title: Childhood metatarsal shaft fractures: treatment outcomes and relative indications for surgical intervention.
abstract: OBJECTIVE
  Although the epidemiology of childhood metatarsal fractures is known, the appropriate treatment has not been elucidated. This study was undertaken to ascertain the outcomes of both non-operative and surgical treatment of these common childhood injuries and to discern any indications for treatment.
  
  
  METHODS
  A retrospective review was performed of all children identified from 2006 to 2007 with a metatarsal fracture by the ICD-9 code, 825.25. After dividing the cohort into groups by age in years (0-5, 6-10, 11-15, 16 and older), we collected demographics, mechanism of injury, and associated injuries, as well as clinical information concerning metatarsal involvement, treatment, complications, return to activities/sports, and residual pain. Radiographic information was also collected, including fracture location, displacement, comminution, and union.
  
  
  RESULTS
  We identified 337 children that met the criteria. The mean age was 10.5 years (range 1.8-20.6). Only ten children had surgery. Only age, multiplicity of metatarsal fracture, and fracture translation was statistically different between the non-surgical and surgical cohorts. None of the patients under the age of 12 years underwent surgical intervention (p = 0.005). Evidence of multiple metatarsal fractures was seen in only 28 % of the non-surgical group compared to 70 % of the surgical group (p = 0.009). The amount of fragment translation significantly correlated with a decision for surgery (p = 0.001), but not angulation. Logistic regression demonstrated that, for every year of age, the likelihood for surgery increased by 32 % and that children were 6.6 times more likely to have surgery if they had multiple metatarsal fractures. Complete union was achieved in 84.6 %, with no difference in treatment groups regarding the time of release to full activities, and of the 50 delayed unions, only two required subsequent operative interventions. Return to sports took longer in the operative group, with a mean of 4.0 compared to 2.1 months (p < 0.001). Only 14 children complained of residual post-treatment pain and all of those cases had been treated without surgery. The presence of post-treatment pain did not correlate with the mechanism of injury or the amount of displacement.
  
  
  CONCLUSIONS
  Each metatarsal injury pattern is unique and surgeons should utilize their clinical judgment to determine appropriate treatment; however, there appears to be some relative indications for surgical treatment. Whereas open and articular fractures may be absolute indications for surgery, the relative indications for surgical intervention in metatarsal shaft fractures appear to be adolescent age and multiple fractures. Successful non-surgical management may consist of a short-leg walking cast for a mean of 4 weeks and activity restrictions for an additional month. However, children should be followed to radiographic union, since 15.4 % may have a delayed union and 4.3 % have short-term residual problems related to the injury.
authors.affiliation: University of California, San Diego, CA USA.
authors.forename: Nicholas B
authors.initials: NB
authors.lastname: Robertson
authors.forename: Joanna H
authors.initials: JH
authors.lastname: Roocroft
authors.forename: Eric W
authors.initials: EW
authors.lastname: Edmonds
keywords: Epidemiology; Fracture treatment; Metatarsals; Outcomes; Pediatrics