Metatarsal Fractures in Children

Metatarsal Fractures and Jones Fractures in Children

Children are incredibly resilient and their tissues are very pliable and plastic. With that being said, their immature skeleton can often bring additional considerations into play when evaluating kids for possible fractures (ex, Toddler’s Fracture, Nasal Fractures, Pelvic Avulsion Fractures). We have already discussed how Ankle Injuries need to be thought of a little differently in children. Certainly, the foot is a frequently injured area (ex, Plantar Puncture Wounds), but do foot fractures warrant special consideration also? Let’s take a minute to digest a morsel on Metatarsal Fractures in Children:

 

Metatarsal Fractures: Basics

  • With increasingly active children (and Extreme Sports), foot fractures are becoming more common.
  • The 5th metatarsal is the most commonly fractured metatarsal in children. [Singer, 2008]
  • Most commonly associated with:
    • Twisting mechanism (like during sports)
    • Repetitive Stress (like during sports)
    • Direct Trauma
  • When 2nd, 3rd, or 4th metatarsals are fractured, they are frequently associated with another metatarsal fracture, while 1st and 5th metatarsal fractures can be isolated. [Singer, 2008]
  • Metatarsal fractures are frequently missed on initial inspection of radiographs. [Mounts, 2011]

 

Metatarsal Fractures: Age Matters

  • Children 5 years or Younger:
    • More likely (>50% of cases) to be injured by Fall from Height. [Singer, 2008]
    • More likely to fracture 1st metatarsal!
  • Children older than 5 years of age:
    • More likely (> 50% of cases) to be injured by “Fall” from Standing. [Singer, 2008]
    • Greater likelihood of being related to sport activities. [Singer, 2008]
    • More likely to fracture 5th metatarsal!

 

5th Metatarsal Fractures: Location Matters

  • There are 5 types of 5th metatarsal fractures: [Herrera-Soto, 2007]
    1. Fleck
      • Fracture at the base of the 5th metatarsal tubercle.
      • Treated with walking cast for 3-6 wks.
      • Displaced avulsions may take longer to heal, but do so with low rate of complications.
    2. Intra-articular
      • Tubercle fracture that extends to intra-articular area
      • May extend to metatarsal-cuboid joint or to the joint with 4th metatarsal.
      • Treated with short leg walking cast or non-weight bearing cast for 4-6 wks.
    3. Jones
      • Fracture at the proximal diaphysial region.
      • Problematic region as there is tenuous vascular supply.
      • Prone to re-fracture after cast removal.
      • Debate over best treatment strategy for Jones fractures.
        • Ones related to stress injuries / repetitive stress (have cortical sclerosis and have poor blood supply) are better treated by internal fixation.
        • Acute Jones fractures may be treated with conservative approach.
        • Children > 13 years more prone to re-fracture.
        • Surgery allows for earlier return to sports for the active adolescents.
        • Strategy needs to be tailored to the individual.
    4. Diaphyseal
      • Treated with non-walking cast for 4-6 weeks.
      • Low rate of complications.
      • “Significant” angulation or open fractures may require surgery.
    5. Neck
      • Treated with short-leg walking cast for 3-4 weeks.
      • Low rate of complications.
      • “Significant” angulation or open fractures may require surgery.
  • Risk for complications:
    • Often based on “classifications” or “zones” of the metatarsal.
      • Can be difficult to discern. [Mahan, 2015]
      • Hard to apply on initial assessment. [Mahan, 2015]
    • Can be based on simple measurement from proximal tip of metatarsal. [Mahan, 2015]
      • Fractures 0-20 mm had low rate of requiring surgery.
        • More commonly seen in young children.
      • Fractures 20-40 mm (or 25-50% of overall metatarsal length) had highest rate of requiring surgery.
        • More commonly seen in adolescents.
      • Fractures > 40 mm had lowest rate of requiring surgery.

 

Moral or the Morsel

  • Look carefully! Metatarsal fractures are overlooked often… scrutinize those images!
  • 2nd, 3rd, 4th? Think of another! The middle 3 metatarsals rarely fracture in isolation.
  • 20-40 mm? Think of surgery! While the exact therapy will be tailored to the individual, communication about the “at-risk” location to the orthopod will help develop that strategy.

 

References

Mahan ST1, Lierhaus AM, Spencer SA, Kasser JR. Treatment dilemma in multiple metatarsal fractures: when to operate? J Pediatr Orthop B. 2016 Jul;25(4):354-60. PMID: 26990060. [PubMed] [Read by QxMD]

Mahan ST1, Hoellwarth JS, Spencer SA, Kramer DE, Hedequist DJ, Kasser JR. Likelihood of surgery in isolated pediatric fifth metatarsal fractures. J Pediatr Orthop. 2015 Apr-May;35(3):296-302. PMID: 24992354. [PubMed] [Read by QxMD]

Mounts J1, Clingenpeel J, McGuire E, Byers E, Kireeva Y. Most frequently missed fractures in the emergency department. Clin Pediatr (Phila). 2011 Mar;50(3):183-6. PMID: 21127081. [PubMed] [Read by QxMD]

Singer G1, Cichocki M, Schalamon J, Eberl R, Höllwarth ME. A study of metatarsal fractures in children. J Bone Joint Surg Am. 2008 Apr;90(4):772-6. PMID: 18381315. [PubMed] [Read by QxMD]

Herrera-Soto JA1, Scherb M, Duffy MF, Albright JC. Fractures of the fifth metatarsal in children and adolescents. J Pediatr Orthop. 2007 Jun;27(4):427-31. PMID: 17513965. [PubMed] [Read by QxMD]

Ribbans WJ1, Natarajan R, Alavala S. Pediatric foot fractures. Clin Orthop Relat Res. 2005 Mar;(432):107-15. PMID: 15738810. [PubMed] [Read by QxMD]

Manusov EG1, Lillegard WA, Raspa RF, Epperly TD. Evaluation of pediatric foot problems: Part I. The forefoot and the midfoot. Am Fam Physician. 1996 Aug;54(2):592-606. PMID: 8701839. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

1 Response

  1. April 18, 2018

    […] Ped EM Morsels – Metatarsal Fractures in Children […]

Leave a Reply

Your email address will not be published. Required fields are marked *