552482

research-article2014
FAIXXX10.1177/1071100714552482Foot & Ankle InternationalPetnehazy et al

Article
Foot & Ankle International®

Fractures of the Hallux in Children

2015, Vol. 36(1) 60­–63
© The Author(s) 2014
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DOI: 10.1177/1071100714552482
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Thomas Petnehazy, MD1, Johannes Schalamon, MD1,

Charlotte Hartwig, MD1, Robert Eberl, MD1, Tanja Kraus, MD1,
Holger Till, MD, PhD1, and Georg Singer, MD1

Abstract
Background: Foot fractures account for 5% to 13% of pediatric fractures. Fractures of the hallux require special attention
due to its role in weight bearing, balance, and pedal motion. In this study, a large series of children with hallux fractures is
presented.
Methods: All children treated with fractures of the hallux between June 2004 and December 2011 were included. The
medical records were analyzed and X-rays were reviewed. The fractures were classified according to their anatomic
location and the type of fracture. Three hundred seventeen patients (mean age = 11.7 years; range, 1-18 years; 65% male)
sustained a fracture of the hallux.
Results: Most accidents (28%) occurred at sports facilities, and soccer was the most common cause of a fracture of the
hallux (28%). Closed injuries were diagnosed in 92% of the patients; 8% of the children presented with open fractures.
In 144 children, the growth plate was affected. Fifty-nine patients presented with diaphyseal fractures, 42 patients with
osseous avulsions, and 40 patients with fractures of the distal part of the phalanx. Nineteen children had incomplete
and 13 patients comminuted fractures. The vast majority of the children (86%) were treated conservatively. Operative
interventions were required in 14% of the patients. Good outcome was achieved in both conservatively and operatively
treated patients.
Conclusion: In children, fractures of the hallux were most often caused by ball sports and had a good prognosis. The vast
majority of these fractures could be treated conservatively yielding good outcome.
Level of Evidence: Level IV, case series.

Keywords: children, fractures, hallux

Introduction
Fractures of the foot account for approximately 5% to 13%
of all pediatric fractures.5,12 Fractures of the toes represent
the most common foot fractures in the pediatric age group.
Nevertheless, aggressive medical management is seldom
required.4 Fractures of the second to fifth toes are typically
treated by buddy taping, and complications or long-term
sequelae are uncommon. Due to its role in weight bearing,
balance, and pedal motion, the first toe, however, plays a
pivotal role in foot function.4 In addition, injuries of the
growth plate of the hallux may result in growth arrest, and
intra-articular fractures may cause degenerative joint dis-
ease, resulting in continuous pain and disability.8
Few reports describing hallux fractures in the adult pop-
ulation have been published.7 Moreover, information about
these fractures in the growing skeleton is scarce and reports
are confined to case reports or very small case series.8
Therefore, the aims of the present study were to present a
series of children and adolescents with fractures of the hal-
lux and to analyze the circumstances of accidents, injury
pattern, treatment strategies, and outcome of these injuries.
Methods
All pediatric trauma patients (0-18 years of age) treated at
our department between June 2004 and December 2011
were evaluated. For every patient, a questionnaire was com-
pleted by the medical personnel to document the diagnosis,
demographic information, the site of the injury, the circum-
stances and mechanism of injury, as well as any associated
injuries. In cases of incomplete questionnaires, the medical
records were reviewed to obtain the missing information.
From June 2004 to December 2011, 416 patients were suspi-
cious for a fracture of the hallux. Ninety-nine patients were
excluded in whom the initial diagnosis of a fracture could
not be confirmed during treatment or at the review process.
1
Department of Pediatric and Adolescent Surgery, Medical University of
Graz, Graz, Austria
Corresponding Author:
Thomas Petnehazy, MD, Department of Pediatric and Adolescent
Surgery, Medical University of Graz, Auenbruggerplatz 34, 8036 Graz,
Austria.
Email: thomas.petnehazy@klinikum-graz.at
Petnehazy et al 61

All children with fractures of the hallux were selected (ini- Table 1.  Additional Injuries Occurring in 9% (n = 30) of 317
tial International Statistical Classification of Diseases and Children and Adolescents With Hallux Fractures.
Related Health Problems [ICD] 10 code at first presentation: Additional Injury No.
S92.4 or S92.41). Information was obtained regarding the
fracture type (closed or open fracture, complete or incom- Contusions 10
plete fracture, Salter Harris classification11 in cases of growth Fracturesa 9
plate injuries). Fractures were additionally classified accord- Woundsb 5
ing to their anatomic location (proximal or distal phalanx). Skin abrasions 3
Treatment consisted of immobilization for undisplaced Polytrauma 3
fractures (86% short-leg cast; 11% buddy taping; 2% rest a
Toes n = 3; metatarsal n = 2; metacarpal n = 2; finger n = 1; tibia n = 1.
only). K-wire or screw osteosynthesis was used for unstable b
Foot n = 2; lower leg n = 2; forearm n = 1.
or comminuted fractures, for dislocated joint fractures, or if
acceptable alignment could not be achieved with closed Table 2.  Fracture Characteristics of 317 Hallux Fractures in
reduction and casting. Epiphyseal fractures were treated by Children.
operative stabilization if more than 25% of the joint surface
was involved or more than 2 mm of displacement occurred. Fracture Percentage No. of Patients
In cases of open fractures, antibiotic prophylaxis with amoxi- Salter Harris I 4% 14
cillin was administered. The duration of immobilization Salter Harris II 21% 65
depended on the radiographic signs of callus formation or Salter Harris III 16% 51
clinical symptoms and generally was applied for 3 weeks. Salter Harris IV 4% 14
Outpatient follow-up was continued until painless full weight Diaphysis 19% 59
bearing was possible. Osseous avulsions 13% 42
All X-rays were reviewed by 1 of the authors. All data Distal part 13% 40
were entered into a computerized database (Microsoft Incomplete 6% 19
Excel). For statistical analysis, SPSS 20 was used. The Comminuted 4% 13
independent samples t test was used to compare the mean Total 100% 317
age between the 2 sexes. P values of less than .05 were con-
sidered statistically significant. The study was approved by
the local ethics committee. deviation = 3.4 days). Nine percent of the children sustained
additional injuries (Table 1).
Results
The majority of the 317 remaining patients (mean age = Fracture Classification
11.7 years; range, 1-18 years) were male (65%), with male
patients being older compared to female patients (male age: In 57%, the fractures occurred on the right side, and in 43%,
mean = 12.1 years; female age: mean = 10.9 years; P < .05). on the left side. Whereas closed injuries were diagnosed in
Most accidents occurred at a sports facility (28%), fol- 92% of the patients, 8% of the children presented with open
lowed by accidents outside (24%) and at school or kinder- fractures. In 54%, the proximal phalanx was fractured; the
garten (21%). Less frequent were accidents at home (19%) remaining 46% of the patients sustained fractures of the dis-
or traffic accidents (5%). In 3% of the patients, the place of tal phalanx. The fracture characteristics of the 317 patients
accident was unknown. treated are displayed in Table 2.
A detailed analysis of the mechanisms of accidents revealed
that ball sports were the most common cause of a fracture of
the hallux (32%), with soccer causing most of the fractures
Treatment
(28%). Whereas 23% of the fractures were caused by crushing The vast majority of the children (86%, n = 274) were
injuries, 14% of the children sustained the fracture by kicking treated conservatively. Immobilization in a short-leg cast
an object. Gymnastics and sports equipment were involved in was used in 237 patients (86%) for a mean period of 18 days
14% of the accidents. Nine percent of the patients sustained a (range, 3-43 days). Another 30 patients (11%) had buddy
fall and 5% were involved in a traffic accident. The exact taping between the first and second toes, and 5 children
mechanism of the accident was unknown in 4% of the patients. (2%) were treated with physical rest only. Two children
The majority of the patients were referred to our depart- (1%) refused treatment. Two children were admitted for
ment on the same day (58%, n = 183) or 1 day after the antibiotic treatment and 2 for pain control.
trauma (24%, n = 77). The median interval between acci- Operative interventions were required in 14% of the
dent and referral was 0 days (range, 0-31 days; standard patients (n = 43). In 35 of these 43 children, operative
62 Foot & Ankle International 36(1)
Figure 1.  Radiographs of a patient with a displaced condylar
fracture of the proximal phalanx (A), treated with K-wire
osteosynthesis (B). X-rays after implant removal revealed
anatomic reduction of the fracture (C).
interventions for fracture stabilization (K-wire n = 17, screw
osteosynthesis n = 16, removal of bone fragment n = 2) were
necessary (Figure 1). In the remaining 8 cases, operative
wound management was performed. Four of these patients
sustained wounds without affecting the toenail or nail bed,
and treatment consisted of operative wound management
without antibiotics. Three of these patients sustained nail bed
injuries with avulsion of the toenail, and nail bed repair was
performed and postoperative antibiotic treatment was initi-
ated. The remaining patient had an avulsed toenail, which
was replaced and treated without antibiotics. The mean dura-
tion of hospitalization was 3.3 days (range, 1-17 days).
When using K-wires, implant removal was performed
after a mean of 1 month. In 12 of the 16 cases treated with
screw osteosynthesis, the implants were left in situ, whereas
in the remaining 4 cases, the screws were removed after a
mean of 10 months.
Outcome
At discharge from outpatient treatment of the 274 conserva-
tively treated patients, the majority of the patients were free
of symptoms (n = 182, 65%). Forty children were lost to
follow-up because they did not return for cast removal
(15%). Whereas 37 patients (14%) complained of minimal
pain in the hallux region, 13 children (5%) had decreased
range of motion. Another child was sent to the general prac-
titioner for wound management. A 16-year-old girl follow-
ing multiple traumas (fall from height) showed a 27-degree
angulation of the proximal phalanx similar to hallux valgus
following a complete diaphyseal fracture. Operative correc-
tion with wedge-osteotomy and plate osteosynthesis was
performed 5 months after the initial trauma.
The last documented visit of the 43 operatively treated
patients after a mean of 97 days revealed that 31 patients (73%)
were completely free of symptoms, 6 children had a limited
range of motion (15%), and 2 (4%) were lost to follow-up.
Two children (4%) complained of minimal pain, 1 child (2%)
developed a toenail deformity, and in 1 girl (2%), a nonunion
of the fixated fragment was found. However, this girl was free
of symptoms and therefore no treatment was initiated.
Discussion
The child’s foot is generally a forgiving location for frac-
tures. Complications in cases of nonoperative management
are rare and complete restoration of function occurs in a
short period of time in the majority of patients.5 Because of
the role of the great toe in weight bearing, balance, and
pedal motion, fractures of the hallux require referral much
more often than other toe fractures.4 Deformity, decreased
range of motion, and degenerative joint disease in this toe
can impair a patient’s functional ability and may cause pres-
sure sores with conventional shoe wear. Persistent displace-
ment and articular incongruity can lead to degenerative
changes and hallux rigidus.10 Although the genesis of a hal-
lux rigidus is not yet fully understood, there is growing evi-
dence that trauma may play an important role in the etiology
in children and adolescents.2
Almost half of our patients presented with fractures affect-
ing the growth plate. This may result in growth cessation or
angular/longitudinal growth abnormalities.3 Therefore, fol-
low-up of 6 and 12 months after injury has been recom-
mended by Maffulli.8 We could not identify children with
growth arrest in our series of hallux fractures. However,
growth arrest may become obvious after 2 or more years, and
therefore, long-term investigations in our series of patients
would be necessary in order to exclude these severe sequelae.
Noonan et al9 described patients with partial epiphyseal clo-
sure after hallux injuries. None of these children had any
functional or cosmetic problems at follow-up. The patient’s
age at the time of injury is an important factor influencing a
potential angular deformity resulting from partial growth
arrest. Thus, especially younger children with epiphyseal
injuries should be followed until skeletal maturity to exclude
angular deformities as a consequence of epiphyseal trauma.
Kensinger and coworkers6 described growth arrest related to
open fractures in children who stubbed their great toe and
recommend early antibiotic treatment. Therefore, in the case
of a fractured great toe, the examining physician must evalu-
ate the toe for integrity of the skin.
In comparison to adult injuries, fractures of the growing
skeleton are generally difficult to diagnose due to the fre-
quent occurrence of incomplete fractures (plastic fractures,
bowing fractures), slipped physes (Salter Harris I fractures)
without displacement, and hairline fractures. In addition,
the epiphysis may be injured in its cartilaginous portion
only resembling a Salter Harris I injury, making routine
diagnosis difficult. This may explain the high rate of chil-
dren in our series (24%) in whom the initial suspicion of a
fracture could not be confirmed during the treatment or
review process. However, clinical symptoms justified ini-
tial cast immobilization. In all of these children, symptoms
Petnehazy et al 63
had resolved at regular outpatient follow-up 6 days on aver-
age (range, 4-16 days) after trauma.
Eleven percent of our conservatively treated patients
were treated by buddy taping between the first and the sec-
ond toes, and wearing shoes with hard soles was recom-
mended. This method has been used in children with
hairline fractures and children who refused application of a
cast.5 Although we could not identify problems with bone
healing in these cases, we agree with Ly and Fallat,7 who
did not recommend buddy taping in all cases. The second
toe does not provide sufficient stability in cases of commi-
nuted or displaced fractures when used as a dynamic splint.
To identify possible prevention measures, we analyzed
the accident sites and mechanisms of injury. Playing soccer
was one of the leading activities causing a fracture of the
hallux. Similar to crushing injuries caused by falling objects
or hallux fractures caused by falls from height, prevention
strategies for hallux fractures caused by playing soccer
would be difficult to develop. Although the use of adequate
boots has been proven to be beneficial in equestrian sports,
none of the fractures in our series was related to horseback
riding.1 However, in special situations such as handling of
heavy objects, the use of safety shoes with steel toe caps
may be advantageous in adolescents.
In conclusion, our data indicate that in children, fractures
of the big toe are most often caused by soccer and have a
good prognosis. The vast majority of these fractures have a
good outcome with nonoperative management.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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