Pediatric foot fractures

Fractures of the foot in children usually have a good prognosis and generally are treated nonoperatively. Displaced fractures of the talus and calcaneus and tarsometatarsal dislocations are rare in children and their outcome is generally good in the younger child. Older adolescents with these injuries need treatment similar to how an adult would be treated for the same injury in order to achieve a good result. Foot fractures in children may pose a diagnostic challenge particularly in the absence of obvious radiographic changes. Repeated clinical examination and judicious use of imaging techniques such as isotope bone scans and magnetic resonance imaging are needed to establish a diagnosis. Knowledge of the anatomy and significance of accessory bones of the foot and disorders of the growing foot skeleton are helpful in managing injuries of child's foot. In this study, we review common injuries of a child's foot and include a discussion on differential diagnosis.

Management of a traumatically avulsed skin-flap on the dorsum of the foot

BACKGROUND

It is common for traumatologists to see avulsion injuries with resulting composite skin flaps. Simply reattaching the avulsed flap by suturing it back into its bed may result in ischemic necrosis of the distal portion of the flap.

CASE REPORT

The authors present a case in which an extensive avulsion injury of the dorsum of the foot with amputation of the fourth and fifth toe was treated by defatting the avulsed flap and reattachment as a full-thickness graft. Healing was uneventful and no skin necrosis was encountered. At 1-year follow-up there was a stable skin situation at the dorsum of the foot. The patient has no difficulties with wearing shoes. However, there is diminished sensibility.

CONCLUSIONS

Indications for this type of surgical technique include all types of avulsion or degloving injuries that create composite skin flaps prone to undergo ischemic necrosis if simply reattached. This quick and easy method should be in the armamentarium of each surgeon possibly dealing with this type of injury.

Sesamoid and toe fractures

Injuries of the toes and sesamoids of the first metatarsophalangeal joint comprise a wide spectrum of traumatic entities. Despite the fact that a majority of lesions may well respond to nonsurgical treatment and exhibit an excellent prognosis, appropriate clinical and imaging analysis is mandatory to select those injuries that require specific therapeutic and surgical measures to avoid long-term sequelae of functional disability.

Big-Toe Replantation in a Three-Month-Old Child: Case Report

A 3-month-old child underwent successful replantation of her big toe at the level of the metatarsophalangeal joint after traumatic amputation caused by a falling heavy object. The length of the big toe from the metatarsophalangeal joint to the tip was equal to that of the contralateral big toe at a 6-month follow-up. Within 4 months, pain sensation returned to the toe. Traumatic amputation of the big toe is uncommon and only a few articles have been published on its replantation. The case presented here is the youngest patient for big toe replantation in the literature. The big toe plays an important role functionally in walking and standing. In addition, the appearance of the foot without the big toe may be unacceptable from an aesthetic point of view for many people. Reconstructive microsurgeons should not hesitate to replant the big toe in suitable cases, even if patients are only a few months old.

Relationship between stress fractures of the proximal phalanx of the great toe and hallux valgus

PURPOSE

To clarify the relationship between stress fractures of the great toe and hallux valgus.

METHODS

Ten cases of this fracture were analyzed for their alignment of the great toe.

RESULTS

Nine of them had hallux valgus.

DISCUSSION

The continuous bowstring effect of the extensor hallux longus and shearing stress on the hallux valgus that occur during specific exercises such as sprinting, jumping, and standing on tiptoe, could cause these stress fractures.

CONCLUSION

The hallux valgus could play a role in the cause of stress fractures of the proximal phalanx of the great toe.

Microsurgical free flap and replantation without antithrombotic agents

Microsurgical reconstructions for free flap transfer, digits and limb replantation have been highly successful applications in the past decades. Antithrombotic prophylactic agents, such as low-molecular-weight dextran, aspirin and heparin have been routinely used for the prevention of microvascular thrombosis. Even though these agents are efficacious in microsurgery, some systemic morbidity is still reported. Forty cases of microsurgical reconstruction over the last five years are reported. They include 22 cases of free flap transfer and 18 cases of replantation (19 fingers, 2 toes and one hand). The surgery was performed by the same group of plastic surgeons and no antithrombotic agent was given intraoperatively or during the post operative period Results show one partial flap loss, two replantation losses due to severe crush injuries of the digits and one toe replantation failure in a two year old. The failure of toe replantation was due to surgical technique and poor post operative immobilization. The result shows that successful microsurgical reconstruction depends on many factors. One of the most important factors is microsurgical technique. Use of antithrombotic agents alone does not appear to play a significant role in the patency of microvascular structures.

An assessment of vascular pain using the flexor reflex in anesthetized rats

This study assessed the flexor reflex induced by intraarterial algogenic drugs in anesthetized rats. The experiments were performed on male Sprague Dawley rats weighing 290-350 g. The animals were anesthetized with urethane (1.3 g/kg i.p.) and an arterial cannula was inserted to the level of the bifurcation of the femoral artery. The magnitude of the flexor reflex was examined by recording the electromyograph from the posterior biceps femoris/semitendinous muscles. Results showed that the flexor reflex evoked by intra-arterial injection of capsaicin (0.05-0.5 microg) was dose-dependent. A similar reflex resulted from pinching the toe of the hindlimb. These responses were inhibited by morphine (5 mg/kg s.c.) and restored with naloxone (1.5 mg/kg s.c.). Intraarterial preinjection of procaine (2%, 200 microl) and capsazepine (20 microg), which is a selective vanilloid receptor antagonist, inhibited the capsaicin-evoked response, but not that of pinching. These results indicate that the flexor reflex is a useful tool for assessing vascular pain in anesthetized animals.

Management of comminuted fractures of the proximal phalanx in horses: 64 cases (1983-2001)

OBJECTIVE

To report the outcome of surgical treatment of comminuted fractures of the proximal phalanx in horses.

DESIGN

Retrospective study.

ANIMALS

64 horses.

PROCEDURE

Medical records and radiographs were reviewed to obtain information regarding signalment, fracture classification, and treatment. Follow-up information was obtained by telephone conversation or evaluation of production records.

RESULTS

Thirty-eight horses had moderately comminuted fractures of the proximal phalanx. Two horses were euthanatized immediately. Fractures of the proximal phalanx in 36 horses were repaired with open reduction and internal fixation with a successful outcome in 33 (92%) horses. Reconstruction of the fracture was performed in most horses by use of a long curved incision, transection of the collateral ligament of the metacarpophalangeal or metatarsophalangeal joint, and open exposure of the proximal articular surface of the proximal phalanx. Twenty-six horses had severely comminuted fractures of the proximal phalanx. Six horses were euthanatized immediately. One horse was euthanatized after 9 days of treatment with a cast alone. Severely comminuted fractures of the proximal phalanx in 13 horses were treated with an external skeletal fixation device, and fractures healed in 8 of those horses. Six horses with severely comminuted fractures of the proximal phalanx were treated with transfixation pins incorporated into a fiberglass cast, and fractures healed in 4 horses.

CONCLUSIONS AND CLINICAL RELEVANCE

Moderately comminuted fractures of the proximal phalanx can be successfully repaired; however, fractures that are too severe to permit accurate reconstruction of the fragments remain difficult to treat and horses have only a fair prognosis for survival.

Evaluation and management of toe fractures

Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. Joint hyperextension and stress fractures are less common. Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. Referral is indicated in patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, displaced intra-articular fractures, or fractures of the first toe that are unstable or involve more than 25 percent of the joint surface. Most children with fractures of the physis should be referred, but children with selected nondisplaced Salter-Harris types I and II fractures may be treated by family physicians. Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe to limit joint movement. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction.

Salter Harris type II injury of the proximal phalanx of the fifth toe: case report

Fractures of the growth plate are unique to childhood. The risk of growth disturbances depends on the type of fracture, its location, the age of the patient, the vascularization to the epiphysis, the state of the surrounding soft tissues, and whether the injury is open or closed. Epiphyseal fractures of the foot are uncommon, and only rarely are the phalanges involved. We report a Salter-Harris type II injury in the fifth toe. The patient, a 3-year-old girl, was successfully managed conservatively with no sequelae.

Acquired constriction ring syndrome

A case of "acquired constriction ring" or "toe-tourniquet" syndrome is presented to increase awareness of the condition in the orthopaedic community. If treated promptly, this condition has a very good prognosis and, if the diagnosis is missed, may lead to amputation. We also discuss the potential causes and presentation of this condition, along with the need for urgent surgical exploration if there are doubts over tissue viability.

Giant acquired digital fibrokeratoma

We describe a 33-year-old patient with a giant skin tumor on her right big toe. The tumor was characterized by unusual clinical manifestations including huge size and papillomatous surface. Chronic long-standing irritation as a result of aerobic exercise may have been involved in the development of giant fibrokeratoma with papillomatous surface.

Toe tourniquet syndrome in association with maternal hair loss

Increased hair loss a few months after delivering an infant is a common postpartum condition known as telogen effluvium. A much less common condition involving young infants is the hair-thread tourniquet syndrome, or toe tourniquet syndrome, which involves hair or thread becoming so tightly wrapped around an appendage that pain, injury, and sometimes loss of the appendage result. This case report is the first known description of the hair-thread tourniquet syndrome in association with maternal telogen effluvium. A literature review shows that accidental cases involving human hair almost always involve the toes, and usually occur at the age when mothers are experiencing excessive hair loss. This association is significant in that anticipatory guidance of new parents experiencing rapid hair loss may prevent cases of the toe tourniquet syndrome and its associated morbidity.