Prognosis of fracture of the talus in children. 21 (7-34)-year follow-up of 14 cases

Identification of fractures on pediatric foot radiographs: do localization cues improve diagnostic accuracy and reduce interpretation time?

OBJECTIVE

To investigate the diagnostic accuracy and time in the detection of fractures on pediatric foot radiographs marked without and with localization cues.

METHOD

One-hundred randomly selected foot radiographic examinations that were performed on children (<18 years old) after injury and with at least 4 weeks of follow-up were included. Blinded to history and diagnosis, 4 readers (one each: medical student, pediatrician, pediatric orthopedic surgeon, and pediatric musculoskeletal radiologist) retrospectively and independently reviewed each examination twice (without and with cue, at least 1 month apart, and after randomization). Each reader recorded the presence or absence of a fracture, fracture location, diagnostic confidence, and the total (interpretation) time spent on each study. Diagnostic accuracy, reader confidence, and interpretation time were compared between examinations without and with cues.

RESULTS

Our study included 59 examinations without and 41 with fractures (21 phalangeal, 18 metatarsal, and 2 tarsal fractures). Localization cues improved inter-reader agreement (κ=0.36 to 0.64), overall sensitivity (68 to 72%), specificity (66 to 73%), and diagnostic accuracy (67 to 73%); thus, overcalled and missed rates also improved from 34 to 27% and 32 to 28%, respectively. Reader confidence improved with cue (49 to 61%, p<0.01) with higher incremental improvement with younger children (30% for 1-6 years; 14% for 7-11 years; and 10% for 12-17 years). Interpretation time decreased by 40% per examination (40±22 s without to 24±13 s with cues, p<0.001).

CONCLUSION

Localization cues improved diagnostic accuracy and reader confidence, reducing interpretation time in the detection of pediatric foot fractures.

Pediatric Sports Trauma

Pediatric foot and ankle fractures are common in athletic participation. Treatment of pediatric sports trauma must take into account the unique challenges this population presents, and aim to minimize long-term complications. Given the excellent remodeling potential of pediatric bone, conservative treatment can often be used. However, a thorough understanding of physeal anatomy, fracture patterns, and biomechanics is needed to guide treatment choice and determine when surgical intervention is warranted.

Use of Ilizarov Device to Gain Early Range of Motion in the Treatment of Pediatric Talus Body Fractures: A Series of Four Cases and Literature Review

Background

Talus fractures are rare in children but can lead to severe outcomes if untreated. The Ilizarov external fixator has been used in the treatment of a variety of lower extremity pathologies. The purpose of this study was to investigate the clinical outcomes of talus body fractures treated with the Ilizarov external fixator.

Case Presentation

Four male pediatric patients (age range, 5–11 years) with talus body fractures who were treated by open reduction and internal fixation combined with Ilizarov external fixator between November 2015 and April 2016 were reviewed. Mean follow‐up period was 4 years (range, 4–5). Clinical outcome was evaluated using the clinical rating scale of the American Orthopaedic Foot and Ankle Society (AOFAS). All four patients achieved good to excellent results at the last follow‐up. None of the patients developed avascular necrosis. One patient developed automatic fusion of tibiotalar joint.

Conclusion

Use of the Ilizarov external fixator to gain early range of motion is a valuable option for treatment of talus body fractures in children.

Paediatric talus fractures: A guide to management based on a review of the literature

BACKGROUND

Talus fractures are devastating injuries in both adults and children. Well recognised complications such as avascular necrosis (AVN), post-traumatic arthritis and non-union contribute to patient morbidity. This systematic review aimed to assess the literature on these injuries in children and their associated incidence, classification, management and outcome.

METHODS

A systematic review of Embase and Medline databases was carried out in accordance with PRISMA guidelines. Inclusion criteria were clinically orientated studies looking at talus fractures in paediatric patients (less than 18 years old). Exclusion criteria were conference abstracts, opinion-based reports, articles not published in English and articles published prior to 1980. Data extracted included patient demographics, fracture classification, management and outcomes.

RESULTS

31 studies were included encompassing 143 patients and 167 fractures with a mean age of 11.9 years (1.2-18). The majority of fractures (43.7%, n = 73) were of the talar neck. 70.6% (n = 101) were managed operatively. The overall rate of AVN was 15.4% (n = 22), with a 96.5% union rate. Observed rates of AVN were 5.7% in Hawkin's 1, 11.8% in Hawkin's 2, 53.3% in Hawkin's 3 and 0 in Hawkin's 4 injuries. All cases of non-union occurred in children over 12 years, and seven children required arthrodesis (1x pantalar, 1x subtalar and 5x subtalar and tibiotalar) with a mean age of 14.4 years (9-17).

CONCLUSIONS

Talus fractures are rare but potentially devastating injuries in children. This systematic review has shown comparable rates of AVN in children to their adult counterparts, with higher rates of non-union and arthrodesis in adolescent patients. A lower threshold for operative intervention to achieve anatomical reduction in these patients should be considered.

Pediatric Trauma

Musculoskeletal injuries of the lower limb are frequent in pediatric patients and represent the most common cause of emergency department admissions. Acute sports-related injuries commonly involve the lower extremity, as the knee and ankle are the most frequently injured parts. Physeal fractures are common injuries in children and adolescents participating in contact sports, which may lead to growth disturbances and cause limb length discrepancy. It is imperative for pediatric trauma centers to implement evidence-based multispecialty protocols for the perimanagement of the injured child, especially through the postdischarge and rehabilitation phases, in order for the child to resume active daily living.

Rare shear-type fracture of the talar head in a thirteen-year-old child — Is this a transitional fracture: A case report and review of the literature

BACKGROUND

Talar fractures are exceedingly rare in childhood. There are very few studies on the clinical aspects, the long-term outcomes and the appropriate treatment of these fractures in pediatric patients. The mechanism of trauma consists of the application of a sudden dorsiflexion force on a fully plantar-flexed foot. Traumatic mechanism, symptoms and imaging of injuries of the talar head are similar to transitional fractures that are normally described at the distal epiphysis of the tibia: the so-called transitional fracture is defined as an epiphyseal injury when the growth plate has already started to close.

CASE SUMMARY

A thirteen-year-old girl reported a high-energy trauma to her right foot, due to falling from her horse. X-rays at the Emergency Department were negative. Because of persistent pain, the patient was assessed by an orthopedic surgeon after two weeks and computed tomography scans revealed a misdiagnosed displaced shear-type fracture of the talar head. Hence, surgical open reduction and fixation with two headless screws was performed. The girl was assessed regularly, and plain films at follow-up revealed complete healing of the fracture. Within six months after surgery, the patient returned to pre-injury sport activities reporting no complications.

CONCLUSION

Injuries of the talar head in childhood should be considered as transitional fractures. Open reduction with internal fixation aims to reduce malalignment and osteoarthritis. Computed tomography scans are recommended in these cases.

Talus Fracture Dislocation Management With Crossed Kirschner Wires in Children

Skeletal trauma accounts for 10% to 15% of all childhood injuries, with approximately 15% to 30% of these representing physeal injuries. Talus fractures are rare injuries in children with an estimated prevalence of 0.008% of all childhood fractures. Cast immobilization is sufficient treatment for non-displaced fractures, however displaced fractures of the talus require surgical intervention to minimize the risk of trauma-related avascular necrosis (AVN) due to disruption of the vascular supply originating from the talar neck. A 13-year-old boy was brought to the accident and emergency (A/E) department following a road traffic accident while he was pillion riding a bike. Following the accident, he was unable to bear weight on his right foot and his anterior ankle region was swollen, with no neurological deficit or open wound. He had no other injury and no medical or surgical history. On review of the ankle and foot radiographs, he was noted to have a right talar neck fracture with subtalar and ankle dislocation. His computer tomographic (CT) images demonstrated a Hawkins Type IV talus fracture. Initial treatment involved a plaster of Paris (POP) back slab with the ankle in a neutral position. His right leg was elevated on pillows and treated with elevation and ice to alleviate the swelling. As the fracture was comminuted and displaced with ankle and subtalar dislocation, operative intervention (open reduction and fixation of talus with crossed K wires) was planned. The patient was discharged in below knee slab which was changed to a non-walking cast at two weeks. The patient was kept non-weight bearing until fracture united. These types of fractures are rare in children and proper clinical and radiological evaluation is essential. Such fractures should be reduced as early as possible to reduce the ischemia time thus prevent the chances of osteonecrosis. Lastly avoid tourniquets and stable anatomical reduction of fracture is must.

Operative Management of a Pediatric Talar Body and Neck Fracture: A Case Report

Pediatric talus fractures are rare injuries that generally result from high-energy trauma. The relative elasticity of pediatric bone is thought to contribute to the lower rate of fracture in children. Although these injuries are rare, complications of talar body fractures, including avascular necrosis, collapse of the talar dome, and tibiotalar arthrosis, are well described. In the pediatric patient, these complications can result in poor outcomes and a disabling position for the patient. There is a relative paucity of data given the low incidence of these injuries and lack of consensus on operative versus nonoperative management. The authors present the case of an 11-year-old female with a combined talar neck and body fracture. The patient underwent open reduction internal fixation of her fractures with combined cannulated screw and Kirshner wire fixation. She was followed to 7 years postoperatively with excellent functional outcome and no evidence of avascular necrosis or collapse of the talar body.

Is the Midterm Progress of Pediatric and Adolescent Talus Fractures Stratified by Age?

The outcomes of pediatric talus fractures have been minimally reported in published studies. The purpose of the present retrospective study was to determine the clinical and radiographic outcomes after talus fractures in pediatric and adolescent patients and to define the differences among the different age groups in this population. A total of 52 children and adolescents (54 fractures) with 24 type 1 (44.44%), 13 type 2 (24.07%), 8 type 3 (14.81%), and 9 type 4 (16.67%) Marti-Weber fractures were considered. Of the 52 patients, 19 (35.19%; 21 talus fractures) with follow-up data available for >12 months were included in the final study population. Of the 21 fractures, 9 (42.86 %) were type 1, 4 (19.05%) were type 2, 1 (4.76%) was type 3, and 7 (33.33%) were type 4. The mean patient age was 14.7 (range 4 to 18) years. The patients were divided into 3 age groups: group 1, age ≤11.9 years; group 2, age 12.0 to 15.8 years; and group 3, age 16.1 to 18.0 years. Of the 21 fractures, 3 (14.29%) were treated nonoperatively and 18 (85.71%) operatively. The overall mean follow-up duration was 40.3 (range 14 to 95) months. The outcomes of interest included fracture nonunion, talar avascular necrosis, ankle range of motion, pain, arthrosis, and arthrodesis. After treatment, the mean ankle range of motion was 20° (range 0° to 35°) of dorsiflexion and 40° (range 0° to 45°) of plantarflexion. Complications included persistent pain in 10 fractures (47.62%), 3 cases of nonunion (14.29%), 3 cases of avascular necrosis (14.29%; of which, 1 [4.76%] required ankle and subtalar fusion), and arthrosis developing in ≥1 surrounding joint in 12 fractures (57.14%). Of the 12 fractures in group 3, 9 (75.00%) developed arthrosis and 2 (16.67%) subsequently required arthrodesis. Our observations suggest that the incidence of displaced talus fractures, as well as complications, increases with patient age.

Fractures of the talus: Current concepts and new developments

Fractures of the talus are challenging to manage, with historically poor outcomes and a high rate of complications. The rare nature of this injury limits the number of studies available to guide treatment. Fortunately, a number of advancements have been made in the last decade. There is increased recognition regarding the importance of anatomic reconstruction of the osseous injury. Advanced imaging is used to assess the subtalar joint, where even slight displacement may predispose to arthritis. Increasing use of dual anteromedial and anterolateral approaches, along with plate fixation, has improved our ability to accurately restore the anatomy of the talus. Modification of the original Hawkins classification can both guide treatment and allow us to better predict which patients will develop avascular necrosis. Lastly, improved reconstructive techniques help address the most common complications after talus fracture, including arthritis, avascular necrosis, and malunion.

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)

Paediatric Salter-Harris type IV injury of distal tibia with talus fracture

Fracture of talus with Salter-Harris injury of the distal end of tibia is a rare injury in paediatric age group. The authors report a case of a 13-year-old male child who sustained type IV Salter-Harris injury to the medial malleolus with coronal spilt along with spilt and depressed fracture of the neck of talus and fracture of the lateral process of talus with stable compression fracture of spine sustained due to fall from 6 meters height. CT scan delineated the morphology of fracture pattern and helped in preoperative planning. Talar articular fracture was reduced and fixed arthroscopically while distal tibial fracture was fixed under image intensifier. We observed favourable outcome following arthroscopic reduction at 4-year follow-up.

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.

The use of a cell-free chondroinductive implant in a child with massive cartilage loss of the talus after an open fracture dislocation of the ankle: a case report

BACKGROUND

We present a case report of a 3-year-old girl who sustained a severe open fracture dislocation of her talus with complete loss of full-thickness articular cartilage and subchondral bone over 80% of the talar dome. At presentation there was an extensive soft tissue defect including absent anterior joint capsule. She required a free anterolateral thigh flap to reconstruct this defect. The talar dome defect was treated with a cell-free chondroinductive implant made of resorbable polyglycolic acid felt and hyaluronic acid. This was the first use of such an implant in the United Kingdom and the first use in a child anywhere in the world.

METHODS

The case has been followed prospectively for 3 years.

RESULTS

At 3 years postoperative, the patient underwent thinning of the anterolateral thigh flap and trimming of an anterior tibial overgrowth, which was causing impingement. At surgery the talar dome cartilage looked pristine, with a line representing the tidemark between the original cartilage and the new formed. Biopsies were taken and histopathology performed.

CONCLUSIONS

This was a rare and difficult case that has achieved an excellent outcome at this follow-up stage.

LEVEL OF EVIDENCE

Level V.

Unusual fracture combination in a paediatric acute ankle (combined medial talar compression fracture with medial malleolus fracture in an immature skeleton): a case report

Talar compression fractures are uncommon orthopaedic injuries, especially in the immature skeleton. Fractures of the talar body constitute >5% of all foot and ankle fractures. The combination of a medial compression fracture and corresponding medial malleolar fracture is rare and not previously reported injury in the literature. We present a case report of a skeletally immature 15-year-old Caucasian male who sustained a medial malleolar and corresponding medial talus fracture after being ejected from his pushbike. This report outlines the potential difficulties in diagnosing an unusual fracture combination and the importance of initial management including necessary diagnostic imaging to identify such injuries. Through this case, we aim to highlight the need for having high suspicions of underlying fractures in paediatric trauma cases. The long-term complications and risks of osteonecrosis of the talus can have detrimental effect on a patient's outcome; therefore, we also emphasize the need for regular monitoring and long-term follow-up.

Hawkins Group I fracture of neck of talus and Salter Harris Type III tibial epiphyseal injury of medial malleolus

We are reporting an unusual combination of Hawkins Group I fracture of the neck of left talus in association with Salter Harris Type III distal tibial epiphyseal injury of medial malleolus in a child with cerebral palsy and hemiplegia of contralateral limbs and discussed the possible mechanism as well as management. Fractures of medial malleolus usually occur in Hawkins Group III fracture-dislocations in adults. Forced dorsiflexion of talus against the anterior edge of tibia appears to be the accepted common mechanism, despite limited experimental and clinical evidence incriminating axial compression. Fracture of medial malleolus implicates supination. We managed this unusual pattern of injury conservatively. At 15 months, the child was asymptomatic with no radiological evidence of avascular necrosis of body of talus or growth disturbance of distal tibial epiphysis.

Fracture of the talar neck associated with a compression fracture of the calcaneocuboid joint in a 5-year-old child: a case report

OBJECTIVE

The objectives of this present case study are to report a rare combination of a displaced talar neck fracture with a compression fracture of the calcaneocuboid joint in a 5-year-old child and to describe its radiological features, surgical treatment and clinical outcome. A 5-year-old male boy was injured in a car accident in which his left foot underwent one of the tires. On arrival at the hospital, a displaced talar neck fracture associated both with a cuboid fracture and compression of the articular surface of the cuboid at the calcaneocuboid join was identified. Fractures were fixed surgically. Leg was protected with a below-knee plaster split immobilization and non-weight-bearing for 5 weeks. After that period, the patient initiated a rehabilitation protocol with active and passive motion exercises.

DISCUSSION

Fractures and fracture dislocations at the mid-tarsal joint have an important impact on the global foot function because malunion can result in post-traumatic arthritis and three-dimensional deformities of the foot. If a cuboid compression fracture is not reduced properly, it can result in the shortening of the lateral column with the development of an abduction, pronation and flat foot deformity. A talar neck fracture, if unreduced, can result in medial column displacement and rotational dislocation of the talar head, leading to a subluxation in the talonavicular joint with severe restriction of foot function. With early surgical treatment and open reduction and internal fixation, our patient recovered from the accident without having symptoms of pain, avascular necrosis, postoperative foot deformities or neurovascular deficits.

CONCLUSIONS

The combination of a displaced talar neck fracture with a compression fracture of the calcaneocuboid joint in children usually requires correct diagnoses and early treatment with anatomic reduction and internal fixation to prevent severe post-traumatic deformities.

LEVEL OF EVIDENCE

V.

[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.

Paediatric talus fracture

Paediatric talus fractures are rare injuries resulting from axial loading of the talus against the anterior tibia with the foot in dorsiflexion. Skeletally immature bone is less brittle, with higher elastic resistance than adult bone, thus the paediatric talus can sustain higher forces before fractures occur. However, displaced paediatric talus fractures and those associated with high-energy trauma have been associated with complications including avascular necrosis, arthrosis, delayed union, neurapraxia and the need for revision surgery. The authors present the rare case of a talar neck fracture in a skeletally immature young girl, initially missed on radiological review. However, clinical suspicion on the part of the emergency physician, repeat examination and further radiographic imaging revealed this rare paediatric injury.

Complications of talus fractures in children

BACKGROUND

Pediatric talus fractures are rare with variable rates of posttraumatic complications reported in the literature. The purpose of this retrospective study was to evaluate posttraumatic complications in children after talus fracture and report injury characteristics.

METHODS

This study included 29 children with talus fractures sustained between 1999 and 2008 at an average age of 13.5 years (range, 1.2-17.8). Patient records and radiographs were reviewed to determine the mechanism of injury, fracture type, associated injuries, and treatment. Posttraumatic complications assessed were avascular necrosis, arthrosis, nonunion or delayed union, neurapraxia, infection or wound-healing problems, and the need for further unanticipated surgery. Clinical follow-up averaged 24 months (range, 6 mo-5 y).

RESULTS

Twenty-nine children sustained a major fracture of the talar body, neck, or head. Avascular necrosis occurred in 2 patients (7%), arthrosis in 5 (17%), delayed union in 1 (3%), neurapraxia in 2 (7%), infection in 0, and the need for further surgery in 3 (10%). Both high-energy mechanism and fracture displacement corresponded to a greater number of posttraumatic complications. The number and severity of talus fractures increased in older children.

CONCLUSIONS

In this case series, posttraumatic complications after pediatric talus fractures occurred more frequently after a high-energy mechanism of injury or a displaced fracture. Talus fractures occurred more commonly and with more severity in older children.

LEVEL OF EVIDENCE

Level IV. Retrospective case series.

An unusual presentation of talus fracture in a child: a case report

Talar fracture in children is extremely rare. In 1919, Anderson described talar fractures and used the term of aviator astragalus in his series. We report a case of talar neck fracture in a 9-year-old boy which does not match with any type of Hawkins' classification. We describe the radiological features of the fracture and outline its therapy and prognosis. To the best of the authors' knowledge, such a case with this unusual presentation has not been previously reported in the literature.

Fractures of the talus--differences between children and adolescents

BACKGROUND

Fractures of the talus represent serious injuries of the foot skeleton. The most significant complications include osteonecrosis and posttraumatic malalignment with subsequent arthritis. The aim of our study was to compare treatment and outcome of fractures of the talus between children and adolescents.

METHODS

From 1990 to 2005, 24 patients (18 male, 6 female) presented with 25 fractures of the talus. The medical records were reviewed retrospectively. Follow-up was performed by radiographical grading, and the functional outcome was measured using the Foot-Function-Index.

RESULTS

Nine patients were 12 years of age or younger, and 15 patients presenting 16 talar fractures were older than 12 years. Although most fractures of the talus in children younger than 12 years were classified as Marti-Weber type I and II fractures, more than two thirds of the fractures in patients older than 12 years were Marti-Weber type III and IV fractures. Two thirds of the patients younger than 12 years were treated nonoperatively, whereas nonoperative treatment was possible in only three talar fractures in adolescents. No necrosis at follow-up (mean period, 3.2 years; range, 7 months to 8.4 years after end of treatment) was detected in children (<12a), whereas five patients older than 12 years developed persisting necrosis.

CONCLUSION

Even though there is no apparent difference in the cause of the trauma leading to fractures of the talus, adolescents present with more severe fractures of the talus compared with children younger than 12 years. In addition, we did not observe persistent osteonecrosis in patients younger than 12 years old, and the outcome is favorable in most cases irrespective of the mode of treatment.

Fractures and dislocations of the foot in children

The challenge of managing pediatric foot injuries is the identification of the rare injuries that require operative treatment and the management of complications such as compartment syndrome, post-traumatic foot deformities, and avascular necrosis. With these complications in mind, the authors discuss fractures of the talus, calcaneus, lesser tarsal bones, Lisfranc's joint, metarsals, and phalanges. Dislocation of metatarsophalangeal or interphalangeal joints is also discussed.

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.

Pediatric foot fractures: evaluation and treatment

Foot fractures account for 5% to 8% of all pediatric fractures and for approximately 7% of all physeal fractures. A thorough understanding of the anatomy of the child's foot is of central importance when treating these injuries. Due to the difficulties that may be encountered in obtaining an accurate physical examination of a child with a foot injury and the complexities of radiographic evaluation of the immature foot, a high index of suspicion for the presence of a fracture facilitates early and accurate diagnosis. Although the treatment results in pediatric foot trauma are generally good, potential pitfalls in the treatment of Lisfranc fractures, talar neck and body fractures, and lawn mower injuries to the foot must be anticipated and avoided if possible.

Avascular necrosis after minimally displaced talus fracture in a child

This is a case report of a delayed diagnosis in a 5 year old child who sustained a minimally displaced fracture of the proximal or posterior aspect of the talar neck of the left foot with no subluxation at the subtalar or ankle joint of his left talus. Avascular necrosis (AVN) appeared 6 months after the injury. The further course was protracted with another 12 months of non-weight bearing. The case was followed until 36 months after the injury with nearly full functional recovery. An extensive literature review revealed a calculated incidence of AVN after reportedly non-displaced talus fractures in children of 16 per cent which is considerably more than is reported in adults. Nearly half of all reported cases occurred after the fracture had been missed initially. 8 of 11 cases with reported age occurred between 1 and 5 years. No child was older than 9 years, which indicates that the immature talus may be more prone to AVN. Some possible causes for the higher incidence of AVN in children with non-displaced talus fractures are discussed. Prolonged non weight-bearing cannot be recommended, since it reportedly does not alter the course of the disease.

Treatment of talar neck fractures: clinical results of 50 patients

Fractures of the neck and body of the talus present as one of the most challenging and rare injuries. These fractures are often associated with other ankle, foot, and skeletal injuries, which complicate their treatment. The clinical course of 50 patients with a mean age of 29 years with a severe talus fracture between 1992 and 1997 is presented. According to the Hawkins classification there were 16 (32%) of type I, 14 (28%) of type II, 9 (18%) of type III, and 11 (22%) of type IV. Forty-three patients (86%) underwent operative treatment: 27 (63%) by open reduction and internal fixation with screws, seven (16%) by external fixation, five (12%) with percutaneous screws, and four (9%) by closed reduction with K-wire fixation. Mild osteoarthritis of the talocrural joint was seen in 14 patients (28%) and severe osteoarthritis in 10 patients (20%), five of whom required subsequent arthrodesis of the ankle joint. Arthrodesis of the subtalar joint was observed in 4 cases. Avascular necrosis with collapse of the talar body was seen in four patients (8%). The function of the ankle joint was evaluated according to the Weber score. Patients with talus fractures of Hawkins' type I and II had considerably better outcomes (with 95% being excellent or good) than individuals suffering dislocated fractures with involvement of the articulating surface with 70% good results in Hawkins' type III and 10% good results in Hawkins' type IV fractures. For the evaluation of the vitality of the talus body in cases with titanium implants, the authors used magnetic resonance imaging and intraosseous phlebography in cases with stainless steel implants. The displaced talus fractures must be treated by closed and, if necessary, open reduction with internal fixation. The initial postoperative management should consist of ambulation without weightbearing until radiographic appearance of trabecular bone in the fracture zone, indicating revascularization, can be manifested.