Metatarsal and Phalangeal Fractures Metatarsal and phalangeal fractures are common in children, with fifth metatarsal fractures occurring most frequently Radiographic evaluation should include anteroposterior, lateral, and oblique views of the foot For nondisplaced or minimally displaced fractures, a splint can be applied and crutches given for ambulation Phalangeal fractures can be managed with buddy taping and/or a hard sole shoe for stabilization Intraarticular fractures of the first toe or significantly displaced fractures of the other phalanges require orthopedic referral for possible pinning Fractures at the base of the fifth metatarsal may be confused with accessory ossification centers that occur at this site, which are parallel to the long axis of the metatarsal shaft and are nontender to palpation The base of the fifth metatarsal is the site of two common fractures: avulsion fractures and fractures of the proximal fifth metatarsal diaphysis, which is called a Jones fracture The avulsion fracture of the base of the fifth metatarsal, also called a pseudo-Jones fracture, occurs from the pull of the peroneus brevis, the abductor digiti minimi quinti tendon, or lateral cord of the plantar aponeurosis Typically, the fracture line is perpendicular to the long axis of the metatarsal shaft, and there is minimal displacement Treatment is with a short leg weight-bearing cast for weeks This fracture is more proximal and has a better prognosis than the Jones fracture, which is associated with delayed union and nonunion The Jones fracture occurs at the metaphyseal–diaphyseal junction at the base of the fifth metatarsal, which is a watershed area with a tenuous blood supply Due to complications in healing, this injury should be splinted, the patient should be made non-weight-bearing, and referred to the orthopedist for possible operative management Tarsometatarsal injuries of the foot, referred to as a Lisfranc injury, can be caused by a direct blow to the foot or when there is forced plantar flexion of the forefoot combined with a rotational force This is more commonly seen in the skeletally mature patient and may be difficult to diagnose as the injuries are subtle and will present with minor pain and swelling at the base of the first and second metatarsals Weight-bearing radiographs (AP, lateral, oblique views of the foot) are recommended to stress the joint complex Fracture at the base of the second metatarsal should raise suspicion for a possible tarsometatarsal dislocation ( Fig 111.55 ) Further imaging with CT or MRI may be required to fully visualize the injury The foot should be immobilized and the patient should follow up with outpatient orthopedics FIGURE 111.54 Radiograph of the right foot of a 13-year-old boy demonstrating fractures of the calcaneus (small arrow ), talus (medium arrow ), and the first metatarsal (large arrow ) FIGURE 111.55 Lisfranc fracture, with acute fractures of the second and third metatarsals with widening of the Lisfranc interval (arrow ) (Reprinted with permission from Bridgeforth GM Lippincott’s Primary Care Musculoskeletal Radiology Philadelphia, PA: Lippincott Williams & Wilkins; 2010.) INJURIES OF THE THORACOLUMBAR SPINE Goals of Treatment Injuries to the thoracolumbar spine are uncommon in children as a result of their anatomy and the biomechanics of the growing spine; however, they represent the potential for significant morbidity An understanding of the mechanisms and energy level most likely to cause injury, as well as the key examination findings indicative of thoracolumbar injury, can prevent further incidental morbidity during evaluation in the ED In general, any child with significant head or multisystem trauma should be assumed to have a spinal injury until proven otherwise Diagnosis of a spinal injury in the child with a severe brain injury can be particularly problematic given that these patients are often sedated and/or paralyzed, thus limiting the examination Therefore, initial treatment should always maintain spinal immobilization until a more detailed neurologic examination becomes possible Injury mechanisms most commonly associated with spinal injury include motor vehicle collisions (across all age groups), falls (toddlers and school age children), sports-related trauma, and gunshot wounds (adolescents) CLINICAL PEARLS AND PITFALLS Because of the overall high elasticity of the pediatric spine, significant spinal cord injury can occur in the absence of radiographic signs of bony injury The risk of posttraumatic scoliosis after a complete spinal cord injury in children is high Pediatric sacral injuries are rare and seldom associated with neurologic injury Patients with fracture and dislocation have a higher incidence of associated neurologic injury than patients with simple fractures Patients improperly restrained by a lap belt in a motor vehicle collision should be carefully evaluated for “seatbelt syndrome” with abdominal bruising (“seatbelt sign”), an associated hyperflexion-induced lumbar fracture (often a Chance fracture), and intra-abdominal injury Current Evidence Structurally, the child’s spine differs from the adult spine as there is increased ligamentous laxity resulting in greater mobility, more shallow angulations at the facet joints, and incomplete ossification of the vertebrae By adolescence, the spine has mechanical qualities more like those of the adult, and the fracture patterns are similar Injuries to the spine are rare in pediatrics; however, they contribute to a significant morbidity and mortality in children and frequently occur in association with multisystem trauma Injuries of the lower thoracic region to upper lumbar region (T11-L1), for example, have been noted to be associated with significantly increased risk of associated gastrointestinal injury Injuries to the lumbar and sacral regions (L2-sacral) are noted to be associated not only with abdominal injuries, but appendicular orthopedic trauma as well Studies have indicated that high-risk mechanisms include motor vehicle crashes, falls, ... wounds (adolescents) CLINICAL PEARLS AND PITFALLS Because of the overall high elasticity of the pediatric spine, significant spinal cord injury can occur in the absence of radiographic signs of... injury The risk of posttraumatic scoliosis after a complete spinal cord injury in children is high Pediatric sacral injuries are rare and seldom associated with neurologic injury Patients with fracture... like those of the adult, and the fracture patterns are similar Injuries to the spine are rare in pediatrics; however, they contribute to a significant morbidity and mortality in children and frequently