Pediatric Tarsal and Metatarsal Fractures

Key Points:

• Fractures of the cuboid, cuneiforms and metatarsals can largely be treated non-operatively in children.
• Operative fixation should be considered for fractures involving the 1st metatarsal, multiple metatarsals, articular surface, and Lisfranc injuries. 
• Base of 5th metatarsal fractures can be treated non-operatively, however families should be counseled about the nonunion rates and earlier return to function with operative fixation.

Description:

• (https://posna.org/Physician-Education/Study-Guide/Foot-Dislocations-(Lisfranc,Subtalar)
• https://posna.org/Physician-Education/Study-Guide/Calcaneus-Fractures). 

Epidemiology:

• Foot fractures account for 5-8% of pediatric fractures and 7% of physeal injuries.6,9,10
• Metatarsal fractures are most likely to involve the first metatarsal in children less than 5 years old and the base of the 5th metatarsal in children older than 10 years old.3 
• Hindfoot and midfoot fractures are uncommon, and often misdiagnosed.11

Clinical Findings:

• Cuboid, cuneiform and metatarsal fractures generally present with pain, swelling, and bruising at their anatomic locations. 
  • Cuboid:  lateral aspect of the foot midfoot, just proximal to the prominence of the 5th metatarsal base
  • Cuneiforms: medial midfoot, proximal to first through third metatarsals
  • Metatarsals: forefoot pain that can be localized by gentle palpation
    • Certain stress fractures should be evaluated for predisposing conditions. For example, 2nd metatarsal stress fractures may be associated with relative energy deficiency (“Female Athlete Triad”).8 
• Isolated fractures of the cuboid and cuneiforms are uncommon, and it is important to evaluate them with suspicion for Lisfranc joint complex injuries. 

Imaging Studies:

• Radiographs should be the initial imaging for each of these fractures
  • Weight bearing (standing) radiographs should be obtained when possible
  • Contra-lateral imaging may be helpful 
• Initial x-rays of cuboid and cuneiform fractures may be normal13, therefore clinical exam may determine management
  • Repeat imaging may reveal periosteal reaction or sclerotic line as the bone heals11
  • Cuneiform fractures should be evaluated like Lisfranc joint complex injuries, including weight-bearing radiographs
• 5th metatarsal base fracture x-rays
  • normal apophysis development can be confused with avulsion fractures
    • appears at ~8 years
    • ossifies at ~12 years in girls and ~15 years in boys
  • Special considerations given to Jones fractures, defined as metadiaphyseal fractures aligning with the 4th-5th articulation on the internal oblique XR.
  • Fractures proximal and distal to this landmark are considered zones 1 and 3, respectively. (Figure 1)

Treatment:

• Cuboid fractures are generally treated with a short-leg walking cast for approximately 4 weeks and heal reliably without sequelae.13 
• Isolated cuneiform fractures can be treated with 2-3 weeks of a walking short-leg cast.2 
• Metatarsal shaft fractures without articular involvement can be treated in 4-6 weeks of a walking short leg cast. 
  • There is limited evidence regarding acceptable displacement, however there are reports of success with nonsurgical management with < 75% displacement. 
  • Operative fixation should be considered for fractures involving the 1st metatarsal, the articular surface, and multiple metatarsals.5,12    
• Proximal 5th metatarsal fractures
  • apophyseal fractures (zone 1 or “avulsion type”) do well in a short-leg walking cast for 3-6 weeks1
  • metadiaphyseal (zone 2) fractures can be successfully treated with a non-weightbearing short leg cast for 6-8 weeks. Complete radiographic healing has been reported to take an average of 12 weeks. However, patients should be counseled about1,7:
    • the risk of refracture
    • risk of non-union (reported as high as 44%) 
    • earlier return to function and sport with operative fixation
      • the most common method of acute fracture fixation is intramedullary cannulated screws
  • proximal diaphyseal fractures (zone 3) should be treated similarly to zone 2 fractures with a non-weightbearing cast for 6-8 weeks and shared decision making regarding operative fixation.
• Walking boot may be considered for fractures in place of weight bearing casts. 

Complications:

• There are no particular reported complications of cuboid fractures. If children have a persistent limp after 4 weeks of immobilization, prior studies have shown success with immobilizing them for 2-4 more weeks. 
• as in adults, metatarsal fractures by crush mechanisms should be monitored for compartment syndrome
• growth arrest in the first metatarsal can cause improper development of the medial longitudinal arch11. 
• Jones’ fractures are associated with an approximately 30% risk of non-union, and this rate has been reported to be higher in athletes

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References:

1. Herrera-Soto JA, Scherb M, Duffy MF, Albright JC. Fractures of the fifth metatarsal in children and adolescents. J Pediatr Orthop. 2007 Jun;27(4):427–431. doi:10.1097/01.bpb.0000271323.56610.da
2. Kay RM, Tang CW. Pediatric foot fractures: evaluation and treatment. J Am Acad Orthop Surg. 2001 Oct;9(5):308–319. doi:10.5435/00124635-200109000-00004
3. Landin LA. Epidemiology of children’s fractures. J Pediatr Orthop B. 1997 Apr;6(2):79–83. doi:10.1097/01202412-199704000-00002
4. Lawrence SJ, Botte MJ. Jones’ fractures and related fractures of the proximal fifth metatarsal. Foot Ankle. 1993 Aug;14(6):358–365. doi:10.1177/107110079301400610
5. Mahan ST, Lierhaus AM, Spencer SA, Kasser JR. Treatment dilemma in multiple metatarsal fractures: when to operate? J Pediatr Orthop B. 2016 Jul;25(4):354–360. doi:10.1097/BPB.0000000000000311
6. Mizuta T, Benson WM, Foster BK, Paterson DC, Morris LL. Statistical analysis of the incidence of physeal injuries. J Pediatr Orthop. 1987 Oct;7(5):518–523. doi:10.1097/01241398-198709000-00003
7. Mologne TS, Lundeen JM, Clapper MF, O’Brien TJ. Early Screw Fixation versus Casting in the Treatment of Acute Jones Fractures. Am J Sports Med. 2005 Jul 1;33(7):970–975. doi:10.1177/0363546504272262
8. Moreira CA, Bilezikian JP. Stress Fractures: Concepts and Therapeutics. J Clin Endocrinol Metab. 2017 Feb 1;102(2):525–534. doi:10.1210/jc.2016-2720
9. Peterson CA, Peterson HA. Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma. 1972 Apr;12(4):275–281. doi:10.1097/00005373-197204000-00002
10. Peterson HA, Madhok R, Benson JT, Ilstrup DM, Melton LJ. Physeal fractures: Part 1. Epidemiology in Olmsted County, Minnesota, 1979-1988. J Pediatr Orthop. 1994 Aug;14(4):423–430. doi:10.1097/01241398-199407000-00002
11. Ribbans WJ, Natarajan R, Alavala S. Pediatric foot fractures. Clin. Orthop. Relat. Res. 2005 Mar;(432):107–115. doi:10.1097/01.blo.0000156451.40395.fc
12. Robertson NB, Roocroft JH, Edmonds EW. Childhood metatarsal shaft fractures: treatment outcomes and relative indications for surgical intervention. J Child Orthop. 2012 Jun;6(2):125–129. doi:10.1007/s11832-012-0403-5
13. 13. Simonian PT, Vahey JW, Rosenbaum DM, Mosca VS, Staheli LT. Fracture of the cuboid in children. A source of leg symptoms. J Bone Joint Surg Br. 1995 Jan;77(1):104–106. 

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