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.

Thromboelastagram and Trauma

Thromboelestagram and TraumaTrauma and accidental injuries keep us all quite busy in the Emergency Departments across the country. Unfortunately, despite advances in prevention, trauma is still the leading cause of mortality in children. Appropriately, we have discussed numerous topics pertaining to trauma (ex, Pneumothorax, Traumatic Aortic Injury, Major Brain Injury, Abdominal Trauma) and recently even touched upon the notion of Damage Control Resuscitation. One aspect of damage control resuscitation is the idea that coagulopathy is risk factor for mortality and, thus, it is important for us to understand a patient’s coagulation characteristics early on in management. Unfortunately, traditional PT/PTT and INR do not reveal the complete picture. Let’s look at a tool that may help us see that picture better – The Thromboelastagram:

 

Coagulopathy and Trauma

  • The “Terrible Triad of Trauma” = Hypothermia, Acidosis, and Coagulopathy
    • Severe hemorrhage and large volumes of saline or packed RBCs exacerbate all three aspects of this terrible triad.
      • Lots of isotonic fluids can dilute clotting factors, in addition to causing numerous other intracellular and extracellular chaos (increase inflammatory markers) complicating the patient’s physiologic status.
      • Even pRBCs can cause coagulopathy.
    • Acidosis and Coagulopathy are associated with requiring blood products. [Smith, 2016]
  • Trauma, itself, can lead to coagulopathy.
    • Patients who have had major trauma can arrive to the ED already having developed evidence of fibrinolysis and coagulopathies.
    • This can be further exacerbated by our therapies (… like lots of saline).
  • Early coagulopathy is associated with increased mortality in trauma patients (both adult and pediatric). [Strumwasser, 2016; Hendrickson, 2012; Talving, 2009; Niles, 2008; MacLeod, 2003]
    • Damage Control Resuscitation aims to reduce this effect by empirically treating coagulopathy with balanced blood product transfusions (ie, massive transfusion protocols).
      • It also focuses on using limited amounts of saline.
      • The true efficacy of massive transfusion protocols in pediatric trauma patients is still debated and broad application to all severely injured children may not be beneficial. [Cannon, 2017]
    • Empirically treating all severely injured may not be the best method to treat coagulopathy.
      • It may be better to treat those who actually have it.
      • But, PT/PTT and INR do not tell the whole story…

 

Thromboelastogram for Trauma

  • Thromboelastography (TEG) generates a Thromboelastogram [See below from Nylund, 2009].
  • TEG is a rapid, point-of-care test. [Nylund, 2009]
    • Traditional coagulation studies can take ~30-60 min to run.
    • TEG can be complete in ~10 min.
    • Point-of-care PT/PTT and INR tests do exist, but…
  • TEG measures the ENTIRE coagulation cascade. [Nylund, 2009]
    • It uses whole blood… PT/PTT and INR use just the plasma.
    • PT/PTT only evaluate part of the coagulation cascade.
    • PT/PTT does not evaluate the interaction between clotting factors and platelets.
    • PT/PTT does not assess fibrinogen or platelet function.
  • TEG is the only readily available test that assesses the fibrinolytic system.
  • Thromoboelastograms generates a tracing that can help providers tailor therapies (like FFP and Platelets) to what an individual patient may require. [Nylund, 2009]
    • Can identify the coagulopathic.
    • Can identify the patient who may benefit from anti-fibrinolytic.
    • Can identify the hypercoagulable patient also (which also can happen in the setting of trauma).
    • Each segment (ex, r-time, MA) describe specific characteristics of the clotting process (see Nylund, 2009 for nice description).

Thromboelastography

 

Moral of the Morsel

  • Clotting involves more than plasma. TEG can help you see the entire picture.
  • Coming to an ED near you… The TEG will be a tool that we need to become familiar with.

 

References

Cannon JW1, Johnson MA, Caskey RC, Borgman MA, Neff LP. High ratio plasma resuscitation does not improve survival in pediatric trauma patients. J Trauma Acute Care Surg. 2017 Aug;83(2):211-217. PMID: 28481839. [PubMed] [Read by QxMD]

Strumwasser A1, Speer AL, Inaba K, Branco BC, Upperman JS, Ford HR, Lam L, Talving P, Shulman I, Demetriades D. The impact of acute coagulopathy on mortality in pediatric trauma patients. J Trauma Acute Care Surg. 2016 Aug;81(2):312-8. PMID: 27032006. [PubMed] [Read by QxMD]

Smith SA1, Livingston MH2, Merritt NH3. Early coagulopathy and metabolic acidosis predict transfusion of packed red blood cells in pediatric trauma patients. J Pediatr Surg. 2016 May;51(5):848-52. PMID: 26960738. [PubMed] [Read by QxMD]

Hendrickson JE1, Shaz BH, Pereira G, Atkins E, Johnson KK, Bao G, Easley KA, Josephson CD. Coagulopathy is prevalent and associated with adverse outcomes in transfused pediatric trauma patients. J Pediatr. 2012 Feb;160(2):204-209. PMID: 21925679. [PubMed] [Read by QxMD]

Nylund CM1, Borgman MA, Holcomb JB, Jenkins D, Spinella PC. Thromboelastography to direct the administration of recombinant activated factor VII in a child with traumatic injury requiring massive transfusion. Pediatr Crit Care Med. 2009 Mar;10(2):e22-6. PMID: 19265363. [PubMed] [Read by QxMD]

Talving P1, Benfield R, Hadjizacharia P, Inaba K, Chan LS, Demetriades D. Coagulopathy in severe traumatic brain injury: a prospective study. J Trauma. 2009 Jan;66(1):55-61; discussion 61-2. PMID: 19131806. [PubMed] [Read by QxMD]

Niles SE1, McLaughlin DF, Perkins JG, Wade CE, Li Y, Spinella PC, Holcomb JB. Increased mortality associated with the early coagulopathy of trauma in combat casualties. J Trauma. 2008 Jun;64(6):1459-63; discussion 1463-5. PMID: 18545109. [PubMed] [Read by QxMD]

MacLeod JB1, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma. 2003 Jul;55(1):39-44. PMID: 12855879. [PubMed] [Read by QxMD]

Holmes JF1, Goodwin HC, Land C, Kuppermann N. Coagulation testing in pediatric blunt trauma patients. Pediatr Emerg Care. 2001 Oct;17(5):324-8. PMID: 11673707. [PubMed] [Read by QxMD]

The post Thromboelastagram and Trauma appeared first on Pediatric EM Morsels.

Kohler’s Disease: Avascular Necrosis of the Navicular Bone

Kohler's Disease: Avascular Necrosis of the Navicular BoneThe “limping child” is commonly encountered in the ED, and while we may consider the common entities like Osgood Schlatter’s Disease, the potential issues that lead to a child limping are vast. Certainly we concern ourselves with weighing Toxic Synovitis versus Septic Arthritis. Some kids would be at risk for osteomyelitis, while others may be suffering from Legg-Calve-Perthes Disease. Obviously, we cannot forget fractures (ex, Toddler’s Fracture) or SCFE… while also considering issues “outside” of the leg – Appendicitis, PID, EpididymitisOvarian Torsion, Testicular Torsion, or Acute Cerebellar Ataxia. After an extensive review of your Ddx list, you may be inclined to call it “Growing Pains,” but before you do, consider avascular necrosis in the foot… and Kohler’s Disease:

 

Avascular Necrosis

  • Also called “osteonecrosis.”
  • Lack of blood circulation in a bone leading to cellular death.
    • Can be due to occlusion of arterial or venous flow.
    • Can be from anatomic disruption of the blood vessel.
  • Most often related to trauma, particularly in the foot. [DiGiovanni, 2007]
  • Other conditions / behaviors increase the risk for it:
  • Radiographically, osteonecrosis can appear as: [DiGiovanni, 2007]
    • Increased radiodensity
    • Bony collapse
    • Loss of trabecular pattern
    • Fragmentation
    • Flattening
    • Sclerotic bone
  • Osteonecrosis can occur in any bone, but some are more prone than others, particularly in the foot. [DiGiovanni, 2007]
    • Talus
    • 1st metatarsal
    • 2nd metatarsal
    • Navicular

 

Navicular Avascular Necrosis

  • The Navicular is the last tarsal bone to ossify. [Alhamdani, 2017]
    • Susceptible to mechanical compression by the adjacent ossified talus and cuneiform bones.
    • The perichondral blood supply gets compressed and leads to ischemia of the central bone.
  • The Navicular has vulnerable vascular supply. [DiGiovanni, 2007]
    • Doralis pedis artery provides several perforating branches.
    • Medial plantar artery supplies the plantar surface of the bone.
    • Intraosseous blood flow is centripetal and has a central watershed area [DiGiovanni, 2007]
  • Avascular necrosis of the navicular can be related to trauma.
    • Feet are poorly protected in high-speed MVCs.
    • Injury may not be apparent at first.
    • Persistent pain following trauma warrants consideration for this.
  • Avascular necrosis of the navicular can also be idiopathic. [DiGiovanni, 2007]
    • Or… the trauma was remote and just not considered significant at the time.
    • Termed Kohler’s Disease in children and Muller-Weiss disease in adults.

 

Kohler’s Disease

  • Relatively rare.
  • Self-limited condition, although therapy hastens improvement.
  • Kohler’s Disease presents between ages of 2 and 9 years.
  • More common in males, but females often present at younger age compared to male counterparts.
  • May present with:
    • Sudden onset of pain and limping
    • Can also be insidious.
    • Midfoot pain
    • Child may favor walking on lateral aspect of affected foot. [Gillespie, 2010]
    • Tenderness and swelling over dorsal mid foot.
    • Occasionally, even redness
  • The radiographic findings of slcerosis, fragmentation, and flattening can also be a NORMAL VARIANT, so need to be found in the appropriate clinical setting. [DiGiovanni, 2007]
  • Treatment:
    • Generally, conservative management is used.
      • Rest
      • Pain control
      • Limited weight bearing
      • Soft arch supports or medial heal wedge [Shastri, 2012]
    • Short leg cast applied for a brief period (a few weeks), can help reduce duration of symptoms. [Alhamdani, 2017]
    • Overall prognosis is good!

 

Moral of the Morsel

  • Don’t just look at the leg! Think “outside” of the leg as a possible source for a child’s limp.
  • Don’t forget the foot! We commonly consider the knee and hip, but foot pain can be difficult to discern in young children, so actively look for it.
  • Midfoot pain? Think about avascular necrosis of the navicular bone!

 

References

Alhamdani M1, Kelly C2. Kohler’s disease presenting as acute foot injury. Am J Emerg Med. 2017 Nov;35(11):1787. PMID: 28801039. [PubMed] [Read by QxMD]

Shastri N1, Olson L, Fowler M. Kohler’s Disease. West J Emerg Med. 2012 Feb;13(1):119-20. PMID: 22461942. [PubMed] [Read by QxMD]

Gillespie H1. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr Sports Med Rep. 2010 Sep-Oct;9(5):265-8. PMID: 20827090. [PubMed] [Read by QxMD]

DiGiovanni CW1, Patel A, Calfee R, Nickisch F. Osteonecrosis in the foot. J Am Acad Orthop Surg. 2007 Apr;15(4):208-17. PMID: 17426292. [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 Kohler’s Disease: Avascular Necrosis of the Navicular Bone appeared first on Pediatric EM Morsels.