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]

The post Metatarsal Fractures in Children appeared first on Pediatric EM Morsels.

First10EM Journal Club: March 2018

Welcome back – another episode of the sporadic journal club this month.  In this month’s episode, Justin and I cover chest pain, LPs, nebulised furosemide, the Lazarus phenomenon and of course, the sport of Quidditch.  Spoiler alert: Quidditch players suffer wrist sprains and insightless injuries to their own pride…

You can check out the written version and some choice videos of hipsters playing Quidditch over at the First10EM blog.

Here are the papers we cover this month:


Syed S, Gatien M, Perry JJ. Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest pain who can safely be removed from cardiac monitoring. CMAJ. 2017; 189(4):E139-E145. PMID: 28246315 [free full text]

Bottom line: The rule is probably not ready for prime-time, but the data here does remind us that not every chest pain patient requires a cardiac monitor.


Gongora CA, Bavishi C, Uretsky S, Argulian E. Acute chest pain evaluation using coronary computed tomography angiography compared with standard of care: a meta-analysis of randomised clinical trials. Heart. 2018; 104(3):215-221. PMID: 28855273

Bottom line: In the RCTs we have to date, CCTA demonstrate no benefit, but leads to an increase in unnecessary invasive procedures.


Owens D. Nebulized Furosemide for the Treatment of Dyspnea. Journal of Hospice & Palliative Nursing. 2009; 11(4):200-201. DOI: 10.1097/NJH.0b013e3181b06227

Bottom line: This won’t be first-line for me, but it is nice to know about.


Driver B, Dodd K, Klein LR. The Bougie and First-Pass Success in the Emergency Department. Annals of emergency medicine. 2017; 70(4):473-478.e1. PMID: 28601269

Bottom line: The bougie is a great device


Nath S, Koziarz A, Badhiwala JH. Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis. Lancet. 2017. PMID: 29223694

Bottom line: This one is done. It is time to stop doing studies and just use the atraumatic needles.


April MD, Long B, Koyfman A. Emergency Medicine Myths: Computed Tomography of the Head Prior to Lumbar Puncture in Adults with Suspected Bacterial Meningitis – Due Diligence or Antiquated Practice? The Journal of emergency medicine. 2017; 53(3):313-321. PMID: 28666562

Bottom line: There is no clear evidence-based answer here. Just be sure that no matter what you do those antibiotics are given as soon as possible if you are considering bacterial meningitis.


Aboltins CA, Hutchinson AF, Sinnappu RN. Oral versus parenteral antimicrobials for the treatment of cellulitis: a randomized non-inferiority trial. The Journal of antimicrobial chemotherapy. 2015; 70(2):581-6. PMID: 25336165

Bottom line: For the most part, stick with oral antibiotics for cellulitis.


Kuisma M, Salo A, Puolakka J. Delayed return of spontaneous circulation (the Lazarus phenomenon) after cessation of out-of-hospital cardiopulmonary resuscitation. Resuscitation. 2017; 118:107-111. PMID: 28750883

Bottom line: Although The Princess Bride provides us with much wisdom, I am not sure “there is a big difference between mostly dead and all dead”

Princess bride:

Monty Python “Not Dead Yet”

Patricia Gerritson’s SMACC DUB Talk on the Lazarus phenomenon...
 


Ilgen JS, Eva KW, Regehr G. What’s in a Label? Is Diagnosis the Start or the End of Clinical Reasoning? Journal of general internal medicine. 2016; 31(4):435-7. PMID: 26813111


 Pennington R, Cooper A, Edmond E, Faulkner A, Reidy MJ, Davies PSE. Injuries in quidditch: a descriptive epidemiological study. International journal of sports physical therapy. 2017; 12(5):833-839. PMID: 29181260 [free full text]

Bottom line: This is just ridiculous. If I catch anyone running around with a broom between your legs, I will mock you endlessly. Seriously – just look at the kids in this video.

 

Yes, that is seriously a thing….

The podcast is below, or download it on your favourite podcast app /thingy.

 

Casey