The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 90, Issue 4

Scientific Articles | April 01, 2008

A Study of Metatarsal Fractures in Children

Georg Singer, MD¹; Martin Cichocki, MD¹; Johannes Schalamon, MD¹; Robert Eberl, MD¹; Michael E. Höllwarth, MD, PhD¹

¹ Department of Pediatric Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036 Graz, Austria. E-mail address for G. Singer: georg.singer@meduni-graz.at

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Investigation performed at the Department of Pediatric Surgery, Medical University of Graz, Graz, Austria

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2008 Apr 01;90(4):772-776. doi: 10.2106/JBJS.G.00547

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Abstract

Background: Metatarsal fractures are common in children. The aim of the present study was to analyze a consecutive series of metatarsal fractures in children and to describe the epidemiology of the fractures, the location of the fractures, and the mechanism of injury.

Methods: A consecutive series of 125 patients with metatarsal fractures who presented to one pediatric surgery department over a twenty-two-month period was evaluated with use of a questionnaire to define the mechanism of injury. All patients were followed until the fracture was healed. The specific location of the fractures and the mechanism of injury were identified.

Results: One hundred and twenty-five children (seventy-five boys and fifty girls; average age, 8.6 years [range, one to seventeen years]) presented with 166 metatarsal fractures. Major differences were found between children who were five years of age or less and those who were more than five years of age. In patients who were five years of age or less, the predominant location of the accident that had caused the fracture was inside the house and the primary mechanism was a fall from a height. In patients who were more than five years of age, most accidents occurred at sports facilities and were caused by a fall on a level surface. The most frequently fractured metatarsal in younger children was the first, whereas the most frequently fractured metatarsal in older children was the fifth.

Conclusions: The mechanism of injury and clinical presentation of metatarsal fractures in children are age-dependent, with patients five years of age or less and those more than five years of age having different mechanisms of injury and different types of metatarsal fractures.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Metatarsal fractures are commonly seen in emergency departments. In children, 61% of all fractures of the foot are located in the metatarsal bones¹. While most fractures can be treated with immobilization only, a small number of these fractures require operative stabilization. It is generally accepted that the majority of these fractures result from either a twisting injury or direct trauma². Previous reports in the medical literature have reviewed metatarsal fractures in a general population^3,4, and additional reports have described the incidence of and injury patterns associated with metatarsal fractures in particular subpopulations^5,6. Other studies have focused on the incidence of fractures of a single metatarsal, such as the first metatarsal^7-9. However, reports about the incidence, the injury pattern, and the mechanism of injury in the pediatric population are rare.

In this prospectively designed study, we attempted to describe all metatarsal fractures in children who were seen in our emergency department over a period of twenty-two months, with special attention to the epidemiology, the fracture location, and the mechanism of injury.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

All pediatric trauma patients who were managed in our department between January 2005 and October 2006 were evaluated. For every patient, a questionnaire was completed by the medical personnel to document the diagnosis, demographic information, the site where the injury occurred, and the circumstances and mechanism of injury as well as any associated injuries. In cases in which the questionnaire was incomplete, the medical records were reviewed in order to obtain the missing information.

For the present study, all children with metatarsal fractures were identified. Information was obtained regarding the fracture type (single or multiple), and the fractures were classified according to their anatomic location (proximal, diaphyseal, or distal) and whether they were closed or open. The treatment consisted of cast immobilization for undisplaced fractures and Kirschner-wire fixation for unstable or comminuted fractures or fractures for which acceptable alignment could not be achieved with closed reduction or maintained with casting. The duration of immobilization depended on the radiographic signs of callus formation and the clinical findings and was continued generally for three weeks. Outpatient follow-up was continued until full weight-bearing was possible and the patient was free of pain.

According to the guidelines of the local ethics committee, institutional review board approval was not required.

Results

Introduction | Materials and Methods | Results | Discussion | References

Epidemiology

Over a twenty-two-month period, 21,582 pediatric trauma patients visited our emergency department. Of these, 3965 patients (18.4%) presented with fractures, including 125 patients with a fracture of at least one metatarsal; this latter group comprised 0.6% of all trauma patients and 3.2% of all patients with fractures. Seventy-five patients (60%) were male, and fifty (40%) were female. The mean age of all patients with metatarsal fractures was 8.6 years (range, one to seventeen years), with girls being younger than boys (mean age, eight years for girls and nine years for boys).

Site of Accident and Mechanism of Injury

The most frequent site of the accidents that resulted in the metatarsal fractures was the outdoors, including the backyard or the playground (thirty-eight patients; 30%). Other sites of accidents included the home (thirty-one patients; 25%); sports facilities, including those used for both school sports and recreational sports (thirty-one patients; 25%); and schools or child-care facilities (fifteen patients; 12%). The remaining ten patients (8%) were injured as the result of traffic accidents.

The study group included eighty-five patients (104 fractures) who were more than five years of age and forty children (sixty-two fractures) who were one to five years of age. While the predominant accident sites in the group of children who were five years of age or less were inside the house (seventeen patients; 43%) and outdoors in the backyard (sixteen patients; 40%) during leisure activities, accidents in older children (those who were more than five years of age) mostly happened during sport activities (thirty patients; 35%). Figure 1 shows the predominant mechanisms leading to metatarsal fractures in children who were five years of age or less and those who were more than five years of age. While the main mechanism in the group of children who were more than five years of age was a fall on a level surface (including twisting), more than half of the fractures in the group of children who were five years of age or less were caused by a fall from a height.

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Fig. 1: Pie charts illustrating mechanisms of injury in 125 children with metatarsal fractures. Note the differences in the rates of falls on a level surface and falls from a height between children who were more than five years of age (n = 85) and those who were five years of age or less (n = 40).

Fracture Location

A total of 166 metatarsal fractures were identified in the 125 patients. The exact distribution of the fractures is presented in Figure 2. Twenty-two patients (18%) had multiple metatarsal fractures, and the remaining 103 patients (82%) had a fracture of a single metatarsal. The majority of fractures (58%) were single fractures of the first or fifth metatarsal. Most fractures of the second, third, and fourth metatarsals were associated with fractures of other metatarsals (Fig. 2), and, in all cases of multiple fractures, the fractured bones were contiguous. Figure 3 shows that the first metatarsal was the most frequently affected bone in children five years of age or less, whereas the fifth metatarsal was the most frequently affected bone in children more than five years of age. There was no significant difference between the left and right sides with regard to the number of fractures, with fifty-six patients (45%) having fractures on the left side and sixty-nine patients (55%) having fractures on the right. The great majority of the fractures were closed injuries, with only one child presenting with an open fracture. While 116 children (93%) had metatarsal fractures only, nine (7%) presented with additional trauma, including leg fracture (three patients), toe fracture (one), cuboid fracture (one), hand injury (one), and additional soft-tissue injuries of the foot (three). One hundred and twenty-two children (98%) had undisplaced or minimally displaced fractures, whereas three had a fracture that was displaced by more than the width of one shaft. Eighty-one fractures (49%) were located proximally, fifty-six (34%) were located distally, and fifteen (9%) were located in the diaphysis; the remaining fourteen fractures (8%) were comminuted.

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Fig. 2: Bar graph illustrating the distribution of 166 metatarsal fractures in 125 patients. Note that fractures of the first and the fifth metatarsal most frequently were isolated fractures.

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Fig. 3: Bar graph illustrating the pattern of metatarsal fractures in children who were more than five years of age and those who were five years of age or less. Fractures of the first metatarsal were most common in children who were five years of age or less, whereas fractures of the fifth metatarsal were most common in children who were more than five years of age.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Knowledge about the location, distribution, and mechanism of injury is important to facilitate the correct treatment of metatarsal fractures in children.

In this consecutive series of metatarsal fractures, most of the accidents occurred outdoors. While sports activities caused the injuries in 25% of the patients overall, the percentage of injuries sustained during sports activities increased with increasing age. This finding is similar to that reported in a previous study, in which sports injuries accounted for 34% of metatarsal fractures in children over the age of five years². Another interesting finding derived from our data is the different mechanisms causing metatarsal fractures in children who were five years of age or less and those who were more than five years of age. While falls on a level surface, including twisting, constituted the predominant mechanism in older children, falls from a height caused more than half of the fractures in patients who were five years of age or less. The mechanism of injury in the older patient group is comparable with findings that have been reported for the adult population, in which twisting and falls from standing caused 64% of all metatarsal fractures and falls from heights caused only 12% of all metatarsal fractures⁴.

In 1995, Owen et al.² reported that the most common pediatric metatarsal fracture (45%) was a fracture of the fifth metatarsal, a rate that compares well with the 40% rate in the present study. While first metatarsal fractures accounted for 22% of the metatarsal fractures in the report by Owen et al., such fractures accounted for a higher percentage of the fractures in the present study (38%). However, we confirmed their findings that first metatarsal fractures were the most common metatarsal fractures in children who were five years of age or less, whereas fifth metatarsal fractures were the most common metatarsal fractures in children who were more than five years of age. In an adult population, fifth metatarsal fractures also have been reported to represent the most common metatarsal fracture, whereas the incidence of first metatarsal fractures has been reported to be 1.5%⁴. These differences may be attributed to the different mechanisms of injury: children who are five years of age or less frequently fall from a height, whereas in older children the main mechanism of injury is a fall on a level surface.

Another observation made in our study was that fractures of the second, third, and fourth metatarsals frequently were associated with fractures of another metatarsal, whereas the majority of first and fifth metatarsal fractures were isolated fractures. Moreover, if multiple metatarsals were fractured, they were always contiguous bones. This finding is consistent with the findings reported by Petrisor et al., who described similar results in a study on metatarsal fractures in adults⁴. Therefore, in cases of fractures involving the second, third, and fourth metatarsals, it is important to specifically concentrate on the adjacent bones in order not to miss a fracture.

One limitation of the present study is that long-term follow-up was not performed and therefore the eventual outcome of these fractures is not known.

In summary, clinicians should search for additional metatarsal fractures if a fracture of the second, third, or fourth metatarsal is found in a child. Patients who are five years of age or less frequently present with fractures of the first metatarsal, whereas fractures of the fifth metatarsal predominate in older children. Image Not Available

References

Introduction | Materials and Methods | Results | Discussion | References

Rammelt S, Heineck J, Zwipp H. Metatarsal fractures. Injury.2004;35 Suppl 2:SB77-86.35SB77 2004 [PubMed]

Owen RJ, Hickey FG, Finlay DB. A study of metatarsal fractures in children. Injury.1995;26:537-8.26537 1995 [CrossRef]

Fetzer GB, Wright RW. Metatarsal shaft fractures and fractures of the proximal fifth metatarsal. Clin Sports Med.2006;25:139-50,x.25139 2006 [CrossRef]

Petrisor BA, Ekrol I, Court-Brown C. The epidemiology of metatarsal fractures. Foot Ankle Int.2006;27:172-4.27172 2006

Guettler JH, Ruskan GJ, Bytomski JR, Brown CR, Richardson JK, Moorman CT 3rd. Fifth metatarsal stress fractures in elite basketball players: evaluation of forces acting on the fifth metatarsal. Am J Orthop.2006;35:532-6.35532 2006

Low K, Noblin JD, Browne JE, Barnthouse CD, Scott AR. Jones fractures in the elite football player. J Surg Orthop Adv.2004;13:156-60.13156 2004

Morris G, Nix K, Goldman FD. Fracture of the second metatarsal base. An overlooked cause of chronic midfoot pain. J Am Podiatr Med Assoc.2003;93:6-10.936 2003

Vorlat P, Achtergael W, Haentjens P. Predictors of outcome of non-displaced fractures of the base of the fifth metatarsal. Int Orthop.2007;31:5-10.315 2007 [CrossRef]

Vu D, McDiarmid T, Brown M, Aukerman DF. Clinical inquiries. What is the most effective management of acute fractures of the base of the fifth metatarsal? J Fam Pract.2006;55:713-7.55713 2006

Topics

fracture ; metatarsal fracture

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Georg Singer, Martin Cichocki, Johannes Schalamon, Robert Eberl, Michael E. Höllwarth; A Study of Metatarsal Fractures in Children. The Journal of Bone & Joint Surgery. 2008 Apr;90(4):772-776.

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