How are toe fractures classified in children. What are the common causes of toe fractures in pediatric patients. When should X-rays be ordered for suspected toe fractures. How are different types of toe fractures managed in the emergency department. What follow-up is required for various toe fracture types in children.

Classification and Types of Toe Fractures in Children

Toe fractures are a common injury in pediatric patients. Understanding their classification is crucial for proper diagnosis and treatment. Phalanx fractures are classified based on several key factors:

• Location of the fracture (which toe and which phalanx is affected)
• Whether the fracture is open or closed (including nail bed injuries)
• Presence of displacement or rotational deformity
• Involvement of the growth plate (classified using the Salter-Harris Classification)

The big toe (1st toe) deserves special attention due to its important role in the toe-off phase of gait. Suspected fractures of the big toe should always be formally diagnosed with an X-ray, and any confirmed fractures require follow-up with the orthopedics team.

Prevalence and Mechanisms of Toe Fractures in Children

Phalangeal fractures are the most common type of foot fracture in children. Understanding the mechanisms of injury can help in prevention and diagnosis. Common causes include:

• Axial loading (e.g., stubbing the toe)
• Abduction injury, often involving the 5th digit
• Crush injuries from heavy objects falling on the foot or motor vehicle tires running over the foot

Less common mechanisms include joint hyperextension or hyperflexion, which can lead to spiral or avulsion fractures. Recognizing these mechanisms can help healthcare providers in their initial assessment and treatment planning.

Clinical Presentation of Toe Fractures in Pediatric Patients

When a child presents with a suspected toe fracture, healthcare providers should be aware of the typical clinical signs. These include:

• Localized bruising and swelling
• Possible angulation or malalignment
• Rotational deformity (compare the position of the nail plate with toes on the other foot)
• Significant nail bed injury (which may indicate a Seymour fracture)

It’s important to conduct a thorough examination to identify these signs, as they can guide the decision-making process for further investigations and treatment.

Radiological Investigations for Suspected Toe Fractures

When should X-rays be ordered for suspected toe fractures in children? While not all toe fractures require radiological confirmation, certain situations warrant X-ray imaging:

• Suspected open fractures
• Fractures with associated angulation
• Presence of nail bed injury
• Any suspected fracture of the great (1st) toe

When ordering X-rays, healthcare providers should request dorsoplantar, oblique, and lateral views to get a comprehensive picture of the injury. However, for suspected fractures of toes 2, 3, 4, or 5 with bruising and swelling but no significant deformity or open wound, it may be reasonable to diagnose and treat clinically without X-ray confirmation.

Radiographic Appearance of Different Toe Fractures

Understanding the radiographic appearance of various toe fractures is crucial for accurate diagnosis and treatment planning. Some common presentations include:

• Seymour Fracture: A Salter-Harris I fracture of the great toe with associated nail plate displacement
• Salter-Harris III fracture at the base of the distal phalanx
• Undisplaced distal phalanx fracture
• Displaced and angulated Salter-Harris II fracture of the 5th toe proximal phalanx
• Undisplaced shaft fracture of the 5th toe proximal phalanx
• Undisplaced Salter-Harris II fractures of the fourth and fifth toes
• Salter-Harris IV and Salter-Harris III fractures of the great toe proximal phalanx

Recognizing these patterns on X-rays helps in determining the appropriate course of treatment and whether reduction or orthopedic consultation is necessary.

Reduction and Orthopedic Referral for Toe Fractures

When is reduction necessary for toe fractures in children? Significantly displaced or angulated fractures typically require reduction. This is particularly important for fractures of the fifth toe, as malunion can lead to long-term issues such as difficulty fitting into shoes.

Orthopedic consultation is necessary in cases of:

• Open fractures
• Significant nail bed injuries (suspected Seymour fractures)

These situations require specialized care to ensure proper healing and prevent complications. Healthcare providers should be prepared to make timely referrals when these conditions are identified.

Emergency Department Management and Follow-up for Toe Fractures

The management of toe fractures in the emergency department varies depending on the type and severity of the fracture. Here’s a breakdown of typical management approaches:

Undisplaced Phalanx Fractures

ED Management:

• Rest, ice, and elevation
• Recommendation to wear firm-soled shoes (e.g., school shoes)

Follow-up:

• No follow-up required for toes 2, 3, 4, and 5 (these typically heal within 3 to 4 weeks)
• Fractures of the big toe should be followed up in fracture clinic due to its important role in gait

Open Fractures

ED Management:

• Immediate referral to Orthopedics

Follow-up:

• As determined by the orthopedic team

It’s important to note that while many toe fractures can be managed conservatively, proper follow-up ensures optimal healing and identifies any potential complications early.

Special Considerations for Seymour Fractures

Seymour fractures deserve special attention in the context of pediatric toe injuries. These are open fractures of the distal phalanx associated with nail plate displacement. They require specific management to prevent complications:

• Prompt recognition is crucial
• Orthopedic consultation is necessary
• Treatment typically involves careful cleaning of the nail bed, reduction of the fracture, and repair of the nail bed
• Antibiotics are often prescribed to prevent infection

Healthcare providers should be vigilant for signs of Seymour fractures, as they can be easily missed if not specifically looked for during the examination.

Long-term Outcomes and Potential Complications of Toe Fractures

While most toe fractures in children heal well with appropriate management, it’s important to be aware of potential long-term outcomes and complications:

• Malunion: Especially relevant for the 5th toe, which can lead to shoe-fitting issues
• Growth plate disturbances: May occur with Salter-Harris fractures, potentially leading to growth abnormalities
• Nail deformities: Particularly with Seymour fractures if not properly managed
• Chronic pain: Rare but possible, especially with improperly treated fractures

Educating patients and their families about these potential issues can help ensure proper adherence to treatment plans and prompt reporting of any concerning symptoms during the recovery period.

Prevention Strategies for Toe Fractures in Children

While accidents happen, there are several strategies that can help reduce the risk of toe fractures in children:

• Encouraging the use of proper footwear, especially during sports and physical activities
• Teaching children about the importance of being aware of their surroundings to avoid stubbing their toes
• Ensuring safe home environments by removing tripping hazards and securing heavy objects that could fall on feet
• Promoting the use of protective gear in sports where toe injuries are common

By implementing these preventive measures, parents and caregivers can help reduce the incidence of toe fractures in children.

The Role of Physical Therapy in Toe Fracture Recovery

While many toe fractures heal well with conservative management, some cases may benefit from physical therapy, particularly for more severe injuries or those involving the big toe. Physical therapy can help in several ways:

• Restoring range of motion in the affected toe
• Strengthening the intrinsic muscles of the foot
• Improving gait patterns that may have been altered due to the injury
• Providing education on proper foot care and injury prevention

Healthcare providers should consider recommending physical therapy for cases where there’s concern about long-term functional impact or for patients who are struggling to regain normal toe function after the initial healing period.

Psychological Impact of Toe Fractures on Children

While toe fractures are generally considered minor injuries, they can still have a psychological impact on children, especially if they result in activity restrictions or changes in appearance. Healthcare providers should be aware of potential psychological effects such as:

• Frustration or anxiety about activity limitations
• Concerns about appearance, particularly with nail deformities
• Fear of re-injury, which may lead to hesitancy in returning to normal activities

Addressing these concerns and providing reassurance can be an important part of comprehensive care for pediatric toe fractures. In some cases, involving a child psychologist or play therapist may be beneficial, especially for children who are particularly anxious or struggling to cope with the injury.

Clinical Practice Guidelines : Toe Fractures

1.

Summary

Toe fractures are common in children

Suspected fractures of the smaller toes (2nd-5th) with no clinical deformity may not require X-ray, as it would be unlikely to change management.  

The big (1st) toe has an important role in toe-off phase of gait; suspected fractures should be formally diagnosed with xray with any fractures followed up in with the orthopaedics team.

Correction of any clinically evident angulation is a key part of Emergency Department Management.

Orthopaedic team management is necessary in the case of toe fractures with associated open nailbed injury (Seymour fractures)

2.

How are they classified?

Phalanx fractures are classified by the following:

• Location of fracture: which toe and which phalanx is affected.
• Open or closed (includes nail bed injuries)
• Displacement / Rotational deformity
• Growth Plate involvement (Salter-Harris Classification)

3.

How common are they and how do they occur?

 Phalangeal fractures are the most common foot fracture in children.

Common mechanisms of injury include:

• Axial loading (stubbing toe)
• Abduction injury, often involving the 5th digit
• Crush injury caused by a heavy object falling on the foot or motor vehicle tyre running over foot

Less common mechanism:

• Joint hyperextension or hyperflexion, which can lead to spiral or avulsion fractures

4.

What do they look like – clinically?

Fractured toes usually present with localised bruising and swelling.

It is important to check for angulation/mal-alignment and for rotational deformity (the position of the nail plate will give a guide to this and compare with toes on the other foot)

It is also important to check for significant nailbed injury. Any nail avulsion or displacement out of eponychial fold may indicate a Seymour fracture (see below)

5. What radiological investigations should be ordered?

Plain film – dorsoplantar, oblique and lateral views should be ordered where there is a suspected open fracture, a suspected fracture with associated angulation, a nailbed injury, or for any fracture of the great (1st) toe.

Note that where there is bruising and swelling of toe 2, 3, 4 or 5 but no significant deformity and no open wound, it may be reasonable to diagnose a fracture clinically (i.e. without X-ray) with management as below (ie simply buddy-tape the affected toe and wear firm-soled shoes for 3 weeks)

6.

What do they look like on x-ray?

 Figure 1: Seymour Fracture of the Great Toe (SH I with associated Nail Plate displacement)

Figure 4 &5: Displaced and anbulated Salter-Harris II of 5th toe proximal phalanx, & undisplaced shaft fracture of 5th toe proximal phalanx . The angulated fracture will need reduction

Figure 6: Undisplaced Salter-Harris II of fourth and fifth toes

Figure 7 & 8: Salter-Harris IV and Salter-Harris III of great toe  proximal phalanx.

7. When is reduction (non-operative and operative) required?

Significantly displaced or angulated fractures require reduction

This is particularly true of the fifth toe as malunion will cause longer-term issues such as fitting into shoes.

8.

Do I need to refer to orthopaedics now?

• Open Fractures require orthopaedic consultation, including where a significant nailbed injury is suspected (see Seymour fracture, above in point 4).

9. What is the usual ED management for this injury, and what follow-up is required?

10. What advice should I give to parents?

Where buddy taping is performed, the parent should observe the method in case re-application is required in the coming weeks (including placing cotton between the toes to prevent skin maceration)

They should be instructed to keep the child in firm-soled shoes, ideally close-toed.

Where expectant management is appropriate, it is advised to keep the affected toe buddy taped for three weeks

11.

What are the potential complications associated with this injury?

• Seymour fractures can result in osteomyelitis particularly where recognition of the injury is delayed
• Displaced Salter Harris fractures of the great toe may cause joint stiffness or growth arrest.

12. References

Boutis, K., 2018. Metatarsal and toe fractures in children, UpTodate.com

Eves, T., Oddy, M.J. Do broken toes need follow up in fracture clinic? The journal of foot and ankle surgery, 2016:55;488-491

Hatch, “Evaluation and Management of Toe Fractures”, Am Fam Physician. 2003 Dec 15;68(12):2413-2418

Morris et al “Open Physeal Fracture of the Distal Phalanx of the Hallux” Am J Emerg Med 2017 35(7) 1035.e1.

Do Broken Toes Need Follow-Up in the Fracture Clinic?

Most toe phalangeal fractures can be successfully treated nonoperatively without any residual deformity and are usually clinically asymptomatic. Toe phalangeal fractures are nevertheless common fracture clinic referrals. Our aim was to evaluate the injury characteristics of patients with toe fractures attending a fracture clinic and to understand how current management affects the fracture clinic workload. We retrospectively evaluated all new referrals to a subspecialized foot and ankle fracture clinic during a 12-month period at our institution under the care of 1 consultant. Data were collected regarding patient demographics, fracture type, patient outcome, and the number of clinic appointments attended, cancelled, or not attended. A total of 707 new patients (mean age 39 ± 19 years; 345 males, 362 females) were seen in 47 foot and ankle fracture clinics within the study period. Seventy-four phalangeal fractures were identified in 65 patients. A total of 135 outpatient appointments were scheduled for these patients (initial and follow-up), with 93 (69%) attended, 25 (19%) not attended, and 15 (11%) cancelled and rescheduled at the patient’s request. Seventeen patients (13%) failed to attend their first clinic appointment. The results of the present study highlight that 9% of all new patient referrals to a fracture clinic were for toe phalangeal fractures. Only 2 patients required surgery for significant loss of articular congruency or deformity. No patient subsequently developed a symptomatic malunion or required toe surgery during the following 2 years. We believe that undisplaced and stable toe phalangeal fractures do not need to be referred to the fracture clinic. This would result in a reduction of outpatient appointments for toe fractures by 52%.

Keywords:

appointment; fracture; phalanx; toe.

Foot x-rays – Don’t Forget the Bubbles

1. Check you have the right views.

There are two views in foot x-rays DP (dorsal-plantar) and oblique. Both should ideally be done when weight-bearing if your patient can manage it.

2. Review the bones. 

Work round the bones one by one (including the metatarsals). Start proximally and work your way down, going medial lateral. This will ensure you check them all.

3. Find any bits that aren’t attached. 

Consider whether any floaty bits might be an ossicle. Pay particular attention to small avulsions from the bones – these are very easy to miss.

There are a couple of common ossicles that you might see:

Os tibiale externum – this is an ossicle present at the medial aspect of the navicular bone (it appears at adolescence)

Os peroneum – this an accessory bone in the peroneus longus tendon

Avulsions commonly occur on:

The lateral aspect of the cuboid

The dorsal surface of navicular and talus (seen only a lateral ankle view)

4.

Check the base of fifth.

Most fractures here are avulsions of the metatarsal tuberosity. This is where peroneus brevis attaches and an inversion injury can cause the fracture.

https://sprintforever.blogspot.co.uk/

A Jones fracture is a transverse fracture at the proximal shaft of the fifth metatarsal. It is managed differently (non-weight bearing).

Also, don’t confuse a base of fifth fracture with an unfused apophysis or vice versa. An unfused apophysis runs longitudinally, whereas fractures are usually transverse. The apophysis appears at age 12 for boys and age 10 for girls, and it usually fuses over the next few years.

https://radiopaedia.org/cases/fifth-metatarsal-apophysis

5. Check for calcaneal fractures

 Look for an avulsion of the anterior process of the calcaneum (oblique view). Look lateral to the calcaneum where extensor digitorum brevis inserts (on the DP view). You can also get injuries to the anterio-lateral aspect of the calcaneus.

6. Check for Lisfranc injuries

Normally aligned bones should have the second metatarsal aligning with the intermediate cuneiform on the DP view; and the third metatarsal aligning with the lateral cuneiform on the oblique view. The Lisfranc ligament connects the cuneiforms and the second metatarsal. Disruption of this ligament leaves an unstable foot and so it’s an important one not to miss.

https://emergencymedicineireland.com/

https://emergencymedicineireland.com/

To see more about Lisfranc injuries, check out Andy Neill’s great video on this here.

7. Consider stress fractures

These commonly occur on the second or third metatarsals. Sometimes they just present with callous formation or sometimes cannot be seen on plain x-ray and require further imaging (e.g. MRI) to diagnose.

Trauma X-ray – Lower limb

Key points

• Carefully check the cortical edge of all bones on all views available
• Always check for alignment of bones at the mid-forefoot junction (tarsometatarsal joints)
• Injury to the Lisfranc ligament may not be visible on initial X-ray – follow up may be necessary
• Metatarsal stress fractures are subtle and may not be visible on the initial X-ray

Foot

Fractures and dislocations of the forefoot (metatarsals and phalanges) are usually straightforward to identify, so long as the potentially injured bone is fully visible in 2 planes. The contour of the bone cortex of all bones must be checked carefully.

Standard views

Dorsal-Plantar (DP) and Oblique – are standard projections of the forefoot. If only a phalangeal fracture is suspected then DP and oblique views of the toe(s) can be acquired. Lateral views can also be helpful.

Foot X-ray anatomy – DP and Oblique views

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Foot X-ray anatomy – DP and Oblique views

• Hindfoot = Calcaneus + Talus
• Midfoot = Navicular + Cuboid + Cuneiforms
• Forefoot = Metatarsals + Phalanges
• 1 = Hind-midfoot junction
• 2 = Mid-forefoot junction = Tarsometatarsal joints (TMTJs)

Foot X-ray anatomy – DP and Oblique views

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Foot X-ray anatomy – DP and Oblique views

• Metatarsals and phalanges of the toes are numbered 1 to 5
• 1 = Big toe
• 5 = Little toe
• MC = Medial Cuneiform
• IC = Intermediate Cuneiform
• LC = Lateral Cuneiform

Forefoot X-ray anatomy – Joints

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Forefoot X-ray anatomy – Joints

• MTPJ = Metatarsophalangeal Joints
• IPJ = Interphalangeal Joint (of big toe only)
• PIPJ = Proximal Interphalangeal Joints
• DIPJ = Distal Interphalangeal Joints
• Note the medial side sesamoid is ‘bipartite’ (in 2 parts) – this is a common normal variant – not a fracture

Foot ligament anatomy

When checking any post-traumatic foot X-ray it is crucial to assess alignment of the bones at the joints. Loss of joint alignment can represent severe injury, even in the absence of a fracture.

Forefoot ligament anatomy – Normal

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Forefoot ligament anatomy – Normal

• DP – Normal alignment of the 2nd Metatarsal with the Intermediate Cuneiform
• Oblique – Normal alignment of the 3rd Metatarsal with the Lateral Cuneiform
• Position of the Lisfranc Ligament shown

Lisfranc injury

The ‘Lisfranc’ ligament stabilises the mid-forefoot junction. Loss of alignment of the 2nd metatarsal base with the intermediate cuneiform indicates injury to this important ligament.

Every post-traumatic foot X-ray must be checked for loss of alignment at the midfoot-forefoot junction (tarsometatarsal joints).

Lisfranc injury – DP

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Lisfranc injury – DP

• Second metatarsal displaced from the intermediate cuneiform
• No fracture is visible but this is a severe injury which is debilitating if untreated
• Note: Lisfranc ligament injury can be subtle and does not always result in displacement – If there is a clinically suspected ligament injury then clinical and radiological follow-up must be arranged

Metatarsal fractures

Metatarsal fractures are usually easily recognised, but are often only visible on one view.

Fractures of the 5th metatarsal base are a common injury. The normal 5th metatarsal apophysis should not be mistaken for a fracture.

Metatarsal shaft fracture

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Metatarsal shaft fracture

• Oblique fracture of the 5th Metatarsal shaft
• Fracture more clearly visible on the oblique image

5th metatarsal base fracture

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5th metatarsal base fracture

• Left image – The fracture line passes transversely across the bone
• Right image – A normal unfused 5th metatarsal base apophysis is aligned more longitudinally along the bone

Metatarsal stress fractures

Stress fractures of the metatarsals are common in athletically active individuals. These may not be visible on initial X-rays but follow up images show periosteal stress reaction. This has the appearance of fusiform bone expansion.

Metatarsal stress fracture

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Metatarsal stress fracture

• Subtle periosteal stress reaction of the 2nd metatarsal
• History of chronic pain worsened by activity
• Note: Stress fractures are not always visible on the initial X-ray – if suspected repeat X-ray or MRI may be required

Acute Trauma to the Foot

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Children And Broken Bones – HealthyChildren.org

How can I tell if my child has broken a bone?

Although the term fracture may sound serious, it is just another name for a broken bone. As you probably remember from your own childhood, fractures are very common. In fact, they are the fourth most common injury among children under age six. Falls cause most of the fractures in this age group, but the most serious bone breaks usually result from car crashes.

A broken bone in a child is different from one in an adult, because young bones are more flexible and have a thicker covering, which makes them better able to absorb shock. Children’s fractures rarely require surgical repair. They usually just need to be kept free of movement, most often through the use of a molded cast.

Types of Fractures

Most  youngsters, broken bones are either “greenstick” fractures, in which the bone bends like green wood and breaks only on one side, or “torus” fractures, in which the bone is buckled, twisted, and weakened but not completely broken. A “bend” fracture refers to a bone that is bent but not broken, and is also relatively common among youngsters. “Complete” fractures, in which the bone breaks all the way through, also occur in young children.

Because your child’s bones are still growing, he is vulnerable to an additional type of fracture that does not occur in adults. This involves damage to the growth plates at the ends of the bones, which regulate future growth. If this part of the bone does not heal properly after the fracture, the bone may grow at an angle or more slowly than the other bones in the body. Unfortunately, the impact on the bone’s growth may not be visible for a year or more after the injury, so these fractures must be followed carefully by the pediatrician for twelve to eighteen months to make sure no growth damage has occurred.

Fractures that involve injury to the growth plate sometimes need surgery to minimize the risk of future growth problems. Fractures around the elbow often cause the arm to heal abnormally, resulting in a crooked position. Many require surgery to minimize this risk. Children with fractures near the elbow may be referred to an orthopedic specialist.

Fractures also are classified as “non-displaced,” when the broken ends are still in proper position, or “displaced,” when the ends are separated or out of alignment. In an “open” or “compound” fracture, the bone sticks through the skin. If the skin is intact, the fracture is “closed.”

Signs and Symptoms

It’s not always easy to tell when a bone is broken, especially if your child is too young to describe what he’s feeling. Ordinarily with a fracture, you will see swelling and your child will clearly be in pain and unable—or unwilling—to move the injured limb. However, just because your child can move the bone doesn’t necessarily rule out a fracture. Anytime you suspect a fracture, notify your pediatrician immediately.

Home Treatment

Until your child can be seen in the pediatrician’s office, emergency room, or urgent care center, use an improvised sling or rolled-up newspaper or magazine as a splint to protect the injury from unnecessary movement.

Don’t give the child anything by mouth to drink or to relieve pain without first consulting the doctor, but if yours is an older child, you can use an cold pack or a cold towel, placed on the injury site, to decrease pain. Extreme cold can cause injury to the delicate skin of babies and toddlers, so do not use ice with children this young.

If your child has broken his leg, do not try to move him yourself. Call 911 for an ambulance; let the paramedics supervise his transportation and make the child as comfortable as possible.

If part of the injury is open and bleeding, or if bone is protruding through the skin, place firm pressure on the wound; then cover it with clean (preferably sterile) gauze. Do not try to put the bone back underneath the skin. After this injury has been treated, be alert to any fever, which may indicate that the wound has become infected.

Professional Treatment

After examining the break, the doctor will order X rays to determine the extent of the damage. If the doctor suspects that the bone’s growth plate is affected, or if the bones are out of line, an orthopedic consultation will be necessary.

Because children’s bones heal rapidly and well, a plaster or fiberglass cast, or sometimes just an immobilizing splint, is all that is needed for most minor fractures. For a displaced fracture, an orthopedic surgeon may have to realign the bones. This may be done as a “closed reduction,” in which the surgeon uses local or general anesthesia, manipulates the bones until they’re straight, and then applies a cast. An “open reduction” is a surgical procedure done in an operating room, but this is rarely necessary for children.

After the surgical reduction, a cast will be used until the bone has healed, which usually takes about half the time that adult bones require, or less, depending on the child’s age. The nice thing about young bones is that they don’t have to be in perfect alignment. As long as they are more or less in the right place, they will remodel as they grow. Your pediatrician may order periodic X-rays while the bone is healing, just to make sure they are aligning properly.

Usually casting brings rapid relief or at least a decrease in pain. If your child has an increase in pain, numbness, or pale or blue fingers or toes, call your doctor immediately. These are signs that the extremity has swollen and requires more room within the cast. If the cast is not adjusted, the swelling may press on nerves, muscles, and blood vessels, which can produce permanent damage. To relieve the pressure, the doctor may split the cast, open a window in it, or replace it with a larger one.

Also let the doctor know if the cast breaks or becomes very loose, or if the plaster gets wet and soggy. Without a proper, secure fit, the cast will not hold the broken bone in position to mend correctly.

Bones that have been broken often will form a hard knot at the site of the break during the healing process. Especially with a broken collarbone, this may look unsightly, but there is no treatment for this, and the knot will not be permanent. The bone will remodel and resume its normal shape in a few months.

The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Normal Foot X-ray – Findings and Discussion

Normal Foot Xray

Xrays are basic investigations for orthopedic problems. To find the abnormal one must have an idea of normal.

This is how a normal foot x-ray looks like. The present image shows an anteroposterior and oblique view x-ray of the left foot.

On the left side of the plate, there is an oblique view x-ray of the foot. On the right side, there is anteroposterior view.

Xray of the foot is ordered in various ailments of the foot including trauma. Anteroposterior and oblique views are most common views that are ordered on the foot. Anteroposterior views are also called dorsoplantar views.

Another view that is commonly done in addition to these views is lateral view.

Here is a video that demonstrates how foot x-ray views are taken. In the video x-ray of the right foot is being done.

What to Look For in Normal Foot Xray?

The normal foot can be divided into three different regions

• Forefoot  – It consists of phalanges[toes] and metatarsals
• Midfoot  – It has navicular, cuboid and three cuneiforms namely medial, intermediate and lateral
• Hindfoot: Talus and Calcaneus

Bones of the midfoot and hindfoot are referred to as the tarsal bones

Following x-ray shows the location of these bones on x-ray.

Foot Xray Showing Marked Bones – Image Credit: University of Virginia

The anteroposterior or dorsoplantar view is very good for visualizing medial elements – first and second metatarsal bones, medial and intermediate cuneiforms and medial articulation of the Lisfranc joint.

In a normal anteroposterior foot x-ray, interphalangeal joints are obscured but metatarsophalangeal joints are well seen and each joint should be checked. All the parts of ray – metatarsal and phalanges are well aligned.

Sesamoid bones in the first toe is a normal finding.

Head, neck, and shaft of metatarsals are clearly visualized but bases blur.

The Lisfranc joint is another name for the tarsometatarsal joint. In this joint, first, second, and third cuneiforms, and the cuboid, articulate with the bases of the metatarsal bones.  The bones are connected by dorsal, plantar, and interosseous ligaments.

Lisfranc joint is very important for stability and subtle injury if missed, can lead to problems. A normal Lisfranc joint is characterized by

– Medial borders of the second metatarsal and intermediate cuneiform should be in line on anteroposterior x-ray.

– Medial borders of the 3rd metatarsal and lateral cuneiform should line up on the oblique view.

Oblique View enables to clearly visualize 3rd, 4th and 5th metatarsals, lateral cuneiform, navicular and cuboid.

Phalanges and interphalangeal joints are better visualized in oblique x-rays. The base of fifth metatarsal [site for Jones’s fracture] and tarsometatarsal alignment should be checked. As noted in anteroposterior x-ray, for tarsometatarsal joints to be normal medial margins of tarsal bone and respective metatarsal should be aligned. Finally, the lateral tarsals and calcaneum should be analyzed. Oblique view x-ray of the foot also gives an opportunity to have second look at the navicular bone.

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90,000 Arthritis after fracture of the little finger – Question to a rheumatologist

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What to do after a toe fracture

A toe fracture is more common than a fracture of another part of the body. Each human finger is made up of several small bones. A fracture or fracture of one of these bones can be very painful and requires urgent immobilization (immobility). After a toe fracture, it usually takes four to six weeks for the injury to heal properly.

Depending on the severity of the toe fracture, immobilization may take longer, especially if surgery is required.

Sometimes it is difficult for a person to understand that a toe fracture has occurred on his leg. Most fractures occur after something has been dropped, pinched, or seized by a toe.

Symptoms of a fractured toe include swelling, pain, and discoloration. If these symptoms have not disappeared within two to three days after the injury, or if you cannot wear normal shoes, you should definitely see a doctor.A fractured toe is treated by a surgeon or podiatrist. Do not hesitate immediately after a fracture, at the first sign, to contact the nearest emergency room or call an ambulance. The compulsory medical insurance for a fracture of a finger is absolutely free for you.

Symptoms of a toe fracture to look out for

A fractured toe may be accompanied by symptoms such as:

• Pain – Acute, intense
• Swelling
• Soft
• Pale or deformed foot
• Abnormal mobility at the site of the fracture
• Crepitation – crunching on pressure caused by friction of bones
• Bleeding or bruising
• Inability to transfer weight to the toe
• Unnatural position of the foot
• Numbness, tingling or paralysis below the fracture (this is rare, especially in the sock , it requires immediate attention).

How is a fractured toe diagnosed

If you see your doctor about a broken toe, they will probably ask you how you broke your toe, what symptoms you experienced, and what types of sports activities you practice.

The doctor will then examine the broken toe and assess the injury, including the condition of the nails or skin. X-rays are likely to be given to determine the extent of the fracture. If additional trauma to surrounding tissue is suspected, your doctor may order an MRI (magnetic resonance imaging or CT scan).

Once the severity of your fracture has been determined, your doctor will recommend an appropriate treatment plan for your broken toe.

Causes of toe fractures – why toes break

Most broken toes are the result of an injury to a limb. Injury can be sudden, for example, even when you simply put out a cigarette butt with the toes of your foot, or a toe fracture can occur as a result of repetitive stress, such as during sporting activities that require starting and stopping quickly, changing running directions, or jumping.Hockey, football, basketball, martial arts – all of these sports are associated with the risk of finger fractures.

A toe can be broken after a heavy object falls on it. This is one of the most common household causes of a toe fracture.

The big toe breaks more often than others. Here’s why:
Unlike the rest of the toes, the big toe has two phalanges, not three! At the same time, when you walk, it is the thumb that experiences the main load, taking on the entire weight of the person.It sticks out the most, so your beloved big toe is at the highest risk of fracture.

Types and types of toe fractures

• Open finger fracture: the integrity of the skin is broken and part of the broken bone can be seen through the wound;
• Closed finger fracture: soft tissue integrity is preserved;
• Displaced fracture: When the force on the finger is applied to the injury, the injured bones are displaced.In this case, infringement of nerves, blood vessels or muscles located nearby may occur.
• fracture without displacement;
• Complete fracture of a toe: in which the bone breaks in two or more parts;
• Incomplete finger fracture: a crack forms in the bone tissue;
• comminuted toe fracture: bone is shattered, leaving debris in the wound.

A toe fracture can occur at:

• on the nail phalanx;
• on the middle phalanx;
• on the main phalanx;

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• on two or more phalanges (combined fracture).

Complications after a toe fracture

If a toe is broken, this is, of course, sad in itself, but after a toe fracture, complications may arise. For example, blood begins to collect under the nail, a condition called a subungual hematoma, which is a painful condition that can lead to loss of the nail.

After a broken toe heals, arthritis or osteoarthritis can develop, causing pain, stiffness, and other unpleasant symptoms.

Sometimes the bones cannot heal properly (improper tissue fusion after injury), or not fusion. If this happens, surgery may be the only option to treat the problem.

How is a broken toe treated

There are several ways to treat a broken toe. Some treatments can be done at home, while others are done by a surgeon or podiatrist. Home treatments for a broken toe usually include rest, ice, compression, elevation.

This method is used to treat many types of lower leg and foot injuries. Your doctor may prescribe crutches for one to three weeks, depending on the severity of the fracture.

Methods for treating a fracture of a toe

Your doctor will choose a treatment regimen for a fracture of a toe depending on the nature of the injury:

• Open fracture of a toe – after matching bone fragments (the medical term is reduction) and fixing the limb in a motionless state, usually performed antibiotic therapy.This reduces the likelihood of secondary infection after a broken toe.
• Treatment of a big toe fracture will most likely require immobilization with a plaster cast. A plaster cast on the toe and upper third of the lower leg is applied for five to six weeks.
• Simple fracture of the second to fifth toes – not required plaster cast. But a splint is applied to the injured toe for a period of four to six weeks.
• Intra-articular toe fracture means the likelihood of surgery, during which the surgeon carefully aligns the bones of the joint and fix them with wires.In severe cases of a finger fracture, a compression-distraction apparatus is applied. Finger function is expected to recover in about 2 months.

For faster bone regeneration after a toe fracture, general strengthening therapy is prescribed.

If you have open sores on or near your toes, you may be given a tetanus shot and / or an antibiotic shot to prevent infection and complications.

Your doctor may prescribe anti-inflammatory and pain relievers such as ibuprofen to reduce pain and swelling.

Children’s bones tend to heal quickly, while older toe fractures take longer to heal. The time it takes to heal a broken toe depends on the type of fracture and the extent of tissue damage. In some cases, treatment can take up to six months or more. In other cases, it may take six to eight weeks for a fractured toe to heal.

Avoiding a toe fracture

In some cases, a toe fracture is inevitable, but there are things you can do to reduce the chances of a toe fracture.Here are some preventative tips:

• Wear shoes that protect your toes, especially for work and sports.
• Wear shoes that are properly sized.
• Your home must be safe to prevent falls. For example, slippery carpets, wobbly stair railings, and slippery floors increase the risk of injury.
• If you have a medical condition such as osteoarthritis, follow your treatment plan to avoid injury.
• Use extreme caution when engaging in injury-prone activities.
• Increase your vitamin C and zinc intake to accelerate bone and tissue healing.
• It is advisable to limit the consumption of strong coffee, alcohol and carbonated drinks, as they remove calcium from the body, reducing bone density.
• See your doctor at the first sign of a fracture.

Questions to ask your doctor after a toe fracture

Here are some questions to ask your doctor after a toe fracture:

• What type of sports shoes do you recommend based on my activity?
• How long will it take before I can resume my normal activities?
• If non-surgical treatments don’t work, how long should I wait before coming back to see you? What symptoms should I watch for?
• How often should I shower while wearing a cast?
• How do I wash my finger while it heals?

Article author: Andrey Selin, “Portal Moscow Medicine” ©

Disclaimer: The information presented in this article is intended only to inform the reader.It cannot be a substitute for advice from a health professional.

VRka – Free flight

If discarded
innate complacency and songs about the greatness of the human mind,
which we were taught from childhood, to be more modest and more honest, then
we have to admit: all of our current civilization is not entirely a merit
humanity. It’s just that humanity is very lucky. Lucky to open
electricity, oil and a couple more useful things. Which, in general,
no one guaranteed us.Therefore, everything has now become simple – included
an electric kettle made of petroleum plastic, took out a sausage from the refrigerator,
had breakfast, left the house, got into an excavator and let’s dig a trench, with
productivity noticeably greater than a hundred slaves and fifty to them
overseers.

What if there were no electricity? Well,
there would not be such an absurd law in nature that on a metal
invisible energy knew how to run along the wire. If you think about it, enough
witchcraft property of wire, don’t you think? But if not
electricity – then no computer, no TV, no flashlight.No
not even an X-ray of a broken pinky finger can be done. Some gas lanterns. And then
if you’re lucky with oil. Also, if you figure it out, quite amazing
combustible thing: it has been regularly accumulated for us for millions of years, so that we
now they have burnt it – it hasn’t burned out, hasn’t gone rotten, hasn’t evaporated. Think about it!
You can leave a can of gasoline in your country house for ten years – and then you’ll make ends meet. Or
it was stolen, or dried up, or burned down along with the barn, or you don’t remember,
where I put it. And here it’s millions of years, without any canister … I’m not even
I ask where it came from.I wonder how it survived.
The planet around is breathing oxygen – burn, oxidize! But no,
endured for so many years. And on the wood, as we understand, of course, you can
build a steam boiler, but you can’t ride a hundred miles, nor into space
fly. And for some reason we are especially proud of space.

With such and such help, a fool will build a civilization. Try it with your bare hands …!

By this
in the summer I happened to visit France on a press tour from DSGW with
Karen Goncharov. And most of all I saw during the trip
struck by one thing – the bridge.

The bridge is … two thousand years old! Length – 275 meters, height – 49
meters. Three tiers. Built by the Romans in 19 BC as
follows from the date stamped by them. Built with bare hands, of stones. But
the most interesting is not even that. The most interesting thing is why it was built
such a tall bridge across the river. You can see that its height
disproportionate to the task, it was possible to cross the river along the first tier, and
much lower. A millennium later, the medieval French gave this
the name of the Pont du Gard (bridge over the Gard river), showing the full
misunderstanding of the author’s intention.After all, it was not quite a bridge, and was being built
it is not quite across the river …

There is such a word “aqueduct”,
which everyone heard, but no one understands its meaning now – something
so ancient and stone. And I didn’t know. Meanwhile the aqueduct is a bridge
for water. Exactly so: a bridge over which clear water flows.

B
Unlike the barbarians of medieval Europe, who lived knee-deep in their own sewage and poured slop under themselves, the ancient Romans appreciated cleanliness:
in the cities they had sewerage, running water and baths (“terms”).And therefore
there were no such epidemics as in the Middle Ages. But self-respecting Romans
for their water supply they will not take water from some river there, in
which the fish pee, and the villagers wash their footcloths upstream. it
unhygienic and tasteless. No, give the Romans the purest water from the mountain
springs. And the springs, naturally, are far from the city – in the mountains. Build
the same city in the mountains for the sake of one water supply is not enough interest. What to do? AND
the Romans lead the water for tens of kilometers. There is nothing to make pipes –
there is no metal in that amount.The tree will rot. The clay will crumble.
Such, to build from anything, and then shift every year
again and on this to roll away money, – such jackal manners have
the Romans were not in use. This is not the asphalt on the Moscow Ring Road. No, the Romans loved
concentrate, build once and solve the problem forever. AND
do something else.

So, from mountain springs to
the city has a large inclined stone gutter with the expectation that on it
clean water always flowed – by itself, without any electric pumps and
snotty slaves with jugs.The city of Rome had 11 aqueducts, and
in general, the Romans built water pipes with a total length of 436
kilometers. Of these, 55 kilometers are aqueduct bridges.

Aqueduct
The Pont du Gard supplied water not to Rome, but to a town called Nemaus. There and
without it, there were several sources of water supply, but this one was
main. He supplied water from a spring 20 kilometers away. But 20
kilometers – this is if you look in a straight line. And you can’t run the water straight,
because continuous gorges, hills, and it is necessary to hollow 8 kilometers of the tunnel
in stone.That even today, not every city budget can afford.
Therefore, the Romans lead the water in a bypass in an arc of 55 kilometers. Complexity
the problem is that the difference in water level from the source to the city is only 11
meters, so the track must be designed so that evenly
share this distance and the water still moved by gravity. Slope
stone gutter – from 7 to 60 centimeters per kilometer! And even this
the spread in numbers is not because “it happened”, but strictly according to the project:
before the Pont de Gard, the Romans lowered the level of the track as much as possible so that
facilitate the construction of the bridge, and then polished millimeters.How do they
managed without laser tape measure so precisely to withstand the slope of the stone
gutters are a mystery. How did they even manage to do such accurate calculations and
adhering to the project so strictly is an even greater mystery, because anew
these laws of hydraulic engineering were discovered only in the 19th century.

How
you guessed it, the main problem of Roman plumbers was
river in the middle of the path. Yes, the river turned out to be a hindrance to the delivery of water. AND
it was necessary to cross the gorge at a high altitude. That’s what it was for
this bridge is designed and built.The goal was to raise to the desired
the height of the stone gutter with water. Well, of those designs that his
supported, at the same time it turned out on the first tier a good track for
pedestrians and chariots. Nothing was done in the building for beauty –
only a strict technological calculation. Three tiers are not made for the sake of
whims, but because it is so optimal, and cheaper. Arched structures
– the only way to build such a colossus, having at your disposal
only lumps of shell rock, which can be cut and adjusted.The protruding blocks on the arches are technological consoles on which
the scaffolding of the builders was fastened. It should be understood that for
mathematical calculations the Romans had enough wax tablets and abacus
(abacus). And few people now remember that our word “calculator” is also
comes from “calculi” – pebbles. Simple pebbles that were moved
on counting boards. But the calculation was made on the conscience, the bridge was built on
all modern standards and even slightly curved in an arc towards the winds and
downstream – an ingenious engineering solution that allows you to increase
sustainability.

The Romans usually built quickly. But
the construction of this bridge took, if I’m not mistaken, years
fifteen, if not thirty. And all because the river turned out to be very
insidious, and hurricanes in this gorge reach 150 km / h. Therefore the Romans
finalized the project along the way, in order to eventually get a bridge with double
margin of safety. By the way, this is also a modern building code –
that’s how they build today. So, but not so. Two consecutive floods – in 2002 and
2003 – almost all new bridges across this river were demolished, but the Roman
the aqueduct is standing as it was.

One last thing left to say:
the water supply system operated for several hundred years, they say, almost in IX
century AD one of the French kings saw him working. But
the Roman Empire ended, and then morons came running, who
began to break and take away stones. Buildings against barbarians
turned out to be powerless, the pipeline route was eventually broken. And here
the bridge was used for a long time – more precisely, only its first tier. Morons even
tried to undermine the columns to get more driveway
their carts, which nearly collapsed the entire structure…

When
standing under this bridge, it strikes the imagination much more than
smartphones, satellite navigation, digital cameras and Japanese
auto industry. What is space and cybernetics compared to simple ones
Roman plumbers, who counted with pebbles on
counting boards and erected with the help of bare palms such complex
grandiose things just because they liked to drink clean water? A little
cleaner than they could have scooped up in the river by sending a slave with a jug.