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Paediatric foot injuries
The Foot (1998) 8,9-16 0 1998 Harcourt BI-ace 81Co. Lrd
REVIEWARTICLE
Paediatric foot injuries D. Stanley Department
of Ovthopaediics, Northern General Hospital, Sheffield, UK
INTRODUCTION
It is perhaps surprising when we consider how much time children spend on their feet that childhood foot injuries are relatively uncommon. From time to time, however, a variety of problems will be encountered and it is, therefore, important that the clinician is familiar both with the types of injury which may occur, and the best method of management. In young children a careful clinical assessment is particularly valuable since at this stage of their development the bones of the foot are predominantly cartilagenous and radiographs often unhelpful. In the older child an epiphyseal injury may not be appreciated when the radiographs are examined, and on occasions the opposite may happen with a normal epiphysis being mistakenly identified as a fracture and treated by plaster immobilization. In all these situations, therefore, a sound knowledge of normal anatomy is vital if the correct clinical and radiological diagnosis is to be made and the appropriate treatment instituted.
become wet or broken (a frequent occurrence in children) will fail to provide satisfactory fracture support and if not replaced will be responsible for the poor outcome of treatment. Open reduction and internal fixation is generally only indicated when closed methods of treatment fail. It must be undertaken with care to avoid excessive soft tissue dissection since this will further impair the blood supply to the fracture. In addition, an appropriate type and size of implant should be selected for fracture fixation. In most situations the use of percutaneous Kirschner wires provides adequate fracture stabilization and fulfills the criteria of causing minimal further soft tissue damage. Finally, unlike the situation in adults, childhood fractures may affect growth. It is important, therefore, that children who sustain potentially growth-retarding injuries should remain under review for a minimum of 2 years, and preferably until skeletal maturity.
ANKLE INJURIES MANAGEMENT
OF FRACTURES
For the majority of children’s foot fractures a satisfactory reduction can be achieved by closed manipulation, and the position held by cast immobilization. Careful application of the plaster is important since too tight a plaster may predispose to Volkman’s ischaemia, and too loose a plaster allows fracture displacement. In addition, ridges in the plaster will cause skin damage which may only become apparent once fracture union has occurred and the plaster has been removed. Although a well applied plaster is a good method of treatment, it is only effective if the plaster remains in reasonable condition. Thus, plasters which Correspondence to David Stanley, Consultant Orthopaedic Surgeon, Department of Orthopaedics, Northern General Hospital, Herr& Road, Sheffield S5, UK.
The frequent inability of children to differentiate ankle and foot injuries, plus their biomechanical ‘oneness’ as a unit for stance and normal locomotion necessitates the brief inclusion of ankle injuries in this chapter. Poland’ made the first major study of ankle injuries in children. He noted that the ligaments around the ankle were seldom torn, and that a plane of weakness existed at the growth plate. Thus, following trauma epiphyseal separation was seen to occur at the zone of provisional calcification between the epiphysis and metaphysis. The exact nature of the epiphyseal injury varies with the type of trauma, and although several classifications have been advocated the one that remains most commonly used is that proposed by Salter and Harris.* This is divided into five major types to which, more recently, a sixth has been added (Fig. 1).
10 The Foot
cc9 TYPE I
TYPE I[
TYPE IF
Fig. l-The Salter results in tethering
Type
Harris across
TYPE III
TYPE P
(1963) classification of distal tibia1 eomhyseal the medial tibia1 growth plate. II_
1
Epiphyseal separation occurs without a metaphyseal fracture and usually results from a shearing or torsional force. The radiographs may be normal if the periosteum remains intact, but if torn, separation of the fragments is more clearly seen. Closed manipulation is almost always possible and the reduction can be satisfactorily held by cast immobilization, Type II Epiphyseal separation extends for a variable distance along the epiphyseal plate and then passes through the metaphysis. The injury results from a combination of plantar flexion and eversion, and as in Type I injuries it should be treated by closed manipulation and plaster immobilization. Although Spiegel et al3 have stated that 10% of children with this injury develop growth disturbances, these are minor and do not normally affect function. Type III This injury results from an intra-articular shearing force. The fracture line extends from the joint surface to the epiphyseal plate and then passes along the epiphyseal plate to the ‘periphery. In adolescence, with partial growth plate fusion the fracture lines may pass laterally producing a Tillaux fracture. This can sometimes be reduced by closed manipulation with internal rotation of the foot, but if The Foot
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TYPE III VARIANT
TYPE XC
injuries.
Type VI has been more
recently
added
and the mjury
not, open reduction should be performed. Since the growth plate is already closed medially a transepiphyseal cancellous screw can be safely inserted, and providing accurate reduction is achieved, growth disturbance is never a problem. Another type of distal tibia1 fracture described by Marmor’ is the triplane fracture. This consists of three fragments whose fracture lines are in three different planes. Radiographic interpretation of this complex injury can be difficult and further information may be obtained using computerized tomography. Unless minimally displaced, these fractures require accurate open reduction and internal fixation. Type IV With this injury the fracture extends from the joint surface, through the epiphysis, the epiphyseal plate and the metaphysis. It occurs when an inversion force applied to the supinated foot produces impingement of the talus on the distal tibia. Reduction may be achieved by closed manipulation but if there is more than 2 mm of displacement, open reduction should be undertaken. Up to 14% of these injuries result in growth disturbances due to premature closure of the displaced fragment’s epiphysis. Type V Severe crush injuries to the tibia1 epiphysis are uncommon but serious injuries. Displacement of the epiphysis is usually minimal and the radiographs 0 1998
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Paediatric foot iniuries
Fig. 2-(A) A talar also seen inferiorly.
fracture in a young child The fracture line can be seen passing (B) The less common lateral wall fracture.
often appear normal. The true diagnosis is frequently not made until premature closure of the growth plate has occurred. The prognosis is poor. Type VI With this injury there is either subperiosteal haemorrhage or degloving soft tissue and bony damage to the ankle. In both situations (organization of haematoma or formation of fracture callus) tethering occurs across the medial tibia1 growth plate producing a progressive angular deformity. Treatment in the form of a corrective osteotomy may become necessary but, if possible, should be delayed until after skeletal maturity.
FRACTURES
OF THE TALUS
This injury was unrecognized in children until 1956 when Stephens5 reported two cases of fracture dislocation of the talus. Since then several other reports have appeared in the medical literature, with the largest series being that of Letts and Gibeault.” The majority of these fractures involve the neck of the talus (Fig. 2) and are caused by forced dorsiflexion when the anterior lip of the tibia impinges with the talar neck. Children sustaining this injury usually present with an inability to weightbear and have pain and swelling over the dorsum of the foot. Occasionally, however, when the fracture is undisplaced, there may be little in the way of physical signs. In all cases, therefore, the clinician must have a high index of suspicion whenever a history of forced dorsiflexion of the foot is 0 1998
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through
the neck of the talus.
I1
A small flake of bone is
obtained, and the X-rays should be scrutinized with care in order to avoid missing an undisplaced fracture. Undisplaced fractures should be treated in a nonweightbearing cast until there is radiographic evidence of union. Progressive partial weightbearing is then permitted for 2 to 3 weeks after which the plaster is removed and the child allowed to become fully ambulant. Displaced fractures require urgent reduction. This can usually be achieved by closed manipulation under general anaesthesia with the foot being held in plantar flexion to maintain the reduction. Plaster treatment is instituted as for an undisplaced fracture but when it is changed to a walking cast the foot position is brought up to neutral. When a satisfactory reduction cannot be obtained by closed means and the fracture remains more than 5 mm displaced or 5” angulated, open reduction should be undertaken. A dorsomedial approach usually gives good access and the fracture can be held with Kirschner wires. Less common fractures may involve the body or lateral wall (Fig. 2) of the talus. These should be treated conservatively provided that there is minimum displacement and only occasionally will open reduction be necessary. Follow-up of all children who have sustained talar injuries is essential since even undisplaced fractures may develop avascular necrosis6’ Although this usually occurs within 6 months of injury, the minimum period of follow-up that is advised is 2 years for undisplaced fractures and until skeletal maturity for all other cases. i-he Foot
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Fig. 3-An os calcis fracture in a child. The prognosis is much better than in an adult because of the Increased density of cancellous bone.
FRACTURES
OF THE OS CALCIS
This is a rare injury in children and because the cancellous bone is denser than in adults it has a much better prognosis. The mechanism of injury commonly involves a fall from a height and the patient presents with an inability to weight-bear together with pain and swelling around the hind foot. Radiographic examination, which must include axial views, confirms the diagnosis (Fig. 3). Immobilization in a nonweightbearing cast for 4-6 weeks allows fracture union to occur. This is followed by 2 weeks of partial weightbearing and then the plaster is removed and full mobilization permitted. When swelling is severe, an initial period of hospital admission with elevation of the limb and the application of ice packs is beneficial and should always be advised. Open reduction is almost never justified since, although the radiographs may be improved, the functional result is rarely altered.
FRACTURES OF THE NAVICULAR, AND CUNEIFORM BONES
CUBOID
These are rare injuries (Fig. 4) which usually result from direct trauma. They should be treated by plaster immobilization in a weightbearing cast for 4-6 weeks, by which time union is usually complete. If swelling is severe an initial period of elevation with ice packs is preferred prior to plaster application. Occasionally a crush fracture of the cuboid occurs in association with a midtarsal injury.
MIDTARSAL
INJURIES
Midtarsal injuries in children were first described by Cehner’ and then by Wiley9 who reported 18 cases in children below the age of 16. The Foot
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Fig. LA fracture of the navicular satisfactorily treated in a below-knee
bone. The injury walking cast.
can usually
be
The mechanism of injury can most easily be appreciated when the anatomy of the midtarsal region is understood.” The key to the area is the recessed second metatarsal base which is strongly bound by plantar ligaments to the cuneiform bones and to the third metatarsal. It has only a weak ligamentous bond to the first metatarsal. If the foot is subjected to a strong abduction force, the second metatarsal fractures near its base and the ligament joining it to the first metatarsal is ruptured. This allows lateral displacement of the forefoot on the lateral cuneiform and cuboid with often the latter bone sustaining a crush fracture. Midtarsal dislocations may also occur following violent plantar flexion of the foot when the weak dorsal ligaments between the metatarsals and tarsal bones are ruptured. This injury may also be associated with metatarsal fractures and can easily be missed if, when the radiographs are examined, only the fractures are noted. Children presenting with a midtarsal injury are unable to weightbear and have pain and swelling in the midtarsal region. In addition, when metatarsal fractures are present they are usually clinically palpable. Radiographs may reveal a fracture of the base of the second metatarsal and a crush fracture of the cuboid but gross displacement may not be apparent if the dislocation has spontaneously reduced. Treatment of dislocations which have reduced consists of elevation with ice packs until the swelling has settled, followed by the application of a non-weightbearing cast. This should be maintained for 4 weeks and then removed to allow the child to become fully ambulant. Displaced fracture dislocations require reduction under general anaesthesia with the reduction 0 1998
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should be maintained for 4 weeks at which stage fracture union is usually complete. Fractures in which there is displacement of the metatarsal head require manipulative reduction under general anaesthesia. If the fracture is unstable, the reduction can be held with Kirschner wires inserted percutaneously. Only rarely is open reduction necessary. Avulsion fractures of the fifth metatarsal base occur following an inversion adduction injury to the foot and should also be treated in a below-knee walking cast for 4 weeks.
PHALANGEAL
L
Fig. 5-A metatarsal fracture, the most common foot fracture in a child. Occasionally the fracture is associated with a midtarsal dislocation.
being held with Kirschner wires. These can be inserted percutaneously and their placement optimized by the use of image intensification. A plaster backslab is sufficient to support the foot until the swelling has settled and then a non-weightbearing cast can be applied. The Kirschner wires should be removed at between 2 and 4 weeks at which stage the child may commence weightbearing. No significant long-term complications from this injury have been reported.
FRACTURES
OF METATARSALS
Metatarsal fractures (Fig. 5) are the most common foot fractures in children and result from either a direct injury when the foot is crushed, or indirectly when it is subjected to violent twisting. Occasionally they also occur with midtarsal injuries. Swelling, pain and tenderness over the affected metatarsal is commonly found, with the diagnosis being confirmed radiographically. The most useful X-rays for showing these fractures are antero-posterior and oblique views, but true lateral views should also be taken in order to show the orientation between the metatarsal head and shaft. This is important since a metatarsal fracture which appears satisfactorily aligned on the antero-posterior view may have plantar displacement of the metatarsal head and if fracture union is allowed to proceed in this position the child will develop painful metatarsalgia. Treatment of the majority of metatarsal fractures involves the application of a below-knee walking cast on which the child is allowed to freely mobilize. This 0 1998
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FRACTURES
Phalangeal fractures usually follow either direct trauma when a heavy weight falls on the foot, or indirect trauma when the child kicks something or someone! The affected toe is swollen and painful and the child is unable to bear weight without discomfort. Radiographs confirm the diagnosis. The majority of fractures do not require reduction and can be treated using neighbour strapping. Occasionally, however, the affected toe is angulated or rotated and in this situation, irrespective of the radiographical appearance, the toe should be manipulated such that the position of the nail bed on the affected toe matches the position of the adjacent nail beds. Injuries to the great toe can be more significant with intra-articular fractures requiring accurate reduction to avoid prolonged painful stiffness and occasional growth arrest. The stubbed great toe may sustain a Salter Harris Type I injury to the distal phalanx with damage to the nail such that it overlies the nail fold. If this occurs, the toe should be carefully cleaned, manipulated and, if possible, the nail repositioned. This provides greater stability to the toe than can be achieved if the nail is removed. Children with this injury must be adequately protected against tetanus and should also receive antibiotic cover as this is a compound fracture.
SOFT TISSUE INJURIES Puncture wounds Puncture wounds can occur when a child is barefoot or wearing shoes, and in both cases foreign material may be inoculated into the foot. A detailed history as to the mechanism of injury is important and must be followed by a careful clinical examination. At times, if a non-radiolucent foreign body is suspected, transillumination of the foot in the region of the puncture site can be more helpful than soft tissue radiographs. Whenever a foreign body is implicated, or pain from a puncture wound does not subside within 2 or 3 days. exploration of the wound must be undertaken. Attempting this in the Casualty Department using The Foot
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local anaesthetic is doomed to failure and invariably results in both the patient and parents becoming distressed. It should be performed in a well equipped operating theatre under general anaesthesia and with tourniquet control. The wound must be thoroughly explored and left open. The place of antibiotics in the management of these injuries remains controversial, and it is probable that since the organism most likely to be recovered from the wound is pseudomonas, a thorough surgical debridement is more important than starting a child on potentially hazardous antibiotics. In all cases, the child’s protection from tetanus infection must be checked and, if appropriate, tetanus toxoid or human immunoglobulin given. Osteomyelitis or septic arthritis may result from late presentation of a puncture wound, and although chronic infection can usually be prevented, joint and growth plate damage is often permanent. Lacerations
Lacerations of the foot in children are commonly encountered and may involve only the skin, or extend more deeply and be associated with tendon, nerve or vascular injuries. All of these wounds should be explored, cleaned and repaired in the operating theatre. Degloving injuries
Degloving injuries of the foot in children are often severe and, in addition to the soft tissue damage, may also be associated with fractures. They usually result from vehicles running over the foot or occur when the foot is trapped by moving machinery. The mechanism of injury is a sudden shearing strain which produces on the dorsum of the foot a plane of cleavage between the skin and the superficial fascia whilst on the sole of the foot, where the skin is firmly attached to the fascia, both these layers are degloved. It is interruption of the blood supply to the dermis which is principally responsible for the resulting skin necrosis although, on occasions, the skin itself may be badly damaged. Initial management of these injuries involves demarcation of the extent of skin damage and, although this might seem straightforward, it can be extremely difficult. Assessment is aided by failure to observe capillary flow or dermal bleeding from a skin edge. A low oxygen saturation when a PO, skin electrode is applied to the suspect skin is also a useful guide. Resuturing of degloved skin always fails, and for most patients the skin should be defatted and reapplied as a full thickness graft. In some patients where the skin has been severely damaged, this will not be possible and split skin grafts may then be necessary. The heel of the foot is a particularly difficult site to treat and for this injury Letts” recommends a The Foot
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microvascular flap. Foot fractures when present require stabilization and this can usually be achieved by Kirschner wire fixation. If the original trauma has resulted in part of the foot becoming non-viable, amputation will be necessary. In this circumstance, defatted skin from the amputated part can be usefully employed to cover an area of the foot denuded of skin.
AMPUTATIONS
Fortunately, amputations of the foot for trauma are rare. They may become necessary after local damage to a single toe, or occasionally follow a more severe injury when part or all of the foot becomes non-viable. Most of the operations described for adults can also be applied to children although wherever possible disarticulation rather than amputation through the shaft of the bone should be performed. This preserves the distal epiphysis, allowing stump growth to continue at a normal rate. Toe amputations
The technique involved in amputation of the second, third and fourth toe is similar. A long plantar and short dorsal skin flap should be fashioned and the flexor and extensor tendons together with the digital nerves divided and allowed to retract proximally. The digital vessels should be ligated. With amputation of the fifth toe, a laterally based skin flap is used, whilst for the great toe the flap is postero-medial. In addition, when the great toe is amputated, the flexor and extensor tendons should be sutured together in order to maintain the position of the sesamoid bones beneath the first metatarsal head. Transmetatarsal amputations
When amputation at this level is necessary, skin flaps should be marked out so as to produce a long plantar and short dorsal flap. The plantar flap should include the subcutaneous fat and a thinned layer of the plantar muscles. The long flexor and extensor tendons, together with the nerves should be divided such that they retract proximally and the major vessels must be ligated. The metatarsals should then be divided and sutured. After the wound has healed, the child will need a shoe-filler but no other prosthesis is necessary. Midfoot amputations
The same operative principles apply to midfoot (Lisfranc and Chopart, Fig. 6) as to transmetatarsal amputations, although with these techniques equinus deformity may occur leading to an unsatisfactory result. This can be prevented, however, by detaching the tibialis anterior tendon from its insertion, passing 0 1998
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Paediatric foot injuries
Transmetatarsal-
Lisfranc
-
Fig. 6-Sites of amputation: the resection Lisfranc and Chopart amputations.
levels for midtarsal,
it through a hole drilled in the neck of the talus and suturing it to itself. In addition, the extensor tendons should be carefully sutured to the fascia and soft tissues of the sole of the foot. Syme amputation
The incision should begin just anterior and distal to the medial malleolus, cross the anterior aspect of the ankle, pass just anterior and distal to the lateral malleolus and then continue across the plantar aspect of the foot to the medial side. All structures down to bone should be divided and the ankle joint opened. By dividing the medial and lateral collateral ligaments, the talus can be mobilized and excised. The tendo-achilles is divided at its insertion and allowed to retract proximally. The under-surface of the calcaneum is then dissected sub-periosteally so as to preserve the important fibro-fatty tissue of the heel pad. In order to prevent this pad migrating posteriorly, the toe extensors and tibialis anterior tendons must be sutured into it during closure. Excision of the distal tibia which is routinely performed in adults is contra-indicated in children because it damages the tibia1 epiphysis and has a significant affect on the growth of the limb. Results of amputation
Amputation of the third, fourth or fifth toes produces minimal problems and has no affect on walking or participation in sport. There is also no affect on gait following amputation of the second toe but when this is performed it predisposes to hallux valgus with the great toe drifting laterally. When the great toe is amputated, the patient is unable to achieve 0 1998
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normal toe-off and, although this does not affect walking, it does produce a slight limp when the child tries to run. The results of more proximal amputations have been assessed by Greene and Cary.” Patients with transmetatarsal amputations were found to have no significant problems and all participated in school sport and physical education. Their gait was good and the only detectable abnormality was a slight prolongation of knee extension at heel-off and a slight increase in knee flexion at toe-off. Lisfranc and Chopart amputations were also found to give satisfactory results providing that the stump did not develop an equinus deformity. Walking without a prosthesis was easily accomplished but only some of the patients in this group participated in school sport. Observation of the gait cycle showed that the knee extension of mid-stance was maintained until double support had been fully established. Once the contra-lateral limb was in the stable foot flat position, the affected limb could progress to knee flexion and toe-off. In addition, it was noticed that at toe-off there was increased pelvic dip. Although these changes in gait were similar to those following a Syme amputation, the functional results were considered superior. Unsatisfactory functional results and gait mechanics occurred if the stump was unbalanced and developed an equinus deformity. None of the patients having a Syme amputation had difficulty walking on level ground but participation in school sport was found to decrease in the early teenage years because of the weight of the prosthesis that was required.
SPORTS INJURY
The ankle and foot are common sites of sports injury in children and result from either a sudden unexpected loss of balance, i.e. a fall from a skateboard, or follow repetitive minor injury. In this latter group shoeware is frequently implicated and is often too new, too old, or too small. Sprains
Sprains most commonly result from football or skateboard accidents. There is usually pain and swelling over the lateral aspect of the ankle and, providing more serious injury has been excluded, treatment should consist of elevation of the limb and the application of ice packs. As the swelling begins to settle a double tubigrip bandage will provide some support to the ankle and will give the child confidence to commence mobilization. If the sprain is a recurrence, the ankle should be immobilized in a below-knee walking plaster for 2 weeks in order to allow the soft tissues to fully heal. The Foot
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Blisters
Stress fractures
These may develop around the heel when a sports shoe with too stiff a back has been worn. or they occur under the forefoot due to a prominent stud or running spike. Treatment consists of deroofing the blister and the application of a protective dressing. In addition, the offending shoe should be repaired or replaced.
These most commonly occur in the second and third metatarsals and are usually the result of excessive running or walking. Radiographs in the early stages may be normal but as healing progresses a cloud of callus will be seen at the fracture site. Treatment consists of 3 to 4 weeks in a below-knee walking cast followed by progressive activity.
Nail problems
Returning to sport after injury
Nail problems are common in children. Subungual haematoma may occur during participation in kicking sports, i.e. karate or football, and should be treated by perforating the nail to release the blood. Ingrowing toe nails are more frequent and may require a variety of treatments. Simple removal of the nail may be all that is necessary, but often, as the nail regrows the problem recurs. If there is marked soft tissue infection a course of antibiotics will be needed and once the acute sepsis has subsided a wedge resection of the nail and nail bed should be performed. If this fails, total removal of the nail and nail bed, as described by Zadik, should be undertaken.
With all the above injuries, children should be warned of the foolishness of trying to return to sport until they have made a full recovery. At that stage a programme of graded activity should be undertaken before competitive sport is resumed. By following such a system the risk of recurrent injury is reduced and the child will continue to enjoy his or her sporting interest.
Heel pain
Children undertaking strenuous sports training may develop heel pain. It is localized to the insertion of the tendo-achilles and is really a traction apophysitis. It usually resolves with rest, and to prevent recurrence once sports activities are resumed, the child should use an impact-absorbing heel raise in the shoes. Another cause of heel pain which may be encountered is inflammation of the bursae superficial and deep to the tendo-achilles. Although these usually settle with rest, if they are associated with posterior heel exostoses the swelling may be such that surgical excision is required so that normal shoes can be worn without discomfort.
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REFERENCES 1. Poland J. Traumatic Separation of the Eplphysis. London: Smith, Elder and Co, 1898. 2. Salter R B, Harris W R. Injurles involving the epiphyseal &ate. J Bone Jomt Surg 1963: 45A: 587-622. 3. Spiegel P G, Cooperman D R, Laros G S. Epiphyseal fractures of the distal end of the tibia and fibula. J Bone Joint Surg 1978: 60A: 1046-1050. 4. Marmor L. An unusual fracture of the tibia1 epiphysis. Clin Orthop 1970; 73: 132-135. 5. Stephens N A. Fracture dislocation of the talus in childhood: a report of two cases. Br J Surg 1956; 43: 600-604. 6. Letts R M, Gibeault D. Fractures of the neck of the talus in children. Foot and Ankle 1980: 1: 74-77. of the neck of the talus. 7. Canale S T, Kelly F B. Fractures J Bone Joint Surg 1975; 60A: 14-56 8. Cehner J. Fractures of the tarsal bones, metatarsus and toes in treatment of fractures in children and adolescents. New York: Springer-Verlag, 1980. joint injuries in children. Journal 9. Wiley J J. Tarso-metatarsal of Pediatric Orthopaedics 1981; 1: 255-260. of tarso-metatarsal joint quries. 10. Wiley J .I The mechanism J Bone Joint Surg 1971; 53B: 474482 11. Letts R M. Degloving inJurIes in children. Journal of Pediatric Orthopaedics 1986; 6: 193-197. 12. Greene W B, Gary J M. 1982 Partial foot amputations in children J Bone Joint Surg 1982 64A; 438443.
0 1998
Harcourt
Brace
& Co. Ltd
REVIEWARTICLE
Paediatric foot injuries D. Stanley Department
of Ovthopaediics, Northern General Hospital, Sheffield, UK
INTRODUCTION
It is perhaps surprising when we consider how much time children spend on their feet that childhood foot injuries are relatively uncommon. From time to time, however, a variety of problems will be encountered and it is, therefore, important that the clinician is familiar both with the types of injury which may occur, and the best method of management. In young children a careful clinical assessment is particularly valuable since at this stage of their development the bones of the foot are predominantly cartilagenous and radiographs often unhelpful. In the older child an epiphyseal injury may not be appreciated when the radiographs are examined, and on occasions the opposite may happen with a normal epiphysis being mistakenly identified as a fracture and treated by plaster immobilization. In all these situations, therefore, a sound knowledge of normal anatomy is vital if the correct clinical and radiological diagnosis is to be made and the appropriate treatment instituted.
become wet or broken (a frequent occurrence in children) will fail to provide satisfactory fracture support and if not replaced will be responsible for the poor outcome of treatment. Open reduction and internal fixation is generally only indicated when closed methods of treatment fail. It must be undertaken with care to avoid excessive soft tissue dissection since this will further impair the blood supply to the fracture. In addition, an appropriate type and size of implant should be selected for fracture fixation. In most situations the use of percutaneous Kirschner wires provides adequate fracture stabilization and fulfills the criteria of causing minimal further soft tissue damage. Finally, unlike the situation in adults, childhood fractures may affect growth. It is important, therefore, that children who sustain potentially growth-retarding injuries should remain under review for a minimum of 2 years, and preferably until skeletal maturity.
ANKLE INJURIES MANAGEMENT
OF FRACTURES
For the majority of children’s foot fractures a satisfactory reduction can be achieved by closed manipulation, and the position held by cast immobilization. Careful application of the plaster is important since too tight a plaster may predispose to Volkman’s ischaemia, and too loose a plaster allows fracture displacement. In addition, ridges in the plaster will cause skin damage which may only become apparent once fracture union has occurred and the plaster has been removed. Although a well applied plaster is a good method of treatment, it is only effective if the plaster remains in reasonable condition. Thus, plasters which Correspondence to David Stanley, Consultant Orthopaedic Surgeon, Department of Orthopaedics, Northern General Hospital, Herr& Road, Sheffield S5, UK.
The frequent inability of children to differentiate ankle and foot injuries, plus their biomechanical ‘oneness’ as a unit for stance and normal locomotion necessitates the brief inclusion of ankle injuries in this chapter. Poland’ made the first major study of ankle injuries in children. He noted that the ligaments around the ankle were seldom torn, and that a plane of weakness existed at the growth plate. Thus, following trauma epiphyseal separation was seen to occur at the zone of provisional calcification between the epiphysis and metaphysis. The exact nature of the epiphyseal injury varies with the type of trauma, and although several classifications have been advocated the one that remains most commonly used is that proposed by Salter and Harris.* This is divided into five major types to which, more recently, a sixth has been added (Fig. 1).
10 The Foot
cc9 TYPE I
TYPE I[
TYPE IF
Fig. l-The Salter results in tethering
Type
Harris across
TYPE III
TYPE P
(1963) classification of distal tibia1 eomhyseal the medial tibia1 growth plate. II_
1
Epiphyseal separation occurs without a metaphyseal fracture and usually results from a shearing or torsional force. The radiographs may be normal if the periosteum remains intact, but if torn, separation of the fragments is more clearly seen. Closed manipulation is almost always possible and the reduction can be satisfactorily held by cast immobilization, Type II Epiphyseal separation extends for a variable distance along the epiphyseal plate and then passes through the metaphysis. The injury results from a combination of plantar flexion and eversion, and as in Type I injuries it should be treated by closed manipulation and plaster immobilization. Although Spiegel et al3 have stated that 10% of children with this injury develop growth disturbances, these are minor and do not normally affect function. Type III This injury results from an intra-articular shearing force. The fracture line extends from the joint surface to the epiphyseal plate and then passes along the epiphyseal plate to the ‘periphery. In adolescence, with partial growth plate fusion the fracture lines may pass laterally producing a Tillaux fracture. This can sometimes be reduced by closed manipulation with internal rotation of the foot, but if The Foot
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TYPE III VARIANT
TYPE XC
injuries.
Type VI has been more
recently
added
and the mjury
not, open reduction should be performed. Since the growth plate is already closed medially a transepiphyseal cancellous screw can be safely inserted, and providing accurate reduction is achieved, growth disturbance is never a problem. Another type of distal tibia1 fracture described by Marmor’ is the triplane fracture. This consists of three fragments whose fracture lines are in three different planes. Radiographic interpretation of this complex injury can be difficult and further information may be obtained using computerized tomography. Unless minimally displaced, these fractures require accurate open reduction and internal fixation. Type IV With this injury the fracture extends from the joint surface, through the epiphysis, the epiphyseal plate and the metaphysis. It occurs when an inversion force applied to the supinated foot produces impingement of the talus on the distal tibia. Reduction may be achieved by closed manipulation but if there is more than 2 mm of displacement, open reduction should be undertaken. Up to 14% of these injuries result in growth disturbances due to premature closure of the displaced fragment’s epiphysis. Type V Severe crush injuries to the tibia1 epiphysis are uncommon but serious injuries. Displacement of the epiphysis is usually minimal and the radiographs 0 1998
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Fig. 2-(A) A talar also seen inferiorly.
fracture in a young child The fracture line can be seen passing (B) The less common lateral wall fracture.
often appear normal. The true diagnosis is frequently not made until premature closure of the growth plate has occurred. The prognosis is poor. Type VI With this injury there is either subperiosteal haemorrhage or degloving soft tissue and bony damage to the ankle. In both situations (organization of haematoma or formation of fracture callus) tethering occurs across the medial tibia1 growth plate producing a progressive angular deformity. Treatment in the form of a corrective osteotomy may become necessary but, if possible, should be delayed until after skeletal maturity.
FRACTURES
OF THE TALUS
This injury was unrecognized in children until 1956 when Stephens5 reported two cases of fracture dislocation of the talus. Since then several other reports have appeared in the medical literature, with the largest series being that of Letts and Gibeault.” The majority of these fractures involve the neck of the talus (Fig. 2) and are caused by forced dorsiflexion when the anterior lip of the tibia impinges with the talar neck. Children sustaining this injury usually present with an inability to weightbear and have pain and swelling over the dorsum of the foot. Occasionally, however, when the fracture is undisplaced, there may be little in the way of physical signs. In all cases, therefore, the clinician must have a high index of suspicion whenever a history of forced dorsiflexion of the foot is 0 1998
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through
the neck of the talus.
I1
A small flake of bone is
obtained, and the X-rays should be scrutinized with care in order to avoid missing an undisplaced fracture. Undisplaced fractures should be treated in a nonweightbearing cast until there is radiographic evidence of union. Progressive partial weightbearing is then permitted for 2 to 3 weeks after which the plaster is removed and the child allowed to become fully ambulant. Displaced fractures require urgent reduction. This can usually be achieved by closed manipulation under general anaesthesia with the foot being held in plantar flexion to maintain the reduction. Plaster treatment is instituted as for an undisplaced fracture but when it is changed to a walking cast the foot position is brought up to neutral. When a satisfactory reduction cannot be obtained by closed means and the fracture remains more than 5 mm displaced or 5” angulated, open reduction should be undertaken. A dorsomedial approach usually gives good access and the fracture can be held with Kirschner wires. Less common fractures may involve the body or lateral wall (Fig. 2) of the talus. These should be treated conservatively provided that there is minimum displacement and only occasionally will open reduction be necessary. Follow-up of all children who have sustained talar injuries is essential since even undisplaced fractures may develop avascular necrosis6’ Although this usually occurs within 6 months of injury, the minimum period of follow-up that is advised is 2 years for undisplaced fractures and until skeletal maturity for all other cases. i-he Foot
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Fig. 3-An os calcis fracture in a child. The prognosis is much better than in an adult because of the Increased density of cancellous bone.
FRACTURES
OF THE OS CALCIS
This is a rare injury in children and because the cancellous bone is denser than in adults it has a much better prognosis. The mechanism of injury commonly involves a fall from a height and the patient presents with an inability to weight-bear together with pain and swelling around the hind foot. Radiographic examination, which must include axial views, confirms the diagnosis (Fig. 3). Immobilization in a nonweightbearing cast for 4-6 weeks allows fracture union to occur. This is followed by 2 weeks of partial weightbearing and then the plaster is removed and full mobilization permitted. When swelling is severe, an initial period of hospital admission with elevation of the limb and the application of ice packs is beneficial and should always be advised. Open reduction is almost never justified since, although the radiographs may be improved, the functional result is rarely altered.
FRACTURES OF THE NAVICULAR, AND CUNEIFORM BONES
CUBOID
These are rare injuries (Fig. 4) which usually result from direct trauma. They should be treated by plaster immobilization in a weightbearing cast for 4-6 weeks, by which time union is usually complete. If swelling is severe an initial period of elevation with ice packs is preferred prior to plaster application. Occasionally a crush fracture of the cuboid occurs in association with a midtarsal injury.
MIDTARSAL
INJURIES
Midtarsal injuries in children were first described by Cehner’ and then by Wiley9 who reported 18 cases in children below the age of 16. The Foot
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Fig. LA fracture of the navicular satisfactorily treated in a below-knee
bone. The injury walking cast.
can usually
be
The mechanism of injury can most easily be appreciated when the anatomy of the midtarsal region is understood.” The key to the area is the recessed second metatarsal base which is strongly bound by plantar ligaments to the cuneiform bones and to the third metatarsal. It has only a weak ligamentous bond to the first metatarsal. If the foot is subjected to a strong abduction force, the second metatarsal fractures near its base and the ligament joining it to the first metatarsal is ruptured. This allows lateral displacement of the forefoot on the lateral cuneiform and cuboid with often the latter bone sustaining a crush fracture. Midtarsal dislocations may also occur following violent plantar flexion of the foot when the weak dorsal ligaments between the metatarsals and tarsal bones are ruptured. This injury may also be associated with metatarsal fractures and can easily be missed if, when the radiographs are examined, only the fractures are noted. Children presenting with a midtarsal injury are unable to weightbear and have pain and swelling in the midtarsal region. In addition, when metatarsal fractures are present they are usually clinically palpable. Radiographs may reveal a fracture of the base of the second metatarsal and a crush fracture of the cuboid but gross displacement may not be apparent if the dislocation has spontaneously reduced. Treatment of dislocations which have reduced consists of elevation with ice packs until the swelling has settled, followed by the application of a non-weightbearing cast. This should be maintained for 4 weeks and then removed to allow the child to become fully ambulant. Displaced fracture dislocations require reduction under general anaesthesia with the reduction 0 1998
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should be maintained for 4 weeks at which stage fracture union is usually complete. Fractures in which there is displacement of the metatarsal head require manipulative reduction under general anaesthesia. If the fracture is unstable, the reduction can be held with Kirschner wires inserted percutaneously. Only rarely is open reduction necessary. Avulsion fractures of the fifth metatarsal base occur following an inversion adduction injury to the foot and should also be treated in a below-knee walking cast for 4 weeks.
PHALANGEAL
L
Fig. 5-A metatarsal fracture, the most common foot fracture in a child. Occasionally the fracture is associated with a midtarsal dislocation.
being held with Kirschner wires. These can be inserted percutaneously and their placement optimized by the use of image intensification. A plaster backslab is sufficient to support the foot until the swelling has settled and then a non-weightbearing cast can be applied. The Kirschner wires should be removed at between 2 and 4 weeks at which stage the child may commence weightbearing. No significant long-term complications from this injury have been reported.
FRACTURES
OF METATARSALS
Metatarsal fractures (Fig. 5) are the most common foot fractures in children and result from either a direct injury when the foot is crushed, or indirectly when it is subjected to violent twisting. Occasionally they also occur with midtarsal injuries. Swelling, pain and tenderness over the affected metatarsal is commonly found, with the diagnosis being confirmed radiographically. The most useful X-rays for showing these fractures are antero-posterior and oblique views, but true lateral views should also be taken in order to show the orientation between the metatarsal head and shaft. This is important since a metatarsal fracture which appears satisfactorily aligned on the antero-posterior view may have plantar displacement of the metatarsal head and if fracture union is allowed to proceed in this position the child will develop painful metatarsalgia. Treatment of the majority of metatarsal fractures involves the application of a below-knee walking cast on which the child is allowed to freely mobilize. This 0 1998
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FRACTURES
Phalangeal fractures usually follow either direct trauma when a heavy weight falls on the foot, or indirect trauma when the child kicks something or someone! The affected toe is swollen and painful and the child is unable to bear weight without discomfort. Radiographs confirm the diagnosis. The majority of fractures do not require reduction and can be treated using neighbour strapping. Occasionally, however, the affected toe is angulated or rotated and in this situation, irrespective of the radiographical appearance, the toe should be manipulated such that the position of the nail bed on the affected toe matches the position of the adjacent nail beds. Injuries to the great toe can be more significant with intra-articular fractures requiring accurate reduction to avoid prolonged painful stiffness and occasional growth arrest. The stubbed great toe may sustain a Salter Harris Type I injury to the distal phalanx with damage to the nail such that it overlies the nail fold. If this occurs, the toe should be carefully cleaned, manipulated and, if possible, the nail repositioned. This provides greater stability to the toe than can be achieved if the nail is removed. Children with this injury must be adequately protected against tetanus and should also receive antibiotic cover as this is a compound fracture.
SOFT TISSUE INJURIES Puncture wounds Puncture wounds can occur when a child is barefoot or wearing shoes, and in both cases foreign material may be inoculated into the foot. A detailed history as to the mechanism of injury is important and must be followed by a careful clinical examination. At times, if a non-radiolucent foreign body is suspected, transillumination of the foot in the region of the puncture site can be more helpful than soft tissue radiographs. Whenever a foreign body is implicated, or pain from a puncture wound does not subside within 2 or 3 days. exploration of the wound must be undertaken. Attempting this in the Casualty Department using The Foot
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local anaesthetic is doomed to failure and invariably results in both the patient and parents becoming distressed. It should be performed in a well equipped operating theatre under general anaesthesia and with tourniquet control. The wound must be thoroughly explored and left open. The place of antibiotics in the management of these injuries remains controversial, and it is probable that since the organism most likely to be recovered from the wound is pseudomonas, a thorough surgical debridement is more important than starting a child on potentially hazardous antibiotics. In all cases, the child’s protection from tetanus infection must be checked and, if appropriate, tetanus toxoid or human immunoglobulin given. Osteomyelitis or septic arthritis may result from late presentation of a puncture wound, and although chronic infection can usually be prevented, joint and growth plate damage is often permanent. Lacerations
Lacerations of the foot in children are commonly encountered and may involve only the skin, or extend more deeply and be associated with tendon, nerve or vascular injuries. All of these wounds should be explored, cleaned and repaired in the operating theatre. Degloving injuries
Degloving injuries of the foot in children are often severe and, in addition to the soft tissue damage, may also be associated with fractures. They usually result from vehicles running over the foot or occur when the foot is trapped by moving machinery. The mechanism of injury is a sudden shearing strain which produces on the dorsum of the foot a plane of cleavage between the skin and the superficial fascia whilst on the sole of the foot, where the skin is firmly attached to the fascia, both these layers are degloved. It is interruption of the blood supply to the dermis which is principally responsible for the resulting skin necrosis although, on occasions, the skin itself may be badly damaged. Initial management of these injuries involves demarcation of the extent of skin damage and, although this might seem straightforward, it can be extremely difficult. Assessment is aided by failure to observe capillary flow or dermal bleeding from a skin edge. A low oxygen saturation when a PO, skin electrode is applied to the suspect skin is also a useful guide. Resuturing of degloved skin always fails, and for most patients the skin should be defatted and reapplied as a full thickness graft. In some patients where the skin has been severely damaged, this will not be possible and split skin grafts may then be necessary. The heel of the foot is a particularly difficult site to treat and for this injury Letts” recommends a The Foot
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microvascular flap. Foot fractures when present require stabilization and this can usually be achieved by Kirschner wire fixation. If the original trauma has resulted in part of the foot becoming non-viable, amputation will be necessary. In this circumstance, defatted skin from the amputated part can be usefully employed to cover an area of the foot denuded of skin.
AMPUTATIONS
Fortunately, amputations of the foot for trauma are rare. They may become necessary after local damage to a single toe, or occasionally follow a more severe injury when part or all of the foot becomes non-viable. Most of the operations described for adults can also be applied to children although wherever possible disarticulation rather than amputation through the shaft of the bone should be performed. This preserves the distal epiphysis, allowing stump growth to continue at a normal rate. Toe amputations
The technique involved in amputation of the second, third and fourth toe is similar. A long plantar and short dorsal skin flap should be fashioned and the flexor and extensor tendons together with the digital nerves divided and allowed to retract proximally. The digital vessels should be ligated. With amputation of the fifth toe, a laterally based skin flap is used, whilst for the great toe the flap is postero-medial. In addition, when the great toe is amputated, the flexor and extensor tendons should be sutured together in order to maintain the position of the sesamoid bones beneath the first metatarsal head. Transmetatarsal amputations
When amputation at this level is necessary, skin flaps should be marked out so as to produce a long plantar and short dorsal flap. The plantar flap should include the subcutaneous fat and a thinned layer of the plantar muscles. The long flexor and extensor tendons, together with the nerves should be divided such that they retract proximally and the major vessels must be ligated. The metatarsals should then be divided and sutured. After the wound has healed, the child will need a shoe-filler but no other prosthesis is necessary. Midfoot amputations
The same operative principles apply to midfoot (Lisfranc and Chopart, Fig. 6) as to transmetatarsal amputations, although with these techniques equinus deformity may occur leading to an unsatisfactory result. This can be prevented, however, by detaching the tibialis anterior tendon from its insertion, passing 0 1998
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Lisfranc
-
Fig. 6-Sites of amputation: the resection Lisfranc and Chopart amputations.
levels for midtarsal,
it through a hole drilled in the neck of the talus and suturing it to itself. In addition, the extensor tendons should be carefully sutured to the fascia and soft tissues of the sole of the foot. Syme amputation
The incision should begin just anterior and distal to the medial malleolus, cross the anterior aspect of the ankle, pass just anterior and distal to the lateral malleolus and then continue across the plantar aspect of the foot to the medial side. All structures down to bone should be divided and the ankle joint opened. By dividing the medial and lateral collateral ligaments, the talus can be mobilized and excised. The tendo-achilles is divided at its insertion and allowed to retract proximally. The under-surface of the calcaneum is then dissected sub-periosteally so as to preserve the important fibro-fatty tissue of the heel pad. In order to prevent this pad migrating posteriorly, the toe extensors and tibialis anterior tendons must be sutured into it during closure. Excision of the distal tibia which is routinely performed in adults is contra-indicated in children because it damages the tibia1 epiphysis and has a significant affect on the growth of the limb. Results of amputation
Amputation of the third, fourth or fifth toes produces minimal problems and has no affect on walking or participation in sport. There is also no affect on gait following amputation of the second toe but when this is performed it predisposes to hallux valgus with the great toe drifting laterally. When the great toe is amputated, the patient is unable to achieve 0 1998
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normal toe-off and, although this does not affect walking, it does produce a slight limp when the child tries to run. The results of more proximal amputations have been assessed by Greene and Cary.” Patients with transmetatarsal amputations were found to have no significant problems and all participated in school sport and physical education. Their gait was good and the only detectable abnormality was a slight prolongation of knee extension at heel-off and a slight increase in knee flexion at toe-off. Lisfranc and Chopart amputations were also found to give satisfactory results providing that the stump did not develop an equinus deformity. Walking without a prosthesis was easily accomplished but only some of the patients in this group participated in school sport. Observation of the gait cycle showed that the knee extension of mid-stance was maintained until double support had been fully established. Once the contra-lateral limb was in the stable foot flat position, the affected limb could progress to knee flexion and toe-off. In addition, it was noticed that at toe-off there was increased pelvic dip. Although these changes in gait were similar to those following a Syme amputation, the functional results were considered superior. Unsatisfactory functional results and gait mechanics occurred if the stump was unbalanced and developed an equinus deformity. None of the patients having a Syme amputation had difficulty walking on level ground but participation in school sport was found to decrease in the early teenage years because of the weight of the prosthesis that was required.
SPORTS INJURY
The ankle and foot are common sites of sports injury in children and result from either a sudden unexpected loss of balance, i.e. a fall from a skateboard, or follow repetitive minor injury. In this latter group shoeware is frequently implicated and is often too new, too old, or too small. Sprains
Sprains most commonly result from football or skateboard accidents. There is usually pain and swelling over the lateral aspect of the ankle and, providing more serious injury has been excluded, treatment should consist of elevation of the limb and the application of ice packs. As the swelling begins to settle a double tubigrip bandage will provide some support to the ankle and will give the child confidence to commence mobilization. If the sprain is a recurrence, the ankle should be immobilized in a below-knee walking plaster for 2 weeks in order to allow the soft tissues to fully heal. The Foot
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Blisters
Stress fractures
These may develop around the heel when a sports shoe with too stiff a back has been worn. or they occur under the forefoot due to a prominent stud or running spike. Treatment consists of deroofing the blister and the application of a protective dressing. In addition, the offending shoe should be repaired or replaced.
These most commonly occur in the second and third metatarsals and are usually the result of excessive running or walking. Radiographs in the early stages may be normal but as healing progresses a cloud of callus will be seen at the fracture site. Treatment consists of 3 to 4 weeks in a below-knee walking cast followed by progressive activity.
Nail problems
Returning to sport after injury
Nail problems are common in children. Subungual haematoma may occur during participation in kicking sports, i.e. karate or football, and should be treated by perforating the nail to release the blood. Ingrowing toe nails are more frequent and may require a variety of treatments. Simple removal of the nail may be all that is necessary, but often, as the nail regrows the problem recurs. If there is marked soft tissue infection a course of antibiotics will be needed and once the acute sepsis has subsided a wedge resection of the nail and nail bed should be performed. If this fails, total removal of the nail and nail bed, as described by Zadik, should be undertaken.
With all the above injuries, children should be warned of the foolishness of trying to return to sport until they have made a full recovery. At that stage a programme of graded activity should be undertaken before competitive sport is resumed. By following such a system the risk of recurrent injury is reduced and the child will continue to enjoy his or her sporting interest.
Heel pain
Children undertaking strenuous sports training may develop heel pain. It is localized to the insertion of the tendo-achilles and is really a traction apophysitis. It usually resolves with rest, and to prevent recurrence once sports activities are resumed, the child should use an impact-absorbing heel raise in the shoes. Another cause of heel pain which may be encountered is inflammation of the bursae superficial and deep to the tendo-achilles. Although these usually settle with rest, if they are associated with posterior heel exostoses the swelling may be such that surgical excision is required so that normal shoes can be worn without discomfort.
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REFERENCES 1. Poland J. Traumatic Separation of the Eplphysis. London: Smith, Elder and Co, 1898. 2. Salter R B, Harris W R. Injurles involving the epiphyseal &ate. J Bone Jomt Surg 1963: 45A: 587-622. 3. Spiegel P G, Cooperman D R, Laros G S. Epiphyseal fractures of the distal end of the tibia and fibula. J Bone Joint Surg 1978: 60A: 1046-1050. 4. Marmor L. An unusual fracture of the tibia1 epiphysis. Clin Orthop 1970; 73: 132-135. 5. Stephens N A. Fracture dislocation of the talus in childhood: a report of two cases. Br J Surg 1956; 43: 600-604. 6. Letts R M, Gibeault D. Fractures of the neck of the talus in children. Foot and Ankle 1980: 1: 74-77. of the neck of the talus. 7. Canale S T, Kelly F B. Fractures J Bone Joint Surg 1975; 60A: 14-56 8. Cehner J. Fractures of the tarsal bones, metatarsus and toes in treatment of fractures in children and adolescents. New York: Springer-Verlag, 1980. joint injuries in children. Journal 9. Wiley J J. Tarso-metatarsal of Pediatric Orthopaedics 1981; 1: 255-260. of tarso-metatarsal joint quries. 10. Wiley J .I The mechanism J Bone Joint Surg 1971; 53B: 474482 11. Letts R M. Degloving inJurIes in children. Journal of Pediatric Orthopaedics 1986; 6: 193-197. 12. Greene W B, Gary J M. 1982 Partial foot amputations in children J Bone Joint Surg 1982 64A; 438443.
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