Occult fracture of the calcaneus in toddlers

A Review of Pediatric Heel Pain

The objective of this review article is to provide orthopaedic surgeons and general practitioners a reference and guidance for the evaluation and workup of heel pain in pediatric patients. The authors performed a comprehensive literature search to review the etiologies and management of heel pain in patients <18 years of age. Relevant studies in Medline/PubMed and EMBASE were searched from inception to March 3, 2022 using medical subject headings and text words without limitations on language or study type. The initial search utilized the following Boolean operators: (children) AND (heel pain); (pediatric) AND (heel pain). Heel pain in the pediatric population is usually a benign condition. Sever's apophysitis is the most common etiology of heel pain in pediatric patients. Most causes of heel pain in the pediatric population do not require imaging or extensive workup. However, providers must maintain a high index of suspicion for symptoms that could indicate a more severe pathology.

Imaging of pediatric foot disorders

Infants and children undergo imaging studies to evaluate a wide variety of congenital and acquired disorders. Imaging protocols have to consider the patient’s comfort, level of anxiety, and smaller size. The first imaging study is usually made with plain radiographs. The routine radiographic examination of the foot includes the anteroposterior (AP), lateral, and oblique projections. Magnetic Resonance Imaging (RMI) provides excellent anatomic detail of cartilage, vasculature and soft tissue thanks to superior soft tissue contrast and spatial resolution, so is valuable in many cases. According to the clinical and objective signs, guided by the radiographs images, we can be oriented to perform Computed Tomography (CT), CT imaging or MRI imaging. CT imaging is useful to observe the bones but it has the disadvantage of using radiation and doesn’t adequately define the bone’s non-ossified portions. On the contrary, MRI imaging is very useful in identifying the cartilaginous parts and vascular and soft tissues, thanks to its superior contrast and spatial resolution. Finally, it is important to orientate the diagnostic process keeping in mind the clinical sign of the patient and to use the most appropriate diagnostic technique. (www.actabiomedica.it)

Foot and ankle fractures during childhood: review of the literature and scientific evidence for appropriate treatment

Foot and ankle fractures represent 12% of all pediatric fractures. Malleolar fractures are the most frequent injuries of the lower limbs. Hindfoot and midfoot fractures are rare, but inadequate treatment for these fractures may results in compartment syndrome, three-dimensional deformities, avascular necrosis and early post-traumatic arthritis, which have a significant impact on overall foot and ankle function. Therefore, the challenges in treating these injuries in children are to achieve adequate diagnosis and precise treatment, while avoiding complications. The objective of the treatment is to restore normal anatomy and the correct articular relationship between the bones in this region. Moreover, the treatment needs to be planned according to articular involvement, lower-limb alignment, ligament stability and age. This article provides a review on this topic and presents the scientific evidence for appropriate treatment of these lesions.

An atypical calcaneal fracture in a child: a literature review concerning the treatment

Calcaneal fractures are considered uncommon accounting for 0.005-0.41% of all children fractures. Few reports concerning treatment are available. Most of these fractures are non-displaced/minimally displaced and are associated with a fall of less than 1 m. The aim of this case report was to discuss the diagnosis and treatment of a child calcaneal fracture, an atypical presentation despite the high energy mechanism of trauma. A 7-year-old child fell from a 5-m ladder with all his weight on his right heel. Significantly hind-foot reduced range of motion associated with a lateral/plantar calcaneal swelling and pain was found. Neurovascular examination and other parts of the body were normal. Radiograph showed an undisplaced calcaneal body fracture and computed tomography confirmed no subtalar joint involvement. A splint followed by plaster was applied. Weight bearing and deambulation were not allowed. After 4 weeks, no pain and limping was reported by the child’s parents. Plaster was removed and radiograph showed fracture consolidation. Patient had no complaints of pain, no restrictions in range of motion and normal walking. Limping in children is a difficult complaint to assess. Differential diagnoses of a calcaneal fractures should be performed, even without a history of trauma or a history of trivial trauma.

Stress fracture of tarsal cuboid bone in early childhood

PURPOSE

We present the clinical characteristics, radiographic, and bone scintigraphy finding of the cuboid fracture in early childhood.

METHODS

From 2008 to 2012, we identified 25 patients (13 boys and 12 girls) with cuboid fracture who were seen in our institution. Medical records and radiographs as well as bone scintigraphy of 25 patients were reviewed. Nutcracker test was performed as a provocation test.

RESULTS

The mean age of the patients was 24.7 months (range 15-38 months). The average duration of symptom before visit was 7 days (range 2-14 days). Most of the parents/caregivers (76 %) did not recall a traumatic episode. Patterns of limping were variable. Nutcracker test was positive in 11 patients. In 10 of 25 patients, initial plain radiographs of the foot showed no abnormal finding. The average duration of symptom of these patients was 4.5 days (range 2-7 days). In 15 patients, the radiograph of the foot showed sclerosis along the base of the cuboid. Bone scintigraphy of the patients with normal radiograph showed hot spot in cuboid. Eleven patients visited our institution to seek for second opinion as their child has persistent limping gait.

CONCLUSIONS

It is not always possible to make an early diagnosis of this fracture since the initial radiographic finding and physical examination are often negative. Considering the consequences of a missed fracture and avoiding unnecessary treatment, bone scan might be useful in the early diagnosis of the stress fracture of the cuboid in young children.

LEVEL OF EVIDENCE

Diagnostic study, Level IV.

[Foot and ankle fractures in children]

Ankle fractures are the most frequent factures of weight-bearing joints in children while fractures of the hindfoot and midfoot are rare. Metatarsal fractures make up the greatest portion of foot fractures in children and mostly heal uneventfully. Generally, the fracture severity increases with increasing age and the fracture patterns in adolescents resemble those in adults but transitional fractures of the distal tibial epiphysis in adolescents between 12 and 14 years of age are an exception. A subtle clinical and radiographic examination is necessary to detect the injury pattern and to discriminate fractures from accessory bones, juvenile avascular necrosis and apophyses. Computed tomography scanning is most useful to precisely evaluate the degree of injury, especially articular involvement and to allow precise planning of the operative approach. Except for the calcaneus and the metatarsals the bones of the foot and ankle do not display a significant potential for spontaneous correction during growth; therefore, open reduction and internal fixation is indicated in all displaced fractures if closed reduction does not yield a satisfying result in order to avoid relevant post-traumatic deformities.

Pediatric and adolescent intra-articular fractures of the calcaneus

Calcaneal fractures in childhood are very rare, whereas particularly intra-articular displaced fractures are not typical in skeletally immature children. Various techniques of osteosynthesis have been described. This study aimed to determine clinical and radiological outcome after surgical treatment of intraarticular calcaneal fractures. Fourteen intraarticular fractures of the calcaneus were included in this retrospective study. Eleven children (2 girls and 9 boys) aged 6-16 years (average age 11.5 years) underwent surgical treatment. One child sustained a Type II open fracture of both calcanei. All injuries occurred after a high-energy trauma; 3 patients had multiple additional fractures. The clinical and radiological postoperative follow up was an average 44 months. In 4 cases, a reduction through a minimally invasive approach and fixation with K-wires or screws could be achieved. Eleven fractures were treated with open reduction and internal fixation with plate osteosynthesis, K-wires or screws. In one case with open fractures of both heel bones, an additional external fixator was applied. The surgical treatment approach adopted enabled the pre-operative Böhler’s angle (average 16°) to be improved to an average 30°. In all cases, except for the patient with open fractures, a good functional result and outcome could be achieved. In calcaneal fractures in childhood, anatomical reduction is the determining factor, as in fractures in adults, whereas the surgical technique seems to have no influence on clinical outcome in children. The wound healing problems that have often been described were not observed in this age group.

[Calcaneal fractures in childhood: a retrospective survey and literature review]

Calcaneal fractures (CF) are uncommon injuries in childhood; most data concerning CF originate from studies of adult trauma. In a retrospective analysis, we evaluated CF in children treated in our department over the last 5 years. In addition, we reviewed the current literature concerning the mechanism of injury, diagnostics, and complications after conservative and operative treatment. In addition, we evaluated the diagnosis and treatment of CF in children and adolescents in another five pediatric trauma centers in Germany by the help of a questionnaire. The data for the last 5 years (48 fractures) and in the current literature confirm that CF remain uncommon in childhood. Regarding the mechanism of injury, fracture pattern, and diagnosis, specific differences between pediatric and adult patients exist. Treatment strategies and recommendations are still inconsistent. In extraarticular and nondislocated fractures, conservative treatment does not seem problematic. But in intraarticular fractures with dislocation of the joint, operative treatment with anatomic reduction is advised in order to avoid long-term consequences.