are caused by axial loading or torsional forces and usually produce spiral fractures of the proximal shaft or neck of the metatarsal. Singer et al.161 found in a recent study of 125 children that if the patient was less than 5 years of age, the primary mechanism was a fall from a height and this usually occurred within the home. In children older than 5 years of age, most injuries occurred while playing sport and occurred on a level playing surface. 

Signs and Symptoms of Metatarsal Fractures

Direct injuries can result in significant swelling and bruising of the foot because of the extensive soft tissue injury as well as the metatarsal fractures. Careful evaluation of a compartment syndrome should take place. An indirect injury usually has more subtle clinical findings and careful palpation will usually locate the site of the fracture. The infant with a metatarsal fracture due to an unwitnessed injury may present with minimal swelling but an inability to bear weight. 

Associated Injuries with Metatarsal Fractures

Proximal fractures of the metatarsals are often associated with tarsal fractures or fracture-dislocations, and this should be evaluated further with a CT scan. A fracture of the second metatarsal and a cuboid fracture are highly suggestive of a TMT joint dislocation rather than two isolated fractures. Singer et al.161 found that the first and fifth metatarsals were usually isolated fractures, whereas if multiple metatarsals were fractured, they were always contiguous bones and involved the second, third, and fourth metatarsals. 

Imaging Evaluation of Metatarsal Fractures

Radiographic evaluation should consist of AP, lateral, and oblique views of the whole foot. The AP view often gives the impression that the fractures are minimally displaced; however, the lateral view often shows significant plantar or dorsal displacement. Other associated fractures may be apparent on the plain radiographs and if any doubt exists, especially if there has been significant trauma, a CT scan is advised. In a young child, if a fractured metatarsal is suspected but not visible on the initial radiograph, a repeat film can be taken 10 to 14 days later that often shows the fracture line or early callus. 

Classification of Metatarsal Fractures

No classification system exists for fractures of the first through fourth metatarsals. Fractures of the fifth metatarsal are classified according to their location along the bone (see section on treatment of the fifth metatarsal below). 

Current Treatment Options for Metatarsal Fractures

The majority of metatarsal fractures in children can be treated nonoperatively in a below-knee cast. The child with a displaced fracture often needs to be admitted overnight in the hospital for pain relief and observation for compartment syndrome. The initial treatment includes elevation for the severe swelling that coexists with the fractures. Immobilization may be performed by a well-padded cast, splint, or a Cam walker. Once the swelling subsides, a molded below-knee cast can be applied. Weight bearing can be initiated when pain allows, and the cast can usually be removed at 3 to 4 weeks at which time the patient can be transitioned to a Cam walker. 
The amount of angulation or shortening to accept in a child has not been determined. A closed reduction of the central metatarsals is indicated in an adult if there is more than 10 degrees angulation in the dorsal plain or more than 4 mm of translation in any plane.159 These criteria may be appropriate for an older adolescent whose growth plates had closed but are far too stringent for a skeletally immature patient. If there is severe dorsal angulation of greater than 20 degrees or “tenting” of the skin and shortening of greater than 5 mm, then a closed reduction is indicated. This is best performed under a general anesthetic when the swelling has subsided. Finger traps have been advocated by some surgeons to help with traction while the metatarsals are manipulated. A below-knee cast can be molded with pressure applied to both the dorsal and plantar aspects of the foot; however, the need to allow for swelling suggests implants should be used to hold fracture reduction rather than molding of a cast. To accommodate the swelling and to relax the plantar fascia, the cast can be applied with the ankle in slight equinus and when it is changed 2 weeks later, it can be bought up into a neutral position. 
Fractures of the first metatarsal need careful attention especially in the adolescent patient. The first ray is important in maintaining the longitudinal arch of the foot and the position of the first metatarsal head in relation to the lesser metatarsal heads is also vitally important. A closed reduction should be considered if there is greater than 10 degrees of dorsal angulation or any shortening of the first metatarsal. It is unusual to have angulation in the coronal plane if the second metatarsal is intact and transverse displacement is acceptable if there is no shortening. 
If a closed reduction is performed, K-wire fixation is at times required. Intramedullary placement is difficult to perform without opening the fracture and passing the wires under direct vision. Small, dorsal, longitudinal incisions are made over the fracture sites and dissection is carefully carried out down to the fracture. The wire is drilled down the distal fragment to exit the plantar skin. The wire is then withdrawn enough to allow the fracture to be reduced, then the wire is driven retrograde across the fracture site and sufficiently far enough into the proximal fragment. Another technique is to hold fracture reduction by placing K-wires across the fractured metatarsal to an adjacent nonfractured metatarsal both proximal and distal to the fracture. The K-wire is cut and bent outside the skin to facilitate removal in the outpatient clinic in 3 to 4 weeks when the patient can be placed in a walking cast for 2 further weeks to allow fracture consolidation. This is the same technique that can be used on the rare occurrence an open reduction is required for an irreducible fracture or when the fracture is open. 

Fractures of the Base of the Fifth Metatarsal

Fractures of the fifth metatarsal are the most common metatarsal fracture in children, comprising almost 50% of all metatarsal fractures in some series.68,125,138,161 Traditionally, treatment has been based on treatment algorithms from the adult literature. Fractures of the base of the fifth metatarsal are discussed separately from the other metatarsal fractures as the anatomy, fracture patterns, and treatment indications are quite different. 

Surgical Anatomy

The fifth metatarsal has a number of tendinous insertions at its base. The peroneus brevis tendon inserts on the dorsal aspect of the tubercle and the peroneus tertius attaches on the dorsal aspect of the fifth metatarsal at the metaphyseal–diaphyseal junction. The strong plantar aponeurosis inserts into the plantar aspect of the tubercle at the base. 
The nutrient artery enters the shaft of the fifth metatarsal medially at the junction of the proximal and middle thirds of the diaphysis and sends intraosseous branches proximally and distally (Fig. 33-33). Proximally within the bone are the metaphyseal vessels, and the small area where these overlap with the proximal vessels from the nutrient artery is known as the watershed area. This region corresponds with Zone 2 and fractures in this area have a higher rate delayed of union or nonunion in those close to maturity. The proximal apophyseal growth center of the fifth metatarsal can often be confused for a fracture. The apophyseal growth center (os vesalianum) has a longitudinal orientation roughly parallel to the metarsal shaft and generally has smooth contours which distinguish it from a transverse orientated fracture (Fig. 33-34). The os vesalianum usually appears by the age of 9 years and unites with the metaphysis between the ages of 12 and 15 years (Fig. 33-35). 
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Figure 33-33
Blood supply of the proximal fifth metatarsal.
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Figure 33-34
 
A: A normal apophysis of the base of the fifth metatarsal at the attachment of the peroneus brevis (arrow) in a 10-year-old girl. B: The thicker arrow points to the normal apophysis, which is roughly parallel to the metatarsal. The thinner arrow points toward a fracture, which is roughly perpendicular to metatarsal.
A: A normal apophysis of the base of the fifth metatarsal at the attachment of the peroneus brevis (arrow) in a 10-year-old girl. B: The thicker arrow points to the normal apophysis, which is roughly parallel to the metatarsal. The thinner arrow points toward a fracture, which is roughly perpendicular to metatarsal.
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Figure 33-34
A: A normal apophysis of the base of the fifth metatarsal at the attachment of the peroneus brevis (arrow) in a 10-year-old girl. B: The thicker arrow points to the normal apophysis, which is roughly parallel to the metatarsal. The thinner arrow points toward a fracture, which is roughly perpendicular to metatarsal.
A: A normal apophysis of the base of the fifth metatarsal at the attachment of the peroneus brevis (arrow) in a 10-year-old girl. B: The thicker arrow points to the normal apophysis, which is roughly parallel to the metatarsal. The thinner arrow points toward a fracture, which is roughly perpendicular to metatarsal.
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Figure 33-35
This 11-year-old girl had pain in her proximal fifth metatarsal after twisting her foot during physical education at school.
 
No fracture was visible; however, her secondary ossification center is clearly seen running parallel to the shaft of the metatarsal.
No fracture was visible; however, her secondary ossification center is clearly seen running parallel to the shaft of the metatarsal.
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Figure 33-35
This 11-year-old girl had pain in her proximal fifth metatarsal after twisting her foot during physical education at school.
No fracture was visible; however, her secondary ossification center is clearly seen running parallel to the shaft of the metatarsal.
No fracture was visible; however, her secondary ossification center is clearly seen running parallel to the shaft of the metatarsal.
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Classification

Fractures of the base of the fifth metatarsal are classified according to their location into one of three zones (Fig. 33-36). Zone 1 is the cancellous tuberosity, which includes the insertion of the peroneus brevis tendon, the abductor digiti minimi tendon, and the strong calcaneometatarsal ligament of the plantar fascia. Zone 2 is the distal aspect of the tuberosity where the dorsal and plantar ligamentous attachments to the fourth metatarsal attach to insert. Zone 3 is the region that extends from distal to these ligamentous attachments to approximately the middiaphyseal area. Herrera-Soto et al.68 tried to define this classification further in their recent review of 103 children with fifth metatarsal fractures. They define a type I fracture as a “fleck” injury. A type II fracture is a tubercle fracture with an intra-articular extension, and a type III fracture represents a fracture at the proximal diaphyseal region (Jones fracture). 
Figure 33-36
The three anatomic zones of the proximal fifth metatarsal.
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Treatment

Traditionally, treatment has been based on treatment algorithms from the adult literature. Treatment of fractures of the base of the fifth metatarsal in children is determined primarily by the zone of the fracture, and somewhat by age. 
Zone 1 Fractures
These injuries are usually traction-type injuries where the force from the peroneus brevis tendon and the pull from the plantar aponeurosis result in an avulsion fracture of the fifth metatarsal. Some authors suggest the fracture may be an avulsion at the origin of abductor digiti minimi.83,143 Treatment involves a weight-bearing below-knee walking cast for 3 to 6 weeks. Herrera-Soto et al.68 found all 30 of their children with an extra-articular type 1 fracture treated in this way healed with good outcomes even if they were displaced. Undisplaced intra-articular tuberosity fractures also healed well in the series68; however, displaced (>2 mm) intra-articular fractures took significantly longer to heal. Radiographic union usually lags behind resolution of symptoms, and most patients are asymptomatic after 3 weeks.68 This delay in radiographic union should not prevent the child returning to full activities as symptoms allow. Treatment with a Cam walker rather than a cast may be considered. Nonunion can occur but usually is asymptomatic.39 Although operative fixation of acute tuberosity avulsions rarely is indicated, it may be considered for significant displacement (more than 3 mm) in young active patients who want to return to competitive sports sooner (Fig. 33-37). 
Figure 33-37
 
A: A 12-year-old boy who is a professional snowboarder with a displaced, intra-articular fifth metatarsal fracture. B: This was reduced open and internally fixed, which allowed him to compete 8 weeks after surgery.
A: A 12-year-old boy who is a professional snowboarder with a displaced, intra-articular fifth metatarsal fracture. B: This was reduced open and internally fixed, which allowed him to compete 8 weeks after surgery.
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Figure 33-37
A: A 12-year-old boy who is a professional snowboarder with a displaced, intra-articular fifth metatarsal fracture. B: This was reduced open and internally fixed, which allowed him to compete 8 weeks after surgery.
A: A 12-year-old boy who is a professional snowboarder with a displaced, intra-articular fifth metatarsal fracture. B: This was reduced open and internally fixed, which allowed him to compete 8 weeks after surgery.
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Zone 2 Fractures
Zone 2 fractures include the Jones fracture. This is an oblique fracture in the watershed area at the proximal metaphyseal–diaphyseal junction. It typically occurs in adolescents and is thought to be caused by a combination of vertical loading and coronal shear forces at the junction of the stable proximal metaphysis and the mobile fifth metatarsal diaphysis. Frequently, these fractures are stress injuries, usually involving athletic adolescents who present with a traumatic event superimposed on prior symptoms.24,36,81,82,92,148 A good history is important to determine the duration of symptoms because chronic injuries are unlikely to respond to nonoperative treatment as well as acute fractures. Critical radiographic analysis will also show cortical sclerosis in the chronic injuries. 
Acute injuries should be immobilized in a short-leg non–weight-bearing cast for 6 weeks. Serial radiographs and examinations are necessary to determine adequate healing, and further non–weight-bearing immobilization may be necessary if the fracture has not healed clinically and radiographically at 6 weeks. With evidence of callus and diminished tenderness, the patient can begin protected weight bearing in a hard-soled shoe or Cam walker for an additional 4 weeks. This protected weight bearing may prevent refracture.68 In a series of adults, Torg et al.171 reported successful healing in 14 of 15 patients treated with non–weight-bearing casts, whereas only 4 of 10 who were allowed to bear weight went on to union. Herrera-Soto et al.68 reported 15 fractures in this zone (type III) and found a higher rate of delayed union and refracture in patients over 13 years of age. They feel that primary internal fixation in this age group may be indicated. 
For chronic fractures in zone 2 where the symptoms have been present for more than 3 months, nonoperative management is unlikely to be successful. Nonetheless, it is worthwhile initially trying 6 weeks immobilization in a non–weight-bearing below-knee cast or brace. If this fails, then internal fixation is required. A useful technique is to insert an intramedullary screw from proximal to distal which stabilizes the fracture site. A 4-mm cancellous screw is usually sufficient; however, in an older adolescent with a capacious intramedullary canal, a 6.5-mm cancellous screw may give better fixation and compression. It is beneficial to curette the intramedullary canal and use cancellous bone graft, which can be harvested from the distal tibia (Fig. 33-38).94 
Figure 33-38
This 15-year-old high-level basketball player sustained a proximal fifth metatarsal fracture at the metaphyseal–diaphyseal junction.
 
The patient chose intramedullary screw fixation because of his desire to return to sport as promptly as possible, lessen his time in immobilization, and lessen the risk of delayed union or nonunion. A: Radiograph at time of injury. B, C: After intramedullary screw fixation.
 
(Courtesy of Keith S. Hechtman, MD.)
The patient chose intramedullary screw fixation because of his desire to return to sport as promptly as possible, lessen his time in immobilization, and lessen the risk of delayed union or nonunion. A: Radiograph at time of injury. B, C: After intramedullary screw fixation.
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Figure 33-38
This 15-year-old high-level basketball player sustained a proximal fifth metatarsal fracture at the metaphyseal–diaphyseal junction.
The patient chose intramedullary screw fixation because of his desire to return to sport as promptly as possible, lessen his time in immobilization, and lessen the risk of delayed union or nonunion. A: Radiograph at time of injury. B, C: After intramedullary screw fixation.
(Courtesy of Keith S. Hechtman, MD.)
The patient chose intramedullary screw fixation because of his desire to return to sport as promptly as possible, lessen his time in immobilization, and lessen the risk of delayed union or nonunion. A: Radiograph at time of injury. B, C: After intramedullary screw fixation.
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Zone 3 Fractures
Fractures in zone 3 are usually stress fractures in active athletes. Acute fractures in this zone with no prodromal symptoms can be treated with a below-knee non–weight-bearing cast for 6 weeks followed by protective weight bearing for 4 weeks. In the more common scenario, where the patient complains of pain with activity for several months, this period of casting is often unsuccessful but worth trying in the first instance. The stress fracture may heal clinically with 6 to 12 weeks of immobilization and radiographs will confirm the reconstitution of the medullary canal and less sclerosis at the fracture site. Electrical stimulation may be used. If the chronic stress fracture does not heal, then surgical intervention is required similar to that in a zone 2 fracture outlined above. Some authors advocate a more aggressive open debridement of the fracture site with bone grafting before introducing the intramedullary screw.137,171 

Complications

The most common complication of treating fractures of the proximal fifth metatarsal is a painful nonunion. This is more common in zone 2 and zone 3 fractures and rarely occurs in zone 1. Herrera-Soto et al.68 concluded that pediatric fifth metatarsal fractures behaved similarly to adult fractures and can be treated the same. If a symptomatic nonunion develops and surgery is indicated, a thorough debridement of the sclerotic medullary canal should be undertaken, the area bone grafted, and strong compression achieved across the fracture site with the appropriate size intramedullary screw.58 

Author's Preferred Treatment

Lesser metatarsal fractures are usually treated nonoperatively in a below-knee walking cast for 3 to 4 weeks. Grossly displaced fractures in older children with greater than 20 degrees of dorsiflexion or more than 5 mm of shortening are treated with closed reduction under a general anesthetic and a well-molded below-knee cast. If the reduction is difficult, percutaneous K-wires are used for supplementary support. Except for open injuries, rarely is an open reduction through longitudinal incisions required. 
A shortened or rotated distal fracture of the first or fifth metatarsal is treated by closed reduction and crossed K-wire fixation. 
Proximal fifth metatarsal fractures present a more challenging problem. Treatment is determined by the location of the fracture in the bone and the age and activity level of the child. If inadequately treated, they can go on to a delayed or nonunion. For zone 1 fractures that are intra-articular and displaced greater than 3 to 4 mm, the author recommends open reduction and internal fixation with a 3.5-mm partially threaded screw, especially if the child is involved in competitive sports, as this will allow an earlier return to sport. This fixation is perpendicular to the fracture line and gives maximum compression. The screw is inserted through a direct lateral approach. Care must be taken to identify and protect the sural nerve which is usually directly under the incision. The peroneous brevis and peroneous tertius tendons are identified, and the area between them at their insertion into the proximal fifth metatarsal is a good starting point for the screw. The author prefers to insert a bicortical cannulated compression screw, and this can either be a partially threaded cancellous screw or a fully threaded cortical screw. The fracture can usually be indirectly reduced and held with a K-wire. In difficult fracture patterns or in delayed presentations, the fracture line needs to be clearly seen and can be held reduced with a compression clamp. 
In zone 2 fractures (Jones fracture), the author treats the patient in a non–weight-bearing cast for 6 weeks and then protected weight bearing in a moon-boot for 2 to 4 weeks as comfort allows. The recent study by Herrera-Soto et al.68 showing poor results with this treatment in patients over 13 years old may make primary internal fixation a better option in this age group. 
Chronic fractures or nonunions should be treated with internal fixation. The author prefers to perform this with an intramedullary screw which compresses the fracture site. If a 3.5-mm cancellous screw does not achieve adequate internal fixation in the medullary canal, the author increases the diameter of the screw until it does. Often, a 4-mm malleolar screw is used. A small curette is used down the medullary canal to help remove the sclerotic bone. If this is not possible, the fracture site should be debrided open with small osteotomes and rongeurs. Bone grafting is required for these chronic injuries and can be harvested from the distal tibia. 
Grossly displaced shaft and distal metaphyseal fractures are treated with closed reduction and cast immobilization for 6 weeks. Occasionally, crossed K-wires are required. 

Phalangeal Fractures

Phalangeal fractures are common in children and may account for up to 18% of pediatric foot fractures.37 Most toe injuries are treated by primary care physicians, so orthopedic surgeons only see the more severe fractures. Phalangeal fractures are the result of direct trauma by a falling object or indirect trauma when the unprotected toe is struck against a hard object (so-called “stubbing”). The proximal phalanx is more commonly injured than the distal phalanges. 
The toes must be closely examined for any break in the skin especially at the base of the nail as this may indicate an open Salter–Harris fracture with an associated nail bed injury. These compound injuries require a thorough debridement, repair of the nail bed, and often a single longitudinal K-wire to stabilize the fracture (Fig. 33-39). IV antibiotics should be given for 24 hours followed by 7 days of oral antibiotics. Nail bed injuries should be repaired as meticulously as in the hand. A poorly repaired germinal matrix will cause abnormal nail growth and difficulty with shoe wear long after the fracture has healed. 
Figure 33-39
 
A: This 7-year-old boy “stubbed” his toe barefoot on his bike and sustained an open fracture of the tuft of the distal phalanx and associated laceration of the germinal matrix. B: Preoperative radiograph shows the small tuft fracture. C, D: The wound was thoroughly debrided, germinal matrix repaired, and a K-wire passed across the fracture to hold the fragment and soft tissues reduced.
A: This 7-year-old boy “stubbed” his toe barefoot on his bike and sustained an open fracture of the tuft of the distal phalanx and associated laceration of the germinal matrix. B: Preoperative radiograph shows the small tuft fracture. C, D: The wound was thoroughly debrided, germinal matrix repaired, and a K-wire passed across the fracture to hold the fragment and soft tissues reduced.
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A: This 7-year-old boy “stubbed” his toe barefoot on his bike and sustained an open fracture of the tuft of the distal phalanx and associated laceration of the germinal matrix. B: Preoperative radiograph shows the small tuft fracture. C, D: The wound was thoroughly debrided, germinal matrix repaired, and a K-wire passed across the fracture to hold the fragment and soft tissues reduced.
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Figure 33-39
A: This 7-year-old boy “stubbed” his toe barefoot on his bike and sustained an open fracture of the tuft of the distal phalanx and associated laceration of the germinal matrix. B: Preoperative radiograph shows the small tuft fracture. C, D: The wound was thoroughly debrided, germinal matrix repaired, and a K-wire passed across the fracture to hold the fragment and soft tissues reduced.
A: This 7-year-old boy “stubbed” his toe barefoot on his bike and sustained an open fracture of the tuft of the distal phalanx and associated laceration of the germinal matrix. B: Preoperative radiograph shows the small tuft fracture. C, D: The wound was thoroughly debrided, germinal matrix repaired, and a K-wire passed across the fracture to hold the fragment and soft tissues reduced.
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A: This 7-year-old boy “stubbed” his toe barefoot on his bike and sustained an open fracture of the tuft of the distal phalanx and associated laceration of the germinal matrix. B: Preoperative radiograph shows the small tuft fracture. C, D: The wound was thoroughly debrided, germinal matrix repaired, and a K-wire passed across the fracture to hold the fragment and soft tissues reduced.
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Closed fractures of the phalanges rarely require reduction and can be treated by simple “buddy strapping” to the adjacent toe and immediate mobilization. A hard-soled shoe or Cam walker may help; however, crowding in the toe box may make this more uncomfortable than bare feet. An angulated toe in both the coronal and sagittal plane usually remodels well if the growth plate is still open. In adolescents, a percutaneous K-wire can be used if the fracture is grossly unstable and unable to be held reduced by strapping alone. This wire can be passed longitudinally through the tip of the affected toe or obliquely across the fracture. It is extremely unusual to get any growth disturbance from a smooth wire crossing the growth plate in the phalanges. These pins can be removed in clinic 4 to 6 weeks later. Laterally angulated fractures of the little toe sometimes need closed reduction before strapping them to the fourth toe. 

Nail Bed Injuries

Nail bed injuries to the toes should be treated similarly to those in the fingers (see Chapter 8). Failure to address the nail bed adequately can lead to abnormal nail growth and problems with shoewear (Table 33-4; Fig. 33-40). 
 
Table 33-4
Repair of Nail Bed Injury
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Table 33-4
Repair of Nail Bed Injury
  1.  
    Use sterile tourniquet (glove)
  2.  
    Remove the nail
  3.  
    Thoroughly clean the nail bed gently
  4.  
    Repair the nail bed with fine absorbable suture (6-0 or 7-0 rapid dissolving suture)
  5.  
    Replace the nail to protect the eponychial fold with skin glue
  6.  
    Cover with sterile dressing and tape
  7.  
    Leave dressing intact for 10 days then debulk dressing
X
Figure 33-40
Second toe distal phalangeal fracture with nail bed split.
 
A: Before repair of nail bed. B: Nail bed repaired with absorbable suture and nail glued back.
A: Before repair of nail bed. B: Nail bed repaired with absorbable suture and nail glued back.
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Figure 33-40
Second toe distal phalangeal fracture with nail bed split.
A: Before repair of nail bed. B: Nail bed repaired with absorbable suture and nail glued back.
A: Before repair of nail bed. B: Nail bed repaired with absorbable suture and nail glued back.
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Great Toe Fractures

The great toe is injured by the same mechanisms as the lesser toes. Standard AP and lateral radiographs are taken; however, it is useful to have the patient hold the lesser toes dorsiflexed with a small towel to maximize visualization on the lateral view. Intra-articular fractures of the proximal phalanx are more common in the great toe than the other toes. They are usually Salter–Harris type III or IV fractures (Fig. 33-41). Most of these fractures can be managed with “buddy strapping” to the second toe; however, if greater than 25% of the joint surface is involved and there is displacement of more than 2 to 3 mm of the joint surface, reduction should be performed. Fracture reduction may be held by strapping to the second toe or a percutaneous K-wire. In the rare occasion that this is not successful, an open reduction can be performed either through a midlateral or dorsal incision. With diaphyseal fractures, axial alignment and rotation both need to be addressed with the closed reduction. Often, the clinical appearance of the toe following the reduction is more useful than the postreduction radiograph as the toe usually looks “fine” even though the radiograph shows malalignment. 
Figure 33-41
 
A: An 11-year-old boy with an intra-articular fracture of the proximal phalanx of the great toe. Successful treatment was achieved with simple buddy strapping. B: A lateral radiograph of the great toe is best taken with the lesser toes held flexed with a bandage.
A: An 11-year-old boy with an intra-articular fracture of the proximal phalanx of the great toe. Successful treatment was achieved with simple buddy strapping. B: A lateral radiograph of the great toe is best taken with the lesser toes held flexed with a bandage.
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Figure 33-41
A: An 11-year-old boy with an intra-articular fracture of the proximal phalanx of the great toe. Successful treatment was achieved with simple buddy strapping. B: A lateral radiograph of the great toe is best taken with the lesser toes held flexed with a bandage.
A: An 11-year-old boy with an intra-articular fracture of the proximal phalanx of the great toe. Successful treatment was achieved with simple buddy strapping. B: A lateral radiograph of the great toe is best taken with the lesser toes held flexed with a bandage.
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Lawnmower and Other Mutilating Injuries

There are approximately 9,400 lawnmower injuries a year in the United States affecting children 20 years or younger with an average age of 10.7 years. This incidence has not changed in 15 years, indicating that new safety regulations have been ineffective.174 These accidents occur with all types of lawnmowers; however, the most severe injuries are a result of a child being run over by a riding-mower.103,175 Seventy-two percent of children who have severe lawnmower injuries are bystanders.46,175 Ross et al.,146 however, had a higher number of children in their series who fell off the riding-mowers and were run over. Seventy-eight percent of all lawnmower accidents occur in boys.174 Loder et al.103 reviewed 235 children who had a traumatic amputation and found that these injuries are more common in the spring and summer. Children under the age of 14 years are most susceptible to injury with those under the age of 6 years having the greatest risk of death.121 The most common body region injured is the hand (34.6%), followed by the leg (18.9%) and the foot (17.7%) (Fig. 33-42).174 
Figure 33-42
A 4-year-old boy with a severe lawnmower accident after being run over by the driver.
 
There was extensive soft tissue loss and compound fractures to the foot. Despite multiple debridements, the leg was amputated below the knee.
There was extensive soft tissue loss and compound fractures to the foot. Despite multiple debridements, the leg was amputated below the knee.
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Figure 33-42
A 4-year-old boy with a severe lawnmower accident after being run over by the driver.
There was extensive soft tissue loss and compound fractures to the foot. Despite multiple debridements, the leg was amputated below the knee.
There was extensive soft tissue loss and compound fractures to the foot. Despite multiple debridements, the leg was amputated below the knee.
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Treatment of Lawnmower and Other Mutilating Injuries

The initial treatment for these children is a thorough assessment of the injuries suffered and appropriate resuscitation. Often, a large volume of blood has been lost from the time of the accident to arriving in the emergency department. Once the child is stabilized, a secondary survey can be conducted to assess the extent of the injury to each limb. With regard to the foot, these injuries are mutilating and heavily contaminated with soil and grass. After inspection, the wound should be dressed and a firm bandage applied to prevent further bleeding. Antibiotics need to be administered as soon as possible and include a cephalosporin, aminoglycoside, and penicillin. The patient's tetanus status should be ascertained and tetanus prophylaxis administered if unknown. 
The child then needs to be taken urgently to the operating room for the initial debridement. Considerable time should be spent removing the foreign material as meticulously as possible. A water jet lavage system can be useful, but should be used with care as it can force debris further in to the soft tissue envelopes. Devitalized tissue should be debrided; however, questionable tissue should be left as there will be multiple return trips to the operating room when further debridements can take place. It is useful to involve a plastic surgeon even at this initial surgery so they can see the extent of the damage and start planning for definitive coverage. The child will generally need at least three trips to the operating room and some cases many more.46 These return trips should be every 24 to 48 hours detreatment and what effect prolonged treatments and hospitalizations will have on the child. Amputation rates vary between 16% and 78% in the literature.7,46,175 A mangled extremity severity score (MESS) has been developed in adults to help surgeons make these decisions.80 The MESS score was validated in children by Fagelman et al.52; however, they did not include fractures below the ankle. It is useful to ask for a colleague's advice when contemplating an amputation so the advantages and disadvantages can be freely debated. If an amputation is performed, as much length of the bone should be preserved as possible, and transdiaphyseal amputation should generally be avoided to prevent problems with stump overgrowth.2,104 The functional outcome for these patients is generally satisfactory. Vosburgh et al.175 reviewed the functional outcome of 21 children with lawnmower accidents and found that patients who had their injury confined to the forefoot had 88% of normal function compared to 72% of normal function in patients who had sustained injuries to the posterior and plantar aspects of their foot pending on the state of the wound. Each debridement is important and should not be left to the most junior member of the surgical team to perform. Every piece of viable skin is vital and may be the difference between a primary closure over an amputation stump or a skin graft or tissue transfer. There is no hurry to close the wound until the soft tissue and bone is completely free of foreign material and the tissues are well perfused. Shilt et al.160 have found the use of VAC safe and effective in managing these types of lawnmower injuries. Fractures need to be stabilized and initially external fixation is useful. This allows plenty of room for further debridements and does not compromise later internal fixation once the soft tissue coverage has been determined. 
Skin grafting or flap coverage of lawnmower injuries is required in approximately 50% of cases.46 Unlike adults, split-thickness skin grafting can function very well on the weight-bearing surfaces in children.46,175 When the soft tissue defect is large or there is exposed bone that would be better to preserve than excise, a free tissue transfer is helpful.50,100 Lin et al.101 recently reviewed 93 microsurgical reconstructions of soft tissue defects of the pediatric foot. They reported excellent results with free musculocutaneous flaps or skin grafted muscle flaps. For plantar foot reconstructions, the musculocutaneous flaps had better results with fewer tropic ulcers and fewer resurfacing procedures. They also found that reconstruction of the tendons in the immediate setting led to fewer subsequent operations than staged tendon reconstructions.101 
One of the problems with free flaps is their bulk and the subsequent problems with shoe fitting. An alternative to a free muscle flap is a free fascial flap. A common one used is the temporoparietal fascial flap33,41,162 This fascia is supplied by the superficial temporal artery which is a terminal branch of the external carotid. The graft can be as large as 12 × 14 cm; however, this varies with the age and size of the child. It is harvested through an incision within the hairline which results in a cosmetic closure (Fig. 33-43A). The fascial flap can then be used to cover exposed bone and tendons in the foot (Fig. 33-43BD). Split skin can then be grafted onto the fascia and any surrounding areas of full thickness skin loss 
Figure 33-43
 
A: Temporoparietal fascia is harvested through the incision marked by the green line. Red line is markings of superficial temporal artery. B, C: Severe crush and degloving injury to the foot in a 6-year-old boy run over by a car D: The incision for harvesting the temporoparietal graft heals with an excellent cosmetic result E, F: The temporoparietal graft has healed with skin grafting to cover the defect.
 
(Photos courtesy Dr Jonathan Wheeler, Consultant Plastic Surgeon, Middlemore Hospital, Auckland, New Zealand.)
A: Temporoparietal fascia is harvested through the incision marked by the green line. Red line is markings of superficial temporal artery. B, C: Severe crush and degloving injury to the foot in a 6-year-old boy run over by a car D: The incision for harvesting the temporoparietal graft heals with an excellent cosmetic result E, F: The temporoparietal graft has healed with skin grafting to cover the defect.
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Figure 33-43
A: Temporoparietal fascia is harvested through the incision marked by the green line. Red line is markings of superficial temporal artery. B, C: Severe crush and degloving injury to the foot in a 6-year-old boy run over by a car D: The incision for harvesting the temporoparietal graft heals with an excellent cosmetic result E, F: The temporoparietal graft has healed with skin grafting to cover the defect.
(Photos courtesy Dr Jonathan Wheeler, Consultant Plastic Surgeon, Middlemore Hospital, Auckland, New Zealand.)
A: Temporoparietal fascia is harvested through the incision marked by the green line. Red line is markings of superficial temporal artery. B, C: Severe crush and degloving injury to the foot in a 6-year-old boy run over by a car D: The incision for harvesting the temporoparietal graft heals with an excellent cosmetic result E, F: The temporoparietal graft has healed with skin grafting to cover the defect.
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One of the most difficult decisions to make while treating these severe injuries is whether to salvage the affected part of the limb or amputate the questionable part. This decision is largely based on what the functional outcome will be with either 

Crush Injuries to the Foot

Severe crush injuries to the foot in children are rare but the consequences of not recognizing the degree of injury can be devastating. The commonest cause is the foot being run over by a car tire and there is both a crush and shearing force (Fig. 33-43). An alternative injury would be a very heavy weight falling on the foot. 
The child presents with an extremely painful, tight foot usually with the skin intact. If the child was wearing shoes these can be difficult to remove and they may need sedation first. Initial primary and secondary surveys need to be carried out to exclude other injuries and then a thorough assessment of the foot undertaken. 
It is important to continually assess the child for compartment syndrome and perform fasciotomies when indicated (see Compartment syndrome below). 

Sesamoid Fractures

There are a number of sesamoid bones in the foot; however, the most commonly symptomatic ones are the two within the plantar plate of the first metatarsophalangeal joint and in the flexor hallucis brevis tendons. These medial and lateral sesamoid bones are important both for shock absorption and to provide a fulcrum to improve the biomechanical function of the tendons to the first toe. 
Acute sesamoid fractures are rare in children and diagnosis is difficult because of the variable anatomy of the medial and lateral sesamoid bones. They can have more than one ossification centre which may or may not unite resulting in a partite sesamoid. The incidence of partite patellas varies between 19% and 31%.45,85 The incidence of a partite sesamoid is approximately 10 times higher in the medial sesamoid compared to the lateral one. The incidence of bilaterality varies between 25% and 85%.35,77 
An acute fracture to the sesamoids is usually caused by a fall from a height onto the forefoot which may be associated with a forced dorsiflexion of the first metatarsal. This results in acute pain and swelling under the first metatarsal head and pain on dorsiflexion of the first toe. A more common cause of sesamoid pain is a stress fracture or inflammation of the sesamoid (sesamoiditis). This occurs from repetitive dorsiflexion of the great toe for example in runners and dancers. 
Specific radiographs need to be taken to help differentiate whether this is an acute or chronic condition. Anteroposterior and lateral weight-bearing views coned on the sesamoids should be requested. A tangential view is also advisable (Fig. 33-44AD). An acute fracture will usually be transverse, have a “jagged” appearance, and have sharp corners. It is not widely displaced as the fragments are contained within the plantar plate. Wide displacement would represent a major disruption to the first metatarsophalangeal joint which would be obvious clinically. Another useful tip is that the sum of the fragment sizes should add up to the “normal sesamoid size.” Two partite fragments are often much larger when combined than one would normally expect with a fracture. Radiographs of the opposite foot can be helpful for comparison however with the variable incidence of bilaterality mentioned above a definitive diagnosis is not always possible. 
Figure 33-44
 
A: Medial sesamoid of the right foot appears fractured following a great toe injury. A radiograph of the left foot confirms a similar partite sesamoid that is asymptomatic. B: Asymptomatic partite patella in the contralateral uninjured foot C: Tangential sesamoid views can be useful however in this case the radiograph does not show the transverse partite sesamoid. D: An MRI scan of the right foot 5 months after the injury for a different problem shows the partite medial sesamoid.
A: Medial sesamoid of the right foot appears fractured following a great toe injury. A radiograph of the left foot confirms a similar partite sesamoid that is asymptomatic. B: Asymptomatic partite patella in the contralateral uninjured foot C: Tangential sesamoid views can be useful however in this case the radiograph does not show the transverse partite sesamoid. D: An MRI scan of the right foot 5 months after the injury for a different problem shows the partite medial sesamoid.
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Figure 33-44
A: Medial sesamoid of the right foot appears fractured following a great toe injury. A radiograph of the left foot confirms a similar partite sesamoid that is asymptomatic. B: Asymptomatic partite patella in the contralateral uninjured foot C: Tangential sesamoid views can be useful however in this case the radiograph does not show the transverse partite sesamoid. D: An MRI scan of the right foot 5 months after the injury for a different problem shows the partite medial sesamoid.
A: Medial sesamoid of the right foot appears fractured following a great toe injury. A radiograph of the left foot confirms a similar partite sesamoid that is asymptomatic. B: Asymptomatic partite patella in the contralateral uninjured foot C: Tangential sesamoid views can be useful however in this case the radiograph does not show the transverse partite sesamoid. D: An MRI scan of the right foot 5 months after the injury for a different problem shows the partite medial sesamoid.
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Treatment for a closed injury with an intact planter plate is nonoperative. Immobilization in a below-knee plaster cast with a toe plate for 4 to 6 weeks is advisable. Alternatively a moot-boot with a midfoot ridge to unload the forefoot can be used. Transition from the cast into a stiff-soled shoe that continues to prevent dorsiflexion will give symptomatic relief. With stress fractures and sesamoiditis a longer period of immobilization may be necessary. 
Surgical intervention is rarely required. If a symptomatic nonunion occurred this can be treated by open reduction and bone grafting which is technically difficult or by excision of the smaller of the two fragments. Either way care needs to be taken to avoid damage to the plantar plate. 

Compartment Syndrome

Compartment syndrome of the foot can occur in children with severe soft tissue injuries in the presence or absence of associated fractures. Most commonly, it occurs with severe crush injuries of the forefoot where there are multiple fractures and dislocations; however, it can occur without any fracture, such as the case of a car running over a foot causing crush and shear injury to soft tissue. The symptoms are not as obvious as they are in compartment syndrome of the forearm or leg, and increased pain with passive motion of the toes is not always present. There is significant pain from the injury itself, which often requires considerable amounts of pain relief. Pallor, pain on passive extension, paresthesia, and a dorsalis pedis pulse that is difficult to palpate likewise can all be clinical signs in a large number of foot injuries. The clinician needs to have a high index of suspicion for a compartment syndrome and if any doubt exists, the compartment pressures should be measured or the child taken urgently to the operating room for a decompression of the foot. 
Compartment pressure measurements are difficult to perform with invasive catheterization in an awake child with trauma to the foot. Often, the compartments need to be measured under a general anesthetic, so the child and parents need to be warned that the surgeon may proceed to a decompression. There are nine compartments in the foot, and it is difficult to confirm exact compartment location. It is important, however, to measure the pressure in the calcaneal compartment because it appears to be the most sensitive.109 When a pressure of greater than 30 mm Hg is measured in any compartment, a fasciotomy should be performed.109,119 It may be more accurate to use a measurement that takes into account the patient's blood pressure. In adults, the threshold is a measured pressure that is less than 30 mm Hg below the patient's diastolic blood pressure.108 
There are nine fascial compartments in the foot that contain the intrinsic muscles and short plantar flexors. When a decompression is carried out, all the compartments should be released regardless of the clinical findings or compartment measurements. The most thorough way to achieve this is by using the three incision technique described by Myerson (Fig. 33-45).119 Two dorsal longitudinal incisions are made in line with the second and fourth metatarsals. Dissection is then carried out through the interosseous compartments and fascia to enable decompression of the deep plantar compartments. Puncturing the fascia and spreading with a hemostat is an effective and safe technique. The lateral compartment is decompressed through the incision over the fourth metatarsal by dissecting deep to the fifth metatarsal. A medial incision is made along the arch of the foot as far posterior as the medial malleolus. This incision allows decompression of the medial compartment and a more thorough decompression of the deep compartments. It also allows decompression of the tarsal tunnel. Dissection is carried out on both the dorsal and plantar surfaces of the abductor hallucis muscle, freeing it from both the plantar fascia and bony attachments. Care must be taken to avoid damaging the lateral plantar nerve and vessels which lie on the quadrates plantae muscle. The deep compartments can now be easily released under direct vision. These three incisions are usually well placed to help with fracture reduction and K-wiring to stabilize the foot at the same time as the decompression. The wounds should be left open initially and closed 5 to 7 days later. Often, one of the wounds will require split-skin grafting. 
Figure 33-45
Surgical approaches for fasciotomy of the foot.
 
A: The dorsal approach is made through an incision over the second and fourth metatarsal shafts and is more suitable for injuries of the forefoot or midfoot. B: The medial approach is more suitable for injuries of the hindfoot, with the incision extending from the base of the first metatarsal to the medial malleolus. A tarsal tunnel release can be done through this incision.
 
(From Myerson MS. Experimental decompression of the fascial compartments of the foot: The basis for fasciotomy in acute compartment syndromes. Foot Ankle. 1988; 8:308–314, with permission.)
A: The dorsal approach is made through an incision over the second and fourth metatarsal shafts and is more suitable for injuries of the forefoot or midfoot. B: The medial approach is more suitable for injuries of the hindfoot, with the incision extending from the base of the first metatarsal to the medial malleolus. A tarsal tunnel release can be done through this incision.
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Figure 33-45
Surgical approaches for fasciotomy of the foot.
A: The dorsal approach is made through an incision over the second and fourth metatarsal shafts and is more suitable for injuries of the forefoot or midfoot. B: The medial approach is more suitable for injuries of the hindfoot, with the incision extending from the base of the first metatarsal to the medial malleolus. A tarsal tunnel release can be done through this incision.
(From Myerson MS. Experimental decompression of the fascial compartments of the foot: The basis for fasciotomy in acute compartment syndromes. Foot Ankle. 1988; 8:308–314, with permission.)
A: The dorsal approach is made through an incision over the second and fourth metatarsal shafts and is more suitable for injuries of the forefoot or midfoot. B: The medial approach is more suitable for injuries of the hindfoot, with the incision extending from the base of the first metatarsal to the medial malleolus. A tarsal tunnel release can be done through this incision.
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Although uncommon in children, late sequelae of missed compartment syndrome can lead to disability including claw toe deformity, paresthesia, cavus deformity, stiffness, and residual pain.14,167 

Puncture Wounds

Puncture wounds to the foot are extremely common in children and frequently treated by primary care physicians or in the emergency department. Most injuries can be treated by simply removing the offending foreign body, irrigating the entry site, giving tetanus prophylaxis if required, and a short course of oral antibiotics. It is important to carefully assess the foreign body that is removed to make sure a small part of it has not been retained in the foot. Often, the patient will bring the offending foreign body with them if it broke off or came out spontaneously. The depth of penetration should also be assessed by looking at the length of the foreign object as well as the point of entry. This may help predict if a joint or tendon sheath has been penetrated. The amount of contamination can also help determine if an open debridement is necessary and the length of administration of antibiotics. 
Radiographs are useful in most cases of acute puncture wounds as occasionally a foreign body will be seen. If the foreign body has punctured a joint, air may be seen as well. When a retained foreign body is still suspected but not seen on radiograph, an ultrasound scan can be useful to identify its location. An MRI scan is even more useful at identifying foreign bodies and has the added advantage of showing secondary changes of septic arthritis or osteomyelitis if the puncture wound is more chronic (Fig. 33-46). 
Figure 33-46
MRI scans are useful following penetrating foot injuries as the extent of the soft tissue or joint involvement can be clearly seen.
 
This 6-year-old boy had pain 4 days after standing on a nail in barefeet, and despite oral antibiotics he had developed a septic arthritis.
This 6-year-old boy had pain 4 days after standing on a nail in barefeet, and despite oral antibiotics he had developed a septic arthritis.
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Figure 33-46
MRI scans are useful following penetrating foot injuries as the extent of the soft tissue or joint involvement can be clearly seen.
This 6-year-old boy had pain 4 days after standing on a nail in barefeet, and despite oral antibiotics he had developed a septic arthritis.
This 6-year-old boy had pain 4 days after standing on a nail in barefeet, and despite oral antibiotics he had developed a septic arthritis.
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If a patient with a treated puncture wound does not rapidly improve clinically, further investigation is required to rule out a retained foreign body, deep soft tissue infection, septic arthritis, or osteomyelitis. Eidelman et al.48 recommend that patients who have an established infection 24 to 36 hours after a puncture wound should be admitted to hospital for IV antibiotics. In their series of 80 children with puncture wounds, a delay in diagnosis or presentation was associated with deep infection.48 The most common organism causing deep infections in their study was Staphylococcus aureus and Group A Streptococcus. A complete blood count, erythrocyte sedimentation rate, and C-reactive protein should be performed, and an MRI scan is the most accurate radiologic investigation.74,90 The patient can then be treated accordingly with IV antibiotics and open debridement of the entry site and deeper tissues. 
Septic arthritis or osteomyelitis should be suspected if a child presents with foot pain and swelling following a puncture wound to the foot with a nail while wearing sneakers. Pseudomonas osteochondritis is thought to occur when the cartilage is damaged at the initial injury.54 The source of the pseudomonas is debatable; however, some authors have postulated that it is from the sneakers.53,91 The patient should be admitted to hospital and a thorough debridement of the affected soft tissues, cartilage, and bone should be carried out. IV antibiotics are administered often for 5 to 7 days or until the infection has clearly resolved.76,78 The long-term sequelae of pain, growth arrests, chronic osteomyelitis, and recurrence make this an important infection to identify early and treat aggressively. 

Stress Fractures

Stress fractures in children are becoming more common because of overtraining in youth athletics and year-round participation in sports.31 The tibia, fibula, femur, and pars interarticularis are the areas most commonly affected; however, stress fractures in the foot can also occur.34,43,60,184 
The predominant symptom is “pain with weight bearing,” and this usually coincides with the beginning of an intense period of training. The repetitive training results in bone fatigue and eventual partial or complete fracture. The normal cortical bone remodeling is accelerated and resorption occurs at a faster rate than the reparative process resulting in weakening of the bone and inevitable microfracture. Treatment, therefore, is aimed at breaking this cycle by activity modification and protected weight bearing to prevent further fracture and allow the reparative process to “catch up.” 
Patients with stress fractures in the foot present with pain on weight bearing and often no history of any particular injury that may have been the cause. A thorough history of their training regimen is essential, particularly any increases or changes in technique playing surface or footwear. On examination, there is point tenderness but minimal swelling. Radiographs taken early in the process are often normal but later show periosteal layering of new bone on the cortex and osteolysis at the fracture site. Bone scans are often more sensitive initially and a three-phase technetium bone scan is helpful when the radiographs are normal in the first 2 to 3 weeks after the onset of symptoms.49 MRI has been shown to identify stress fractures before radiographic changes are evident, and in a prospective study of collegiate basketball players, MRI demonstrated marrow edema even before stress fractures were clinically evident.107 
As well as concentrating on the fracture itself, the patient should be assessed for any conditions that could predispose them to stress fractures. These conditions include metabolic bone diseases, amenorrhea, eating disorders, and incorrect training techniques. There may have been as simple a cause as a change in footwear that has lead to increased stress in a particular bone in the foot. 
The second metatarsal is the most common bone in the foot to get a stress fracture. This usually occurs at the neck of the metatarsal at the junction of the mobile shaft and rigid metaphysis. Treatment involves rest and partial weight bearing in a moon-boot for 4 to 6 weeks. It is best to avoid a cast as during this time the athlete can maintain physical fitness with swimming, deep water running, and exercycling. A gradual return to activity can be restarted when radiographs confirm adequate healing and the symptoms have abated which often takes 8 to 12 weeks. Stress fractures of the navicular are disabling and difficult to treat. They occur most commonly in basketball players, hurdlers, and runners.115 Bennell and Bruckner11 reviewed 18 large studies of stress fractures and found that the incidence of navicular stress fractures can range between 0% and 28.6% of injuries among track and field athletes. These fractures are thought to arise because of overuse and the reduced vascularity that can exist in the central third of the navicular. They are difficult to diagnose and one needs to have a high level of suspicion as with any other stress fracture. The fracture is often diagnosed by technetium bone scan, and if this is positive in the region of the navicular, a CT scan is very helpful in delineating the stress response from an acute injury. The fracture line on CT, and if present on radiograph, is vertically orientated in the middle third of the bone. Most of these fractures heal with rest and protective weight bearing; however, some do go on to delayed or nonunion. The treatment for a painful nonunion is open reduction and internal fixation with autogenous bone grafting.133 The average time for the return to activity following a navicular stress fracture in athletes is 5.6 months.86 Stress fractures of the base of the fifth metatarsal usually occur in zone 2 or 3 and their treatment is discussed earlier in the chapter under the section fractures of the fifth metatarsal base. 
Stress fractures can also occur in the cuboid, calcaneus, and sesamoid bones of the foot. 

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