Differential Diagnosis
- Fractures of the first and second metatarsals
- Midfoot sprain
- Second phalanx dislocation
Diagnosis
The correct diagnosis in this case is fractures of the first and second metatarsals. Oblique fracture at the mid-2nd metatarsal and an angled buckle fracture at the lateral base of the 1st metatarsal can be seen in the x-ray. The injury at the base of first metatarsal is concerning for a pediatric Lisfranc injury.
Metatarsal fractures are common foot injuries. Usually, there is a combination of direct axial loading forces and twisting forces. Typically, a buckle fracture results from axial loading forces being transmitted directly down the long axis of the bone. However, when there is any other force applied, such as a varus, valgus, hyperextension, or hyperflexion force, the axial load is shifted off center and angled buckle fractures of the metaphysis occur, although they are less common.
What to Look For
- The bones of children are soft, and therefore it is common for buckle rather than overt fracture to occur
- Look for complications from the fracture including neurovascular compromise and Lisfranc injury
Pearls for Urgent Care Management
- If nondisplaced or minimally displaced, treatment is immobilization with a posterior leg splint, non-weight bearing, and follow-up in 3-5 days
- Pain management with over-the-counter medications is usually sufficient once immobilization has occurred
- If significantly displaced, reduction is indicated
- If neurovascular complications exist, immediate referral to the emergency department is indicated
Download the Article PDF: 7-Year-Old With Playground Injury