AdultPediatric
Pediatric foot pain ranges from puncture wounds and toddler's fractures to limb-threatening osteomyelitis and missed Lisfranc injuries. Anatomy is divided into hindfoot (calcaneus, talus), midfoot (navicular, cuboid, cuneiforms), and forefoot (metatarsals, phalanges). Apply Ottawa Foot Rules cautiously in children — physes can mimic and mask fractures.
🚩 Red-flag clues (must not miss)
- •Plantar puncture wound through sneaker = Pseudomonas osteomyelitis risk (especially through rubber sole)
- •Midfoot pain and plantar ecchymosis after axial load = Lisfranc injury (may be subtle on XR)
- •Toddler refusing to bear weight + minor or no trauma = toddler's fracture (spiral tibia) or occult osteomyelitis
- •Atraumatic swelling + fever + ↑ inflammatory markers = osteomyelitis or septic joint
- •Compartment swelling, pain with passive toe extension, paresthesias = foot compartment syndrome
- •Open fracture, exposed bone, neurovascular compromise = emergent ortho
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Labs
Imaging
Meds
History
- Mechanism — axial load (jump, fall from height), inversion, crush, puncture, overuse
- Footwear at injury (sneaker punctures = Pseudomonas), barefoot on hot surface
- Fever, recent illness, sickle cell (Salmonella osteomyelitis)
- Weight-bearing ability, gait, duration, prior injury
Exam
- Inspection — swelling, ecchymosis (plantar = Lisfranc), deformity, skin integrity
- Palpation — calcaneus (squeeze), navicular, base of 5th MT, each metatarsal, phalanges, Achilles
- ROM, weight-bearing test (4 steps independently — Ottawa)
- Neurovascular — DP, PT pulses, sensation, cap refill
- Compartment check — pain with passive toe extension is the early sign
Labs
- Trauma: generally not needed
- Atraumatic / suspected infection: CBC, CRP, ESR, blood cx; aspirate if septic joint
- Sickle cell: ensure crisis vs osteomyelitis (overlap; MRI helps)
Imaging
- Foot XR — AP, lateral, oblique; weight-bearing views improve Lisfranc detection
- Ottawa Foot Rules (validated > 5 y): image if pain in midfoot zone + tenderness at base of 5th MT, navicular, OR inability to bear weight 4 steps both immediately and in ED
- Calcaneal axial view if calcaneus tender
- MRI for occult fracture, osteomyelitis, stress fracture, Lisfranc ligament injury
- CT for complex calcaneal/Lisfranc fractures
- Bone scan rarely needed in modern era — MRI preferred
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| Toddler's fracture (spiral distal tibia) | 1–4 y/o, refusing to bear weight, minor twist | Long-leg cast or boot × 3–4 wk; XR may be initially negative — clinical dx |
| Metatarsal shaft fracture | Direct blow or twist | Hard-sole shoe or short-leg walking boot × 4–6 wk; reduce if angulated > 10° dorsally |
| 5th metatarsal base — pseudo-Jones (avulsion) | Inversion, tenderness at tuberosity, transverse fx | Hard-sole shoe, WBAT × 4–6 wk |
| Jones fracture (5th MT metaphyseal-diaphyseal) | Fx 1.5–3 cm distal to tuberosity, athlete | NWB short-leg cast × 6–8 wk; ortho — high non-union risk |
| Iselin disease (apophysitis 5th MT) | 8–13 y/o athlete, lateral foot pain, no acute trauma | Rest, ice, NSAIDs, gradual return |
| Sever disease (calcaneal apophysitis) | 8–14 y/o athlete, posterior heel pain, + squeeze test | Heel cups, stretching, activity modification, NSAIDs |
| Calcaneal fracture | Fall from height, plantar ecchymosis, axial tenderness | Calcaneal axial XR, CT; ortho — assess L-spine for axial-load fx |
| Lisfranc injury | Plantar midfoot ecchymosis, pain with pronation/abduction, > 2 mm widening between 1st-2nd MT base on weight-bearing XR | NWB, ortho — usually surgical |
| Navicular fracture / Köhler disease | Acute fx vs avascular necrosis (4–7 y/o, limp) | XR (Köhler — sclerotic flattened navicular); short-leg cast, ortho |
| Freiberg disease (2nd MT head AVN) | Adolescent female, forefoot pain, MT head flattening | Activity rest, metatarsal pad, ortho |
| Plantar puncture wound — cellulitis / osteomyelitis | Sneaker puncture (Pseudomonas), persistent pain > 5–7 d | Irrigation, tetanus, oral abx; if osteo suspected → MRI, IV ceftazidime or cefepime, ortho |
| Osteomyelitis (calcaneus, metatarsal) | Atraumatic, fever, focal tenderness, ↑ CRP/ESR | MRI with & without contrast, blood cx, IV abx (vanc + cefazolin; add Pseudomonas cover for puncture) |
| Septic arthritis (1st MTP, ankle) | Hot, swollen joint, refusal to move | Aspiration, IV abx, ortho |
| Stress fracture (metatarsal, navicular) | Insidious overuse pain, point tender, female athlete triad | Boot, activity rest, MRI if XR negative, ortho |
| Phalanx fracture (toe) | Stub injury, ecchymosis | Buddy tape, hard-sole shoe; reduce great toe if displaced |
| Ingrown toenail / paronychia | Erythema, drainage along nail border | Warm soaks, partial nail removal, oral abx if cellulitis |
| Plantar wart / foreign body | Localized pain, callus, point tender | US for FB, removal |
| Sickle cell vaso-occlusive crisis (dactylitis) | Hand-foot syndrome in infants/toddlers, symmetric | Hydration, opioids; MRI if osteomyelitis suspected |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| Ibuprofen | 10 mg/kg PO q6–8h (max 600 mg/dose) | |
| Acetaminophen | 15 mg/kg PO q4–6h (max 1 g/dose) | |
| Cefazolin (osteomyelitis, IV) | 25–50 mg/kg IV q8h (max 2 g) | |
| Vancomycin (MRSA cover) | 15 mg/kg IV q6h | |
| Ceftazidime or Cefepime (Pseudomonas — sneaker puncture) | 50 mg/kg IV q8h (max 2 g) | |
| Amoxicillin-clavulanate (puncture wound, outpatient) | 45 mg/kg/day PO div BID (amox) | |
| Tetanus | Td/Tdap per CDC schedule for puncture wounds |
Management / next steps
- Step-by-step: assess weight-bearing → palpate by anatomic zone → apply Ottawa Foot Rules → image as indicated → splint/boot → reassess neurovascular
- Plantar puncture through sneaker → irrigate, tetanus, close follow-up at 48–72 h; admit if signs of deep infection
- Toddler refusing to walk with normal XR → splint and follow up in 7–10 d; repeat XR or MRI if not improving
- Suspected Lisfranc → NWB, ortho — even subtle widening is significant
- Return precautions: ↑ pain, swelling, fever, redness streaking, color change, numbness, drainage, or inability to bear weight after 1 week
Pearls
- Toddler's fracture is a clinical diagnosis — initial XR is normal in up to 50%.
- Lisfranc injuries are missed in up to 20% — get weight-bearing views and look for the 'fleck sign' (avulsion at 2nd MT base).
- Pseudo-Jones (5th MT tuberosity avulsion) heals well; true Jones (1.5–3 cm distal) often needs surgery.
- Sneaker-puncture osteomyelitis = Pseudomonas — cover with antipseudomonal beta-lactam, not just cephalexin.
- Sever disease squeeze test (medial-lateral compression of calcaneus) reproduces pain — purely clinical diagnosis.