Pediatric foot fractures
A child’s foot is not an adult foot in miniature. The main difference is the child’s foot is rapidly and continually changing. From the moment, the child is conceived through the teen years, all of the tissues in a child’s foot and the rest of their body are changing, developing, and maturing.
The most important difference between the child’s and the adult’s foot is that the child’s foot is growing. This means that the tissues are extremely active metabolically, burning nutrients at an accelerated rate to power its development, reabsorbing and remaking itself perpetually. The bony tissue has specialized areas called growth plates that allow the bones to lengthen with the child’s growth. While the growth process is marvelous, it also leaves the child’s bones prone to specific and common injuries.
The growth plate is a zone of cartilage at the end of the bone usually within a centimeter from the joint or weight-bearing surface of the bone. As the child grows the cartilage expands to lengthen the bone through cell division. At the same time, the bony tissue on either side of the growth plate is consuming the cartilage and laying down bone. The rate of bone formation and cartilage formation continues at an even and measured pace until the end of adolescence when the sexual hormones signal to the growth plate to close and completely bridge the growth plate with bone. At that point, further growth in the length of the bone is no longer possible.
This process leaves the growing bone vulnerable to injury. Cartilage is not nearly as strong as bone in tensile strength. This means that when a bone is pulled apart the cartilage will break long before the bone or ligament will. In addition the newly formed bone tissue at the end of the bone is not fully developed and hardened and is not as strong as the adult bone in compressive strength. When the child falls on the bone or stresses it suddenly, it will become injured with much less force than an adult bone even when accounting for its decreased size.
While the cartilage within the bones makes a child vulnerable to injury, the extremely high metabolism of the bones accelerates its recovery. Children return to activity two to three times faster than adults with a similar injury. Growth problems after fractures in the ankles are fortunately rare.
Injuries that disturb the joint or the growth plate and are allowed to heal in a displaced position are more devastating than similar joint injuries in an adult. If an injury through a growth plate is allowed to heal so that the bone on either side of the growth plate touches, the bone will deform because of uneven growth. The unusual and misaligned joint can be very difficult to reposition after healing has begun. It can lead to a short bone in comparison to the uninjured side as well as arthritis and joint deformity.
After an injury, persistently tender bones should be evaluated and usually x-rayed in a child. While serious or dangerous injuries are rare, the window for appropriate treatment is brief and so prompt evaluation is strongly recommended.
The cartilage growth plate is also prone to injury through repetitive trauma. Traction and overuse injuries to the growth plates in children are extremely common. While nearly any growth plate can become painful and irritated by repetitive stress, common areas are the heel, the arch and the inside of the ankle. Sever’s disease is by far the most common form of growth plate irritation. It is an overuse of the calcaneal apophysis, the growth plate at the tip of the calcaneus. Both the Achilles tendon and the plantar fascia attach to the growth plate at the end of the heel. The strong muscles and stout ligaments place a great deal of stress on the calcaneal apophysis making it prone to injury. Calcaneal apophysitis can be more painful at the onset of walking or when getting up in the morning. The muscles recoil when the leg is placed in a relaxed flexed position when sitting. When stretching these structures back out to length when initiating walking, extra stress is needed to bring them out to length. This stress is felt within the injured apophysis as pain.
Treatment of calcaneal apophysitis is similar to plantar fasciitis or Achilles tendonitis in the adult. Aggressive stretching, arch supports if the foot is flat, rocker-soled shoes, and rest are usually successful at keeping the symptoms at bay. It is common for them to recur because these children usually have predisposing factors such as tendon tightness or extreme participation in sports. It is also notoriously difficult to interest any but the most conscientious child in a continuing rehabilitation program. Casting the painful limb can successfully resolve the injury.
Illustrative case 1
Julia is a nine-year-old girl who twisted her ankle when playing volleyball. She fell on the ground and could not walk afterwards. Her parents saw the injury and said that she rolled on the outside of the ankle during the injury. She was sent to the emergency room and x-rays were taken. They were told that the x-rays were negative.
Julia’s ankle was swollen and bruised along her heel. She was not tender along the typical area for an ankle sprain, along the front tip of the fibula bone on the outside of the ankle. She was tender about two centimeters farther up toward the outside of the ankle. The remainder of the ankle was non-tender. Julia’s x-rays were completely normal.
Julia has sustained a fracture of the growth plate at the end of the fibula, a common injury. In the process of turning her ankle, she cracked through the growth plate instead of tearing the ankle ligaments as an adult would in an ankle sprain. Because cartilage is transparent on x-rays, the injury may be impossible to identify. Although Julia’s injury is really a fracture, the ankle remains very stable, owing to the thick soft tissue around the bones and within the ankle.
Julia’s splint was removed and she was placed in a prefabricated cast boot. She was allowed to begin walking on it as the pain allowed her to. Julia returned for follow-up three weeks later, fully ambulatory and with no pain. She was able to progressively begin running and playing volleyball within five weeks of the injury. These injuries very rarely cause significant growth plate damage that affects growth.
Illustrative case 2
Mark is an eleven-year-old boy who is very active athletically. He is involved in travel soccer nearly year round where he is the star forward. Over the weekend, he had a tournament during which he played three games. He had noticed pain in his heels, right worse than left, while he was running for the past several weeks, but had continued to play. His parents noticed that he was limping during his last game. It seemed to get better with some ibuprofen.
The following morning, Mark was unable to get out of bed. When he tried to get on his feet, it brought him to tears. He was brought to his pediatrician’s office. While he was feeling somewhat better, he still limped.
Mark’s feet appeared to be normal. There was no bruising or swelling. He had normal motion and strength. When standing, his feet were mildly flat. He was slightly tender on the inside of his ankle along the medial malleolus. He was very painful along both the bottoms and back of his heel. When asked to touch his toes while keeping his knees fully extended, he was able to reach no farther than mid shin. His x-rays showed a normal heel with calcanealapophysis that was still open.
Mark was placed in a cast boot for four weeks. During this time, he was started on an Achilles tendon and hamstring-stretching program, supervised by a physical therapist for the first four weeks. After four weeks, he was gradually returned to walking, jogging and finally running. He returned to sports two months after treatment was begun. He has had no recurrence of the pain.
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Children have a bewildering array of pains while growing up. In fact, musculoskeletal pain is one of the leading reasons that children are seen in the pediatrician’s office. Parents are typically concerned that the pain represents a form of serious illness. Fortunately, this is rarely the case. At the very least, they are usually distraught because they feel powerless while their children are in pain.
At some time during childhood, 30-60% of children have non-traumatic extremity pain1,2. The syndrome of “growing pains” has been identified for centuries and the cause is unknown. “Growing pains” are most common in children from age 5 to 14. They commonly occur at night or in the late afternoon and rarely interfere with activity although there has been the suggestion that heavy exertion earlier in the day may trigger the growing pains later that evening. This type of pain is characterized by being on both sides of the leg, usually in the shins, thighs, or back of the knee, and usually resolves completely within a few hours. The pain is often more frequent when the child has been more active or moody.
While the cause of “growing pains” has not been identified, a number of interesting observations have been made. Children with more “growing pains” tend to be more flexible and a higher proportion of them have bunions and flat feet3. They seem to have a decreased pain threshold when compared to their peers4. They also seem to have a decreased bone mineral density within their bones suggesting that this is an overuse syndrome4. It does not, as is sometimes supposed, coincide with periods of increased growth.
Laboratory or radiographic evaluation is not necessary in situations where the picture fits the description of “growing pains”.
Treatment usually includes support and reassurance for the parents and the child that the problem is not dangerous. Little data has been gathered on the effectiveness of any treatment. Children who have markedly flat feet may benefit from over-the-counter inserts. Stretching programs may also be helpful. Traditional treatment includes massage and anti-inflammatory medications such as naproxen before bedtime. The problem usually resolves spontaneously.
- Evans AM, Scutter SD. Prevalence of “growing pains” in young children.J Pediatr. 2004 Aug;145(2):255-8.
- Bishop JL, Northstone K, Emmett PM, Golding J. Parental accounts of the prevalence, causes and treatments of limb pain in children aged 5 to 13 years: a longitudinal cohort study.Arch Dis Child. 2010 Sep 30.
- Viswanathan V, Khubchandani RP. Joint hypermobility and growing pains in school children.ClinExpRheumatol. 2008 Sep-Oct;26(5):962-6.
- Uziel Y, Hashkes PJ. Growing pains in children. PediatrRheumatol Online J. 2007 Apr 19;5:5.
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Parents worry about their children. This is only natural. Many parents have concerns about the appearance of the legs in their children. Often, they worry about proper growth, gate changes, and their child’s ability to participate in sports. We all are different. Some are clumsier than others. Some are faster. Some can jump higher. A gait that works well for one child may be very different than the gait of another. There are fortunately very few abnormalities that significantly affect our children’s potential to painlessly work and play. In the vast majority of these cases, there is little indication that braces, surgery, or prolonged therapy is helpful.
Common descriptions of the rotation of the legs in children are being “pigeon toed”, when the toes are rotated to the inside, or having a “duck walk”, when the toes are rotated to the outside. These abnormalities can be caused by rotation of the bones at the tibia, femur or foot. The most common cause for intoeing is a twisting of the femur that begins in the uterus with the positioning of the baby. Often children with this will sit with their legs folded underneath them to the sides of their thighs, the “W” position. Parents describe their children as being clumsy because their toes hit their opposite leg as the leg is swung through during running. This problem usually decreases as the child’s foot becomes smaller in relation to his overall body frame. Twisting in the tibia usually causes out-toeing. This abnormality often decreases as the child grows to maturity. Sometimes, the child consciously compensates for it by adjusting the position of the hip during walking. Athletic abilities are usually not compromised with these problems. The foot progression angle is the angle between the foot and direction of walking. If the foot is within 15-20o of pointing straight forward, this is normal and no treatment is typically necessary.
Bracing, inserts, and stretching are of questionable benefit for this problem. Surgical osteotomy and derotation of the involved bone can be considered for severe and disabling problems, but is emotionally and physically taxing for both the parents and child. It should not be considered when addressing a mild or moderate deformity.
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Knock knees/bowlegs (Genu valgum/varum)
The angle that the thigh makes with the leg at the knee is also a common concern of parents. Again, usually there is nothing with which to be particularly worried except for some very rare exceptions. The angulation between the thigh and the shin can be measured on an x-ray. It can also be measured with a ruler by determining the distance between the knees in bowed legs when the ankles are placed together or the distance between the ankle when the knees are placed together in knock knees.
It is typical for children to be slightly bow legged at birth. If the legs are squeezed together until they touch, the knees are usually separated less than 6 centimeters. While the child is packed into the uterus prior to birth, the legs are crossed over the body causing them to bow. Over the first three years of life, the legs gradually become more valgus or knock-kneed.
Knock-knees are almost never a sign of a significant problem. Most children go through a period of bowleggedness when they are toddlers. In most cases, this spontaneously resolves.
Blount’s disease is a type of developmental illness of the knee growth plates that causes bowed legs. It can be identified through radiographs. Many of these children are overweight. Some believe that the increased weight of these children damages the growth plate on the inside of the knee. As a result, the knees do not grow properly and begins to bow worse. If it is untreated the problem can progresses. As a result, careful follow-up is necessary if the bow deformity is severe or seems to be getting worse. Occasionally, this disease may require bracing or surgical treatment.
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A toe gait is essentially normal in a toddler for some time after learning to walk. Often children are brought in for evaluation when the toe-walking pattern continues when they begin preschool. Usually the children are not concerned about it and it rarely causes pain. Rarely, this is a sign of a neurological problem, but more frequently no cause can be found.
There really is no easy and effective treatment for toe walking, but the good news is that the children develop functionally without treatment. Studies that have looked at bracing, casting, and physical therapy have shown no evidence of improvement after these interventions. Usually, any improvement quickly disappears. In one study, untreated children followed for a period of years with toe walking improve half of the time and remain unchanged in the other 50%. Surgical release of the Achilles tendon improves 75% of children and in 25% the gait remains unchanged or worse. Surgical treatment is reasonable very rarely.
- Eastwood DM, Menelaus MB, Dickens DR, Broughton NS, Cole WG. Idiopathic toe-walking: does treatment alter the natural history? J PediatrOrthop B. 2000 Jan;9(1):47-9.
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