For Patients > Foot & Ankle Procedures > Trauma > Salter Type-IV Epiphyseal Fracture of the Proximal Phalanx of the Great Toe
Director Tuvi Mendel, M.D.
Salter Type-IV Epiphyseal Fracture of the
Proximal Phalanx of the Great Toe
December 9th, 1994
Barbara D. Buch, MD, and Mark S. Myerson, MD
Abstract
Epiphyseal fractures account for about one-fifth of pediatric fractures; approximately 10% cause major growth disturbances, depending on the location and type of the fracture and the skeletal maturity of the child. Intraarticular Salter-Harris type-IV fractures are rare, carry a poor prognosis, and almost always need surgical reduction to prevent deformity. We present a case report of a pediatric patient who returned to normal function after the successful surgical reduction of a Salter-Harris type-IV fracture in the proximal phalanx of the great toe.
Introduction
Epiphyseal fractures in children constitute approximately 15 to 20% of all pediatric fractures.{3920, 3924, 3921, 3926, 3925, 4266} About 10% of these injuries can cause major growth disturbances. Depending on the type of fracture, its location, the age of the patient, the status of the blood supply to the epiphysis, and whether the injury is open or closed, the risk of minor growth disturbances is even higher.{3926, 4266} Salter-Harris type-IV fractures, which are intraarticular and extend from the joint surface through the epiphysis, the epiphyseal growth plate, and the metaphysis, have a poor prognosis.{3920, 3926, 3925, 4267} Most often, effective, timely surgical reduction is required to prevent shortening or angulation deformities.
Epiphyseal fractures of the bones of the foot are uncommon, and only rarely are the phalanges involved. If the digits are fractured, the fractures occur at the distal metatarsals or proximal phalanges.{3920} We present a patient with a rare epiphyseal fracture at the proximal phalanx of the great toe, which was successfully treated by open reduction and internal fixation.
Case Report
A 9-year-old black male ran into a metal post protruding from a wall while running from a dog. He presented to the emergency department that day complaining of swelling and pain in his right great toe and difficulty in walking because of pain. He reported that it felt like his "big toe was bent back and in." The patient was otherwise healthy, with no significant past medical or surgical history, was up to date on his immunizations, had no allergies, and took no medications.
His examination was unremarkable except for his right foot. The toe was slightly ecchymotic, edematous, and in a varus position. The neurovascular examination was normal. His great toe was tender to palpation over the first metatarsophalangeal joint and flexion and extension of this digit caused pain. Radiographs of the right foot demonstrated a Salter-Harris type-IV fracture-dislocation of the epiphyseal plate of the proximal phalanx of the great toe, with 4 mm of diastasis between the epiphyseal fragments (Fig. 1).
The patient was discharged from the emeregency department with a postoperative shoe and crutches, along with instructions for elevation, ice, and a return examination 2 days later.
After the swelling had resolved at 5 days postinjury, the patient underwent open reduction and internal fixation. Intravenous sedation and a regional ankle block (50/50 mixture of 1% lidocaine and 0.25% marcaine) were administered.{3061} A dorsal incision made over the first metacarpophalangeal joint was extended deeper to the level of the bone between the extensor hallucis longus and the extensor hallucis brevis with both muscles retracted out of the operative field. Once the fracture site was delineated, a small towel clip and forceps were used to gently reduce the fractures manually. The reduction was confirmed fluoroscopically, then two 3.2-mm Kirschner wires were placed percutaneously to hold the fracture reduced, which was again verified with fluoroscopy (Fig. 2). After wound closure and dressing placement, the foot was immobilized in a plaster posterior splint, and the patient was discharged with crutches and instructions for non-weight-bearing ambulation.
The fracture was healed by 6 weeks after surgery; at 8 weeks, the cast and pins were removed and the patient was allowed protected weight-bearing (Fig. 3A). At both the 3-month (Fig. 3B) and 6-month postoperative follow-up, the patient was doing well. At the 1-year follow-up, the alignment of the hallux clinically and radiographically was good with full range of motion and no crepitus. Radiographs of the hallux (Fig. 4) show complete healing with good correction. The patient showed no tendency toward nor signs of premature epiphyseal closure or irregularity and was considered to be past the point where epiphyseal growth arrest would have been evident.
Discussion
The pediatric literature abounds with reports of long-bone fractures{4266, 4267} and their treatment.{4267} However, information about epiphyseal fractures of the foot phalanges is sparse.{3920, 3921}
Phalangeal fractures in the foot most often occur as a result of low-energy direct trauma such as falling or kicking an object,{3924} and are usually located proximal or distal to the growth plate.{3920} However, epiphyseal fractures of the phalanges do occur, although this location is the most infrequently documented.{3921}
In an animal experimental study, Salter and Harris{3926} created and classified epiphyseal fractures as types I through IV, according to increasing severity and instability, and examined the healing rates and complications, with and without treatment. They found that a type-I or -II fracture could be managed by immobilization, that a type-III might require surgical management, and that a type-IV (which has an overall poor prognosis) mandated surgical intervention to avoid an even worse outcome. They considered type-IV fractures to be unstable and stated that they tend to heal in malunion with angular deformities.{3920, 4266} Although in general, they are less likely to cause significant length or functional disturbance, in the case of the great toe, shoewear, ambulation, and athletic participation can be markedly affected without proper reduction, restoration of joint surfaces, and stabilization to allow healing.
Salter-Harris type-IV epiphyseal fractures resulting from vertical splitting forces{4266} have been documented as having a poor prognosis, resulting in early growth arrest, length discrepancies, and angulation deformities in long bones. Because the blood supply is often disrupted and a failed reduction can result in premature closure of the epiphyseal plate,{3926} the literature recommends open reduction and internal fixation.
Most type-IV fractures are managed by open reduction, since closed reduction is usually not successful, and careful attention must be paid to avoid injury to the circulation of the epiphysis. As with all type-IV fractures, the principles of reduction of the phalangeal growth plate should be accomplished gently with as little trauma to the delicate plate as possible. It is recommended that little or no instrumentation be used to return a displaced epiphysis into place.{3926} Although the best time to reduce most fractures is at the time of injury, most type-III and -IV injuries to the growth plate fare better without forced reduction and with delayed surgery, if needed, to replace the intraarticular fragments. Most fractures in children will remodel, but those through the growth plate do not. Type-IV injuries require perfect and anatomical reduction, which mandates surgical intervention in the great majority of cases.{3926, 4267} The work of Salter and Harris{3926} and Campbell et al{4207} on the effects of experimental disturbances of the growth plate and surgical trauma have shown that fixation using "fine smooth Kirschner wires . . . . [traversing the epiphyseal plate] perpendicularly and removed after four to six weeks"{3925} are the least traumatic to the epiphyseal and its blood supply. As a rule, because of "their location, [type IV injuries] require the same period of [immobilization] for union as metaphyseal fractures{3926} rather than the shorter period needed for those epiphyseal fractures (Salter-Harris types I and II) with a good prognosis.
It is important to observe traumatized toes carefully in the short term for other associated injuries, especially in the area of the nail beds of the phalanges, to prevent the development of complication such as occult fractures, infection, or cellulitis distal to the epiphyseal injury.{1534}
All epiphyseal injuries should be observed for a period of time after healing. Because "cessation of growth does not necessarily occur immediately after injury to the epiphyseal plate, and growth arrest may be delayed for six months or longer,"{3926} most clinicians recommend a follow-up period of at least six months and a year after injury.{3920, 3926, 3925, 4267}
Conclusion
This Salter-Harris type-IV epiphyseal fracture occurred in an unusual location, the proximal phalanx of the great toe of a pediatric patient. It was managed by open reduction and internal fixation, as would any other type-IV epiphyseal fracture of a long bone. To date, six months after surgery, the patient is doing well and has returned to full preinjury activities. He will be monitored closely for potential growth disturbance of the toe.
Acknowledgments
The authors wish to acknowledge the asistance of Stuart D. Miller, MD and the editorial support of Elaine P. Bulson in the preparation of this manuscript.
Figure Legends
Fig. 1. Preoperative radiographs of acute injury to the proximal phalanx of the right great toe. A, anteroposterior view showing growth plate disturbance and small lateral fragment of the metaphysis. B, lateral view.
Fig. 2. Anteroposterior (A) and lateral (B) intraoperative radiographs showing placement of K-wires.
Fig. 3. Radiograph showing healed fracture at 8 weeks after pin removal (A, note bar across epiphyseal plate) and at 3-month postoperative follow-up (B).
Fig. 4. Anteroposterior (A) and lateral (B) radiographs of the great toe at 1-year follow-up.
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