Version May 2024
INTRODUCTION — This topic will discuss the management of mid- and hindfoot fractures in children. Metatarsal and toe fractures in children and foot fractures in adults are discussed separately. (See "Metatarsal and toe fractures in children" and "Metatarsal shaft fractures" and "Toe fractures in adults" and "Sesamoid fractures of the foot".)
EPIDEMIOLOGY — Although forefoot fractures (metatarsal and toe fractures) account for the majority of pediatric foot fractures, midfoot, and hindfoot fractures have the greatest potential for causing permanent deformity and disability [1,2].
Among these less common foot fractures, talar neck fractures are seen most frequently. Fractures of the calcaneus, cuboid, navicular, cuneiform, or tarsometatarsal (Lisfranc) region are rare [3-5]. However, as more children and adolescents have become users of motorized recreational vehicles (eg, mini scooters, motorized dirt bikes, all-terrain vehicles, snowmobiles) or have participated in snowboarding, the frequency and severity of these foot injuries has increased [1,6].
CLINICAL ANATOMY — 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.
The pediatric midfoot and hindfoot differ from the adult foot due to the presence of large portions of growing cartilage in the young child (under four years of age) [1]. The calcaneus and talus are ossified at birth, and the cuboid ossification center appears at birth or shortly thereafter. The navicular tarsal bone appears around three years of age and is the last of the large tarsal bones to develop a primary ossification center. Thus, a foot radiograph of a child under five years of age lacks significant areas of visible bone. These factors lead to patterns of injuries in young children that may be difficult to identify on plain radiographs and that differ from those in adults.
In contrast, the midfoot and hindfoot of adolescents have enough skeletal maturity that they develop fracture patterns that are similar to those seen in adults.
The high cartilage to bone ratio in children under age eight years permits significant remodeling of foot fractures and provides for good long-term outcomes in many instances. However, fractures of the talar neck in children, although rare, may disrupt the vascular supply of the talus and cause avascular necrosis [1,3].
MECHANISM OF INJURY — Specific fractures of the mid- or hindfoot are associated with certain types of injury patterns:
●Talar neck fractures often result from forced dorsiflexion of the foot during a fall or motor vehicle collision [1,7].
●Fractures of the lateral process of the talus are associated with snowboarding [6,8].
●Calcaneus fractures may occur after trivial falls in toddlers and young children. In older children and adolescents, they are associated with falls on to the heel from a significant height (>3 m [10 feet]) or with foot injuries involving motorized vehicles (eg, all-terrain vehicles, motorcycles) [1].
●Cuboid injuries may also result from a fall from a height if the foot hits the ground in a plantar-flexed position, transmitting axial and rotatory forces up along the lateral midfoot and hindfoot. Compression fractures of the cuboid have also occurred in association with horseback riding [9]. In most instances, cuboid fractures are associated with significant fractures to the talus, calcaneus, or tarsometatarsal region [1].
●Tarsometatarsal fractures (Lisfranc fractures) may result from violent plantar flexion and/or abduction force when falling from a significant height or trying to brake with the foot while riding a motorized vehicle (eg, mini motorized scooter) or bicycle [3]. Less commonly, heel to toe compression (eg, a heavy object falling onto the heel with the foot in a kneeling position) may result in similar injuries.
●Osteochondritis dissecans is a condition in which a segment of articular cartilage, with its underlying subchondral bone, gradually separates from the surrounding osteocartilaginous tissue. Osteochondritis dissecans of the talus is described in greater detail separately. (See "Osteochondritis dissecans (OCD): Clinical manifestations, evaluation, and diagnosis", section on 'Clinical presentation'.)
CLINICAL PRESENTATION AND EXAMINATION — Emergent conditions, such as an open fracture, neurovascular compromise, or compartment syndrome, require prompt recognition and treatment. (See 'Emergency conditions' below.)
A foot fracture, particularly one sustained in a fall from a height, may mask other injuries, especially spinal column compression fractures.
History — In addition to the mechanism of injury, the physician's history should ascertain the following [1]:
●Site of the most significant pain
●Other injured areas (eg, lumbar spine, hip, knee)
●Length of time from injury to presentation
●Neurovascular symptoms (eg, paresthesias, numbness, foot pallor)
●Ability to bear weight after injury
●History of any previous injury or surgery
●Related orthopedic comorbidities (eg, myelomeningocele, cerebral palsy)
Physical examination — Patients who have sustained major trauma (table 1) are at risk for multiple traumatic injuries and warrant a complete physical examination and appropriate ancillary studies. (See "Approach to the initially stable child with blunt or penetrating injury", section on 'Blunt trauma' and "Trauma management: Approach to the unstable child", section on 'Initial approach'.)
For isolated injuries, a complete evaluation of the entire lower extremity should be conducted before assuming that the injury is confined to the foot, especially in a child who is less than five years of age and/or is nonverbal [1]. Most children with foot fractures have significant pain or are unwilling to bear weight on the affected side.
After a foot injury, there is often swelling and pain. Once other injuries are excluded, the examination can focus on the ankle. Analgesia prior to examination (eg, ibuprofen orally for mild pain or intravenous morphine for moderate or severe pain) will often facilitate the child's cooperation. We suggest that the clinician avoid the oral route for patients likely to require sedation or general anesthesia for fracture reduction or repair.
●Inspection – Clinicians should inspect the injured foot for:
•Swelling
•Deformity
•Skin abnormalities (eg, lacerations [possible open fracture], tenting, or blistering [caused by rapid stretching of the skin])
●Palpation – Palpation should include all of the bones of the lower leg, ankle, and foot. Patterns of pain and swelling assist in identifying the site of foot fracture:
•Talar fractures – Pain and swelling of the ankle and tenderness just distal to the anterior ankle joint are present. Nondisplaced talar fractures may lack significant tenderness but should be suspected in patients who have pain on ambulation after a high force dorsiflexion injury.
•Calcaneal fractures – Careful examination of the heel of the foot is warranted in any child refusing to walk after a fall. Associated soft tissue or other skeletal injuries (eg, compression fracture of the lumbar spine, tibial plateau fracture) are present in half of the children with calcaneal fractures [3].
•Cuboid fractures – These injuries present with tenderness in the lateral (outer) aspect of the midfoot.
•Navicular fracture – Pain on the medial (inner) aspect of the midfoot is typical for these fractures.
●Tarsometatarsal (Lisfranc) fractures – Pain and tenderness in the midfoot region and dorsal or plantar ecchymosis are typically present (picture 1) [10]. Pronation-abduction stress may elicit midfoot pain [3].
●Compartment syndrome – Compartment syndrome presents with marked tense swelling of the foot and pain out of proportion to the degree of injury. Pallor, paresthesias, and pulselessness are late signs.
RADIOGRAPHIC DIAGNOSIS
Plain radiographs — Plain radiographs, with anterior-posterior (AP), lateral, and oblique views of the foot, remain the most appropriate initial imaging modality and suffice to diagnose most low energy foot fractures in children. In rare instances, comparison views with the uninjured foot may be helpful in identifying subtle fractures.
Additional views should be based on clinical findings that suggest the area of fracture (see 'Clinical presentation and examination' above):
●Talus – Fractures of the talus include fractures of the neck, body, medial or lateral process, and osteochondral injuries. Among these, talar neck fractures are most common and are described using the Hawkins classification system (figure 2 and image 1). Computed tomography should be included in the radiographic series in a patient with significant lateral foot pain with negative plain radiographs, since fractures of the lateral process of the talus are sometimes occult and radiographs are negative in over 40 percent of cases.
●Calcaneus – Axial views of the foot should be added to the standard series in patients with suspected calcaneus fractures. However, a low threshold for computed tomography should be maintained since up to 50 percent of pediatric calcaneal fractures are initially missed (image 2 and image 3) [11]. Most calcaneus fractures in children heal uneventfully; although fractures with significant intraarticular involvement and displacement can yield poorer results (figure 3). (See 'Computed tomography' below.)
●Midfoot fractures – Most isolated midfoot fractures affect the cuboid (outer aspect of the midfoot) or navicular bones (inner aspect of the midfoot) and consist of minor avulsion or stress fractures. Initial plain radiographs may be normal in children with stress fractures. Repeat films in one to two weeks usually show a sclerotic line of healing. Bone scan will not change the clinical management despite a positive study and is almost never ordered.
Complete fractures of the midfoot typically occur after high force complex foot injuries and are associated with other fractures, especially tarsometatarsal (Lisfranc) fractures. Compression fracture of the cuboid ("nutcracker" fracture) is associated with horseback riding.
Köhler disease, an apophysitis of the tarsal navicular, is an uncommon cause of limp in children between the ages of two and nine years (image 4).
●Tarsometatarsal (Lisfranc) fracture – Children with a suspected tarsometatarsal (Lisfranc) injury based on clinical presentation or radiographs should undergo computed tomography. The most common pediatric injury consists of medial dislocation (first metatarsal displaced from first cuneiform bone) (image 5).
Computed tomography — Talar fractures, intraarticular calcaneus fractures, and tarsometatarsal fractures/dislocations are the most common indications for computed tomography (CT) of the foot (figure 4). With these fractures, CT can provide the primary diagnosis for initial management in the emergency department and provides key information if the need for later operative repair is anticipated.
Magnetic resonance imaging — Magnetic resonance imaging (MRI) of foot injuries is rarely performed as part of the acute evaluation because the information typically does not change initial management. MRI may be useful in children whose radiographic imaging remains normal but whose recovery from injury is prolonged and is especially helpful in detecting osteochondral abnormalities in young children. MRI can also be used to monitor vascularity in children with talar neck fractures.
INITIAL MANAGEMENT
Emergency conditions — The clinician should obtain emergent orthopedic consultation in the patients with the following conditions:
●Open fractures – These injuries usually involve a motor vehicle collision or are machine-related, often involving a lawn mower, chainsaw, or heavy weight [1]. Patients with open fractures 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 be treated with empiric parenteral antibiotics (eg, cefazolin, or, in regions with a high prevalence of methicillin-resistant Staphylococcus aureus, clindamycin or vancomycin, depending upon local resistance patterns. These patients also require thorough operative irrigation and debridement. In addition, tetanus prophylaxis should be provided, as needed (table 2). (See "Minor wound evaluation and preparation for closure", section on 'Irrigation' and "Staphylococcus aureus in children: Overview of treatment of invasive infections", section on 'Empiric antimicrobial therapy'.)
●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 foot fractures most commonly occurs due to compartment syndrome as direct vascular insufficiency due to a displaced fracture is rare in this region.
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, ibuprofen) may suffice for patients with mild pain after a foot injury. Parenteral analgesia (eg, intravenous morphine) 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.
INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL — The following injuries warrant urgent orthopedic consultation:
●Fractures with vascular compromise or suspected compartment syndrome
●Any talar neck fracture
●Intraarticular calcaneus fractures
●Tarsometatarsal fractures
DEFINITIVE TREATMENT — The treatment of pediatric foot fractures is guided by small case series and empirical observation [12].
Talar fractures — Any talar neck fracture should be reviewed by an orthopedist. Due to the risk of avascular necrosis, it is important to have a coordinated approach to acute treatment and close follow-up. However, a minimally displaced talar neck fracture (<5 mm) or lateral process of the talus fracture is typically immobilized using a short leg posterior splint or short leg cast with orthopedic follow-up in five to seven days. Subsequently, these fractures are treated in a long leg plaster cast for six to eight weeks. Fewer than 5 mm of displacement and fewer than five degrees of malalignment on anterior-posterior (AP) view are acceptable because the talus has good remodeling potential in children [3].
Nondisplaced lateral process talus fractures are treated with immobilization and non-weight bearing for four to six weeks.
Displaced talar neck or lateral process fractures typically require open reduction and internal fixation [3,6,8,13].
Calcaneal fractures — Most of these fractures are extraarticular (image 2 and image 3) and usually heal well with immobilization alone [4]. These fractures may be immobilized with a posterior short leg splint or short leg cast. Orthopedic follow-up should occur within seven days.
Satisfactory results are seen even in fractures with some depression of the posterior facet (figure 3) because of good remodeling potential [11]. Nondisplaced or minimally displaced fractures are immobilized in a non-weight bearing short leg cast for five to six weeks to allow healing.
Intraarticular fractures warrant urgent orthopedic consultation. Operative reduction and stabilization is required in children with severe displacement or joint depression [4]. Compartment syndrome is of significant concern in children with these fractures.
Midfoot fractures — Children with avulsion fractures of the navicular or cuboid bones may be immobilized with a posterior short leg splint or short leg cast with orthopedic referral in seven days. Definitive treatment consists of a walking cast for three to four weeks.
For a displaced fracture with articular incongruity, urgent orthopedic surgical consultation is indicated. For compression or "nutcracker" fractures of the cuboid, surgical treatment with bone grafting may be necessary to prevent long-term pain and disability [9,14].
Tarsometatarsal (Lisfranc) fractures — Nondisplaced or minimally displaced (<2 to 3 mm) fractures may undergo posterior short leg splinting or short leg casting with orthopedic follow-up in seven days [10]. Definitive care consists of a short leg cast for three to four weeks. The position should be monitored by frequent follow-up radiographs.
Displaced Lisfranc injuries warrant prompt orthopedic consultation for operative reduction and stabilization [3,15].
COMPLICATIONS — Long-term complications following hindfoot and midfoot fractures are less common in children than adults. The location of the injury strongly determines the likelihood of complications:
●Avascular necrosis of the body of the talus is a serious complication of talar neck fractures that may develop weeks to months after injury. Displaced fractures are at highest risk [3]. Ongoing orthopedic follow-up is typically necessary for one to two years after injury.
●Calcaneal fractures which remain extraarticular or cause mild joint depression typically have good clinical outcomes in children with few complications [5,16]. However, displaced intraarticular injuries may result in long-term joint pain or stiffness.
●Compression fractures of the cuboid ("nutcracker" fracture) may lead to alterations in foot mechanics and severe pain [9,14]. Other midfoot injuries heal well in children.
●Tarsometatarsal (Lisfranc) fractures run a more benign course in children than in adults. Acute associated complications include forefoot ischemia and skin necrosis. Late degenerative changes with pain and loss of function are also possible [3,17].
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: How to care for your child's cast (The Basics)")
●Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Mechanism of injury – Mid- or hind-foot fractures typically result from falling from a significant height or motorized vehicle collisions. A foot fracture, particularly one sustained in a fall from a height, may mask other injuries, especially spinal column compression fractures. (See 'Mechanism of injury' above and 'History' above.)
●Clinical features and examination – Patients who have sustained major trauma warrant a complete physical examination and appropriate ancillary studies (table 1). A complete evaluation of the entire lower extremity should be conducted before assuming that the injury is confined to the foot, especially in a child who is less than five years of age and/or is nonverbal. (See 'Physical examination' above.)
Most patients with isolated fractures of the midfoot and hindfoot are unable to walk or have marked limitation of ambulation. Patterns of swelling and location of tenderness on palpation can assist in identifying the fracture site. (See 'Physical examination' above.)
●Initial management – Emergency conditions, such as an open fracture, neurovascular compromise, or compartment syndrome require prompt recognition and treatment (see 'Emergency conditions' above). For children with no signs of neurovascular compromise or compartment syndrome, initial therapy consists of analgesia and measures to reduce swelling and pain. (See 'Analgesia and initial care' above.)
●Radiographic diagnosis – Plain radiographs, with anterior-posterior (AP), lateral, and oblique views of the foot, remain the most appropriate initial imaging modality and suffice to diagnose most low energy injuries. In rare instances, comparison views with the uninjured foot may be helpful in identifying subtle fractures. An axial view is indicated for children with a suspected calcaneus fracture. (See 'Radiographic diagnosis' above.)
Talar fractures, calcaneus fractures, and tarsometatarsal fractures/dislocations are the most common indications for computed tomography (CT) of the foot. With these fractures, CT can provide the initial diagnosis and information for possible later operative repair. (See 'Computed tomography' above.)
●Specialty consultation – The clinician should obtain emergency orthopedic consultation for patients with vascular compromise, compartment syndrome, or open fractures of the metatarsal bone or proximal phalanx. (See 'Emergency conditions' above.)
The clinician should obtain urgent orthopedic consultation, generally within one to two days, for children with any of the following foot fractures (see 'Indications for orthopedic consultation or referral' above and 'Definitive treatment' above):
•Any talar neck fracture and displaced talar fracture
•Intraarticular calcaneus fractures
•Tarsometatarsal fractures
•Displaced midfoot fractures
●Nondisplaced fractures – Nondisplaced talar and tarsometatarsal fractures, extraarticular calcaneal fractures, and avulsion fractures of the midfoot may be treated with a posterior short leg splint or a short leg cast. These patients should be evaluated by an orthopedist with pediatric expertise within one week. (See 'Definitive treatment' above.)
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