Pediatric Ankle and Foot Injuries: Identification and Management in the Emergency Department

Pediatric Ankle and Foot Injuries: Identification and Management in the Emergency Department (Trauma CME)

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Table of Contents

About This Issue

Pediatric ankle and foot injuries are common complaints in the emergency department. Proper identification and management of orthopedic injuries are imperative for uninterrupted limb development in pediatric patients. In this issue, you will learn:

Traumatic causes of ankle and foot pain in children

Nontraumatic pediatric-specific disease processes that can cause ankle and foot pain

The Salter-Harris classification system for fractures through a growth plate

Key information to obtain while taking the history

A systematic approach for examination of the ankle and foot

Recommendations for obtaining x-ray imaging, including routine radiographic studies and additional radiographic views that can help diagnose different fractures

Recommendations for management of pediatric ankle and foot injuries

Which injuries require immediate orthopedic specialist attention, and which injuries can have close outpatient follow-up

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Epidemiology, Etiology, and Pathophysiology
  7. Differential Diagnosis
    1. Traumatic Causes of Ankle and Foot Pain
      1. Ankle Sprains
      2. Distal Tibia and Fibula Fractures
      3. Hindfoot and Midfoot Fractures
      4. Metatarsal and Phalangeal Fractures
    2. Nontraumatic Causes of Ankle and Foot Pain
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. Ankle and Foot Examination
        • Inspection
        • Palpation
        • Range of Motion
        • Strength and Neurovascular Examination
        • Special Tests
  10. Diagnostic Studies
    1. Radiography
    2. Ultrasound
    3. Computed Tomography
  11. Treatment
    1. Low Ankle Sprain
    2. High Ankle Sprain
    3. Distal Fibula Fractures
    4. Distal Tibia Fractures
    5. Tillaux and Triplane Fractures
    6. Toddler Fractures
    7. Lateral Talus Fractures
    8. Lisfranc Fractures
    9. Metatarsal Fractures
  12. Special Populations
    1. Children With Sever Disease
    2. Children With Iselin Disease
    3. Children With Freiberg Disease
  13. Controversies and Cutting Edge
  14. Disposition
  15. Summary
  16. Time- and Cost-Effective Strategies
  17. Risk Management Pitfalls for Pediatric Patients With Ankle and Foot Injuries
  18. 5 Things That Will Change Your Practice
  19. Case Conclusions
  20. Clinical Pathway for Management of Pediatric Ankle and Foot Injuries in the Emergency Department
  21. Tables and Figures
  22. References


Pediatric ankle and foot injuries are common complaints in the emergency department, and proper identification and management of these injuries is critical for uninterrupted limb development. This issue reviews the presentation, systematic evaluation, and management of common pediatric orthopedic injuries of the ankle and foot. Recommendations are given for the disposition of pediatric patients with ankle and foot injuries, with a focus on which patients need immediate orthopedic evaluation and which patients can be discharged home with appropriate follow-up.

Case Presentations

A 2-year-old girl is brought into the ED by her parents for evaluation of right leg pain...
  • The mother states that for the past 4 hours the girl will not walk and has been crawling around the house. Previously, the patient was walking independently. There was no witnessed fall or trauma.
  • On examination, the patient repeatedly refuses to bear weight on her right leg. There is no obvious injury or deformity of the right leg. The girl cries when the tibia is palpated.
  • What is on your differential? How should you manage this type of injury? Does this injury need immediate orthopedic evaluation?
A 17-year-old boy presents to the ED with right foot pain 4 days after falling while snowboarding…
  • The patient was previously seen in another ED immediately after the injury and was diagnosed with an ankle sprain. The patient states that his foot now looks more swollen and bruised since the incident. The patient also states he cannot bear weight on his right foot.
  • On examination, there is significant ecchymosis and swelling of the right foot. There is also point tenderness on the anterior aspect of the ankle.
  • Should you re-image the injury? What other conditions are of concern?
A 14-year-old girl presents to the ED for left foot pain...
  • The patient is a ballet dancer. She was at dance class today when she said she rolled over her foot after landing a jump. The patient locates the pain to the left fifth toe.
  • On examination, you note point tenderness of the fifth metatarsal.
  • Based on this mechanism of injury and presentation, what injuries are you concerned for?

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Clinical Pathway for Management of Pediatric Ankle and Foot Injuries in the Emergency Department

Clinical Pathway for Management of Pediatric Ankle and Foot Injuries in the Emergency Department

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Tables and Figures

Table 1. Classic Pediatric Ankle and Foot Injuries, by Location
Table 2. Nontraumatic Causes of Pediatric Foot and Ankle Pain
Figure 1. Ligaments of the Ankle Joint
Figure 2. Salter-Harris Classification of Pediatric Physeal Fractures
Figure 3. Tillaux Fracture

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. * Su AW, Larson AN. Pediatric ankle fractures: concepts and treatment principles. Foot Ankle Clin. 2015;20(4):705-719. (Review) DOI: 10.1016/j.fcl.2015.07.004

3. * Fleisher GR, Ludwig S, Anderson A. Injury-Ankle. In Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 6th ed. Lippincott Williams and Wilkins; 2010:337-344. (Textbook chapter) ISBN: 978-1605471594

8. * Fleisher GR, Ludwig S, Bachman D, et al. Musculoskeletal trauma. In Fleisher GR, Ludwig S, ed. Textbook of Pediatric Emergency Medicine. 6th ed. Lippincott Williams and Wilkins; 2010:1335-1375. (Textbook chapter) ISBN: 978-1605471594

10. * Cepela DJ, Tartaglione JP, Dooley TP, Patel PN. Classifications in brief: Salter-Harris classification of pediatric physeal fractures. Clin Orthop. 2016;474(11):2531-2537. (Review) DOI: 10.1007/s11999-016-4891-3

11. * Salter RB, Harris WR. Injuries involving the epiphyseal plateJ Bone Joint Surg Am. 1963;45(3):587-622. (Review) 

13. * Solove M, Turcotte Benedict F. Ankle injuries in the pediatric emergency department. Pediatr Emerg Care. 2020;36(5):248-254. (Review) DOI: 10.1097/PEC.0000000000002097

18. * Smidt KP, Massey P. 5th metatarsal fracture. In: StatPearls. StatPearls Publishing; 2022. Accessed February 1, 2023. (Review)

19. * Bickley L. Bates’ Guide to Physical Examination and History Taking. 10th ed. Lippincott Williams and Wilkins; 2009. (Textbook) ISBN: 978-1605478036

26. * Boutis K, Willan AR, Babyn P, et al. A randomized, controlled trial of a removable brace versus casting in children with low-risk ankle fractures. Pediatrics. 2007;119(6):e1256-e1263. (Randomized controlled trial) DOI: 10.1542/peds.2006-2958

27. Shamrock AG, Varacallo M. Triplane ankle fracture. In: StatPearls. StatPearls Publishing; 2022. Accessed February 1, 2023. (Review)

29. * Boutin A, Misir A, Boutis K. Management of toddler’s fracture: a systematic review with meta-analysis. Pediatr Emerg Care. 2022;38(2):49. (Systematic review; 4 studies, 355 participants) DOI: 10.1097/PEC.0000000000002488

32. * Herrera-Soto JA, Scherb M, Duffy MF, et al. Fractures of the fifth metatarsal in children and adolescents. J Pediatr Orthop. 2007;27(4):427-431. (Retrospective study; 103 patients) DOI: 10.1097/01.bpb.0000271323.56610.da

Subscribe to get the full list of 35 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: ankle injury, foot injury, orthopedic injury, ankle joint, ligament, ankle sprain, low ankle sprain, medial ankle sprain, high ankle sprain, distal fibula fracture, distal tibia fracture, Satler-Harris fracture, Tillaux fracture, triplane fracture, toddler fracture, talus, lateral talus fracture, snowboarder’s fracture, tarsal fracture, metatarsal fracture, Jones fracture, pseudo-Jones fracture, Lisfranc injury, nontraumatic foot pain, nontraumatic ankle pain, IP-PASS, Thompson test, squeeze test, single-leg heel raise, PRICE-FM, Sever disease, Iselin disease, Frieberg disease

Publication Information

Elizabeth Zorovich, MD; Vlad Panaitescu, DO; John Kiel, DO, MPH, FACEP, CAQ-SM

Peer Reviewed By

Joyce Li, MD, MPH; Paula J. Whiteman, MD, FACEP, FAAP

Publication Date

March 1, 2023

CME Expiration Date

March 1, 2026    CME Information

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.
Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma credits, subject to your state and institutional approval.

Pub Med ID: 36790861

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