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Metatarsal and toe fractures in children

Metatarsal and toe fractures in children
Literature review current through: Sep 2023.
This topic last updated: Feb 15, 2022.

INTRODUCTION — The management of metatarsal and toe fractures in children will be reviewed here. Other foot fractures in children and toe fractures in adults are discussed separately. (See "Foot fractures (other than metatarsal or phalangeal) in children" and "Toe fractures in adults".)

EPIDEMIOLOGY — Metatarsal fractures account for the majority of pediatric foot fractures. In children ≤5 years of age, the first metatarsal is most commonly injured [1,2]. In older children, fracture of the base of the fifth metatarsal is more frequent [1,3]. Approximately one-third of metatarsal fractures involve the shaft or distal portion of the metatarsal [4].

Toe fractures also occur commonly in children. The first phalanx (great toe) is most frequently involved. Distal phalangeal fractures may be complicated by nail bed injuries.

CLINICAL ANATOMY — From an anatomic perspective, the foot is divided into three regions (figure 1A-C):

Forefoot – Metatarsal and phalangeal bones

Midfoot – Navicular, cuboid, and cuneiform bones

Hindfoot – Talus and calcaneus

The Lisfranc joint separates the forefoot from the midfoot. The Chopart joint divides the hindfoot and the midfoot.

Additional foot anatomy common to children and adults is discussed separately. (See "Metatarsal shaft fractures", section on 'Clinical anatomy' and "Toe fractures in adults", section on 'Clinical anatomy'.)

The pediatric toe and forefoot differ from the adult foot due to the presence of growth plates (figure 2). Injury to the growth plate may rarely lead to growth arrest and permanent deformity. (See 'Complications' below.)

These growth plates typically close around age 16 years in females and age 18 years in males. Thus, management of metatarsal and toe fractures in older adolescents is the same as for adults. (See "Toe fractures in adults".)

MECHANISM OF INJURY — The most common causes of metatarsal and toe fractures are [4]:

Axial loading (eg, stubbing a toe)

Abduction injury, often involving the fifth digit

Crush injury caused by a heavy object falling on the foot or motor vehicle tire running over the foot

Less commonly, joint hyperextension or hyperflexion can lead to spiral or avulsion fractures. Crush injuries are more likely to involve soft tissue and neurovascular damage.

Metatarsal stress fractures may occur in adolescents who rapidly undertake heavy physical activity or in those who are involved in repetitive intense training. This injury commonly affects the second metatarsal and reflects bone matrix fatigue with bone resorption that exceeds the rate of remodeling and repair [4,5].

CLINICAL PRESENTATION AND EXAMINATION — Children typically present for evaluation because of pain and difficulty walking.

Ecchymosis and swelling are usually present and occur within the first few hours after injury. Palpation along the foot or digit frequently reveals point tenderness at the fracture site. However, the dorsum of the foot or toe may be diffusely swollen and tender, making it difficult to pinpoint the fracture location by examination alone.

Of note, tenderness at the base of the fifth metatarsal after an inversion injury is highly suggestive of a fracture and may not be accompanied by significant swelling soon after the injury.

With displaced fractures and dislocations, deformity is usually apparent. Rotational deformity is assessed by examining the orientation of the nail bed of the fractured toe. Rotational deformity is present if the nail bed does not lie in the same plane as that of the corresponding toe on the opposite foot [6].

In all cases, capillary refill should be assessed and the skin of the digit carefully inspected, seeking lacerations and devitalized skin. Any wound should be carefully examined to exclude communication with the fracture site (ie, an open fracture). Devitalized skin may slough and convert a closed fracture into an open one. Injury to surrounding soft tissue including the nail and nail bed can occur, particularly with crush injuries.

Subungual hematoma is often a marker of an underlying distal phalanx fracture [1]. (See "Subungual hematoma".)

RADIOGRAPHIC FINDINGS — We recommend that patients with significant pain, swelling, or deformity of the forefoot or toe receive plain radiographs, including anterior-posterior, lateral, and oblique views [5]. Growth plate injuries are described using the Salter-Harris classification system (figure 3).

Radiographic findings include growth plate, cortical, and buckle fractures. Salter-Harris I through Salter-Harris III fractures are most common in the great toe (figure 3). (See "General principles of fracture management: Fracture patterns and description in children", section on 'Fracture patterns'.)

Initial radiographs are typically normal in children with Salter-Harris I fractures or metatarsal stress fractures. Repeat radiographs two weeks later show periosteal reaction and callus formation. Bone scan is helpful in doubtful cases, especially for the diagnosis of early stress fractures in adolescents.

The following normal variants may be mistaken for fractures on radiograph (figure 1A-C):

Sesamoid bones of the first metatarsal

Accessory ossicles (eg, os trigonum, os subfibulare)

Bipartite epiphysis of the great toe (normal variant)

Os vesalianum or apophyseal ossification center at the base of the fifth metatarsal. The apophyseal center appears around eight years of age. Fusion usually is complete by 12 years in girls and 15 years in boys. This is typically distinguished from fracture due to the longitudinal orientation of the ossified apophysis, absence of local tenderness, swelling, or separation of this ossification center from the base of the fifth metatarsal.

INITIAL MANAGEMENT

Emergency conditions — The clinician should obtain emergency orthopedic consultation in the patients with the following conditions:

Open fractures – These injuries are usually crush or machine-related, often involving a lawn mower, chainsaw, or heavy weight. They frequently involve multiple digits [4,6]. Patients who have sustained these injuries should be managed in accordance with the principles of advanced trauma life support (ATLS), including a thorough examination of the entire lower extremity (table 1). (See "Trauma management: Approach to the unstable child".)

Open fractures are frequently grossly contaminated wounds and should undergo empiric antibiotic treatment with a thorough operative irrigation and debridement (eg, cefuroxime 50 mg/kg; maximum single dose 1.5 g). In addition, tetanus prophylaxis should be provided, as needed (table 2). (See "Minor wound evaluation and preparation for closure", section on 'Irrigation'.)

Compartment syndrome – Compartment syndrome presents with marked swelling and pain out of proportion to the degree of injury. Pallor, paresthesias, and pulselessness are late signs. Emergent orthopedic consultation is indicated. Once the clinician suspects an acute compartment syndrome, compartment pressures must be measured to determine whether they are elevated, or a clinical decision to perform a fasciotomy is needed. (See "Acute compartment syndrome of the extremities", section on 'Management'.)

Vascular compromise – Vascular compromise following forefoot fractures most commonly occurs due to compartment syndrome as direct vascular insufficiency due to a displaced fracture is rare in this region because of the robust collateral circulation to the toes.

Analgesia and initial care — For children with no signs of neurovascular compromise, initial therapy consists of measures to reduce swelling and pain management.

The affected foot should be elevated above the level of the heart. An insulated ice pack should be applied to help manage swelling.

Oral analgesia (eg, acetaminophen or ibuprofen) may suffice for patients with mild pain who have suffered a nondisplaced metatarsal or toe fracture, especially a Salter-Harris I fracture or buckle fracture. Intranasal (eg, intranasal fentanyl) or parenteral analgesia (eg, intravenous morphine or ketorolac) is most appropriate for initial pain control in patients with moderate to severe pain and should be given prior to radiographic evaluation. We suggest that the clinician avoid the oral route for patients likely to require sedation or general anesthesia for fracture reduction or repair so that the fasting state is maintained.

Injury to the nail bed — Nail bed injuries are seen frequently with distal phalanx fractures sustained from a fallen object. Subungual hematomas can cause severe pain, often indicate the presence of a distal phalanx fracture, and should be drained within 24 hours if painful. (See "Subungual hematoma".)

Treatment of nail bed lacerations is controversial. Some recommend removing the nail to detect the presence of a laceration if there is significant traumatic deformity of the nail or a sizable subungual hematoma [7-9]. They advocate laceration repair with absorbable sutures, following irrigation, if the wound is less than eight hours old [7]. The primary justification for this approach lies in the high correlation between nail bed injury and distal phalanx fracture, with the consequent risk of osteomyelitis associated with open fractures. Others, citing data showing no difference in outcome, advocate against removal of the nail and nail bed laceration repair [10,11]. We do not advocate routine nail removal and nail bed laceration repair, and perform this procedure only when obvious malalignment of the nail bed laceration is present.

Since a distal phalanx fracture with a subungual hematoma is technically an open fracture, some clinicians prescribe prophylactic oral antibiotics for five to seven days (eg, cephalexin 33 mg/kg every eight hours; maximum single dose 1 g).

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL — The clinician should obtain prompt orthopedic consultation for children with any of the following metatarsal or toe fractures:

Fractures with vascular compromise or suspected compartment syndrome

Open fractures of the proximal phalanx or metatarsal bones

Displaced Salter-Harris I or II physeal fractures

Intraarticular fractures including Salter-Harris III or IV fractures

Metatarsal fractures that are completely displaced or have more than 20 degrees of angulation

Acute fractures of the proximal diaphysis (Jones fracture)

Multiple metatarsal fractures

DEFINITIVE MANAGEMENT — Treatment will vary according to the location and characteristics of the fracture. Treatment recommendations for metatarsal and toe fractures in children are guided by case series and empiric observation.

Metatarsal fractures — These fractures are typically managed nonoperatively in skeletally immature children because of the extensive correction of deformity that occurs with remodeling [12]. Absolute indications for surgical intervention include open and articular fractures and relative indications for surgical intervention in metatarsal fractures are adolescent age (>12 years of age) or multiple fractures.

Nondisplaced — Nondisplaced and minimally displaced solitary metatarsal fractures may be treated with a cast boot, posterior splint, or a short leg walking cast. These patients should be evaluated by an orthopedist with pediatric expertise within one week to 10 days. Casting should be avoided in patients with marked foot swelling to avoid the development of a tight cast or compartment syndrome.

Children with multiple nondisplaced or minimally displaced metatarsal fractures should be placed in a non-weight bearing splint or cast and referred to an orthopedist with pediatric expertise within one week. Any proximal metatarsal fractures should be evaluated for possible injury to the tarsometatarsal joint complex (figure 1A-C) [13].

Duration of immobilization ranges from three to six weeks. Younger children require less total immobilization time than older children.

Displaced — Completely displaced metatarsal fractures and those with more than 20 degrees of angulation in children over eight years of age warrant closed reduction followed by immobilization with a non-weight bearing short leg cast or short leg splint. Sedation in the emergency department usually suffices to control the pain of the fracture reduction. Follow-up orthopedic evaluation should occur within one week. (See "Procedural sedation in children: Approach".)

Duration of immobilization depends on the age of the child and whether percutaneous pinning is required and ranges from three to six weeks.

Proximal fifth metatarsal — In children, avulsion of the base of the fifth metatarsal may be confused with an apophyseal center called the os vesalianum (figure 1A-C). Avulsion fractures will have localized tenderness at the base of the fifth metatarsal.

Avulsion fractures arising from the tuberosity of the proximal fifth metatarsal heal well, typically within four weeks, with symptomatic and supportive treatment (eg, stiff soled shoe or cast boot, ice application, elevation, and rest) (figure 4). As an example, in a retrospective observational study of 47 children and adolescents with these fractures, none subsequently underwent surgery [14]. (See "Proximal fifth metatarsal fractures", section on 'Tuberosity fracture: Zone 1 injury'.)

In adolescents, an apophysis (growth center associated with a tendon insertion) can often be seen in the tuberosity. It always lies parallel to the long axis of the fifth metatarsal and has smooth, corticated edges (image 1). Apophysitis, an inflammation of the apophysis, may develop in active adolescents. This self-limiting condition resolves with completion of growth and is treated with rest.

Acute fractures of the proximal diaphysis (Jones fracture), first described by Jones in 1902, occur within 1.5 cm of the metatarsal tuberosity and extend towards or into the intermetatarsal joint (figure 4 and figure 5). The area where these fractures occur is referred to using different terms, including "proximal diaphysis" and "junction of the metaphysis and diaphysis." This region is at some risk for painful nonunion (image 2 and image 3). Initial care consists of immobilization with a below-knee non-weight bearing cast or splint and orthopedic consultation within one week. Symptomatic nonunion can occur in children and young adolescents with a Jones fracture [15].

The site of the fracture appears to strongly influence whether surgery is ultimately needed. As an example, in a study of 238 patients with a fracture of the fifth metatarsal, fractures that occurred between 20 and 40 mm (or 25 to 50 percent of overall metatarsal length) from the proximal tip went on to surgery in 6 out of 32 patients, whereas only 5 percent (9 of 184) of patients with fractures <20 mm for the proximal tip had surgery [14]. For older elite adolescent athletes, surgery may result in more rapid healing. (See "Proximal fifth metatarsal fractures", section on 'Intermetatarsal and proximal diaphysis fractures: Zone 2 injuries'.)  

Stress fractures — These fractures most frequently affect young athletes (eg, long distance runners, gymnasts) and most commonly occur in the neck of the second metatarsal. They usually respond well to cessation of the causative activity for four to eight weeks. Crutches and partial weight bearing for several weeks may be helpful in patients who have mild to moderate pain with walking. A short leg cast with non-weight bearing is appropriate for patients with severe pain. Metatarsal stress fractures are discussed in more detail separately. (See "Stress fractures of the metatarsal shaft".)

Although relatively uncommon, stress fractures of the proximal diaphysis of the fifth metatarsal have high rates of nonunion. They generally occur as a result of repetitive stress. We advise early referral to an orthopedist with pediatric expertise. These injuries are discussed in greater detail separately. (See "Proximal fifth metatarsal fractures", section on 'Stress fractures of proximal diaphysis: Zone 2 injury'.)

Toe fractures — Nondisplaced toe fractures heal rapidly within three to four weeks. Treatment includes:

Strapping of the injured toe to its neighboring toe (buddy taping) (picture 1)

Ice, rest, and elevation above the level of the heart to reduce swelling and pain

Ambulation with a stiff soled shoe or cast boot

Analgesia as needed with acetaminophen (15 mg/kg every four hours; Maximum single dose 1 g) or ibuprofen (10 mg/kg every six hours; Maximum single dose 800 mg)

It is important to instruct the caregiver to properly pad between the toes to prevent skin breakdown (picture 1).

Follow-up with the patient's primary care provider or an orthopedic surgeon may occur in one to two weeks.

Salter-Harris III or IV fractures of the proximal phalanx of the big toe are often intraarticular. If more than one-third of the joint surface is involved or if the displacement is more than 2 to 3 mm, then the clinician should urgently consult an orthopedist with pediatric expertise to perform closed or open reduction with percutaneous pinning [13]. Healing may require up to eight weeks.

Open fractures of the proximal phalanxes warrant urgent orthopedic consultation for operative debridement and alignment. (See 'Emergency conditions' above.)

COMPLICATIONS — Malunion, nonunion, and growth arrest are rare complications of metatarsal fractures in children (image 4). Salter-Harris III or IV fractures of the great toe may cause joint stiffness or growth arrest.

OUTCOMES — Most children rapidly and fully recover from metatarsal or toe fractures.

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

(See "General principles of fracture management: Bone healing and fracture description".)

(See "General principles of fracture management: Fracture patterns and description in children".)

(See "General principles of acute fracture management".)

(See "General principles of definitive fracture management".)

(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General management of pediatric fractures" and "Society guideline links: Lower extremity fractures in children" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Toe fracture (The Basics)" and "Patient education: How to use crutches (The Basics)")

SUMMARY AND RECOMMENDATIONS

Mechanism of injury – The most frequent causes of metatarsal and toe fractures include (see 'Mechanism of injury' above):

Axial loading (eg, stubbing a toe)

Abduction injury, often involving the fifth digit

Crush injury caused by a heavy object falling on the foot or motor vehicle tire running over the foot

Clinical presentation and examination – Following fracture of the toe or metatarsal bone, ecchymosis and swelling are usually present and occur within the first few hours after injury. Palpation along the foot or digit frequently reveals point tenderness at the fracture site. Tenderness at the base of the fifth metatarsal after an inversion injury is highly suggestive of a fracture. Subungual hematomas are often markers of an underlying distal phalanx fracture. (See 'Clinical presentation and examination' above and "Subungual hematoma".)

Imaging – We recommend that patients with significant pain, swelling or deformity of the forefoot or toe receive plain radiographs, including anterior-posterior, lateral, and oblique views. Common injury patterns include growth plate (figure 3), buckle, and cortical fractures. (See 'Radiographic findings' above.)

Emergency conditions – The clinician should obtain emergency orthopedic consultation in patients with vascular compromise, compartment syndrome, or open fractures of the metatarsal bone or proximal phalanx. (See 'Emergency conditions' above.)

Analgesia and initial care – For children with no signs of neurovascular compromise, initial therapy consists of analgesia and measures to reduce swelling and pain, including evacuation of a painful subungual hematoma. (See 'Analgesia and initial care' above and "Subungual hematoma".)

Indications for specialty consultation or referral – The clinician should obtain urgent orthopedic consultation, generally within one to two days, for children with any of the following metatarsal or toe fractures (see 'Indications for orthopedic consultation or referral' above):

Displaced Salter-Harris I or II physeal fractures

Intraarticular fractures, including Salter-Harris III or IV fractures

Metatarsal fractures that are completely displaced or have more than 20 degrees of angulation

Acute fractures of the proximal diaphysis (Jones fracture)

Multiple metatarsal fractures

Metatarsal fractures – Definitive management of metatarsal fractures varies by the location and fracture characteristics. (See 'Metatarsal fractures' above.)

Toe fractures – Nondisplaced toe fractures heal rapidly within three to four weeks. Treatment includes (see 'Toe fractures' above):

Strapping of the injured toe to its neighboring toe (buddy taping) (picture 1)

Ice, rest, and elevation above the level of the heart to reduce swelling and pain

Ambulation with a stiff soled shoe or cast boot

Oral analgesia, as needed (eg, acetaminophen or ibuprofen)

Salter-Harris III or IV fractures of the proximal phalanx of the big toe and open fractures of the proximal phalanges warrant urgent orthopedic consultation.

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