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BMJ Case Rep. 2015; 2015: bcr2015211709.
Published online 2015 August 11. doi:  10.1136/bcr-2015-211709
PMCID: PMC4533604
Case Report

Non-union of the great toe in a 4-year-old child

Abstract

Phalangeal fractures of the foot are very rare in children. They are treated with closed reduction and splinting. Cases reported of non-union in children are rare. We report on treatment of a 4-year-old child with non-union of the proximal phalanx of the great toe foot following an open fracture caused by a motor vehicle accident 4 months prior. No graft was used. We present this case with good clinical outcome at 1 year follow-up.

Background

  • Phalangeal fractures of the foot are very rare in children

Non-union in this group is very rare

Case presentation

A 4-year-old child presented with pain and deformity of her right great toe. She had been hit by a motor vehicle 4 months prior and had suffered a crush injury to her right foot and open fracture of her first proximal phalanx. Her wound had been irrigated and sutured, the fracture had been reduced and a short leg splint had been placed. After her wounds had healed, the patient was lost to follow-up for 4 months.

She did not have accompanying diseases. She had a transverse wound scar on the dorsum of her right forefoot. Her proximal phalanx was deformed and painful on palpation. Her laboratory tests were normal. X-ray of the foot revealed non-union of the proximal phalanx of the great toe (figure 1).

Figure 1
Preoperative foot X-ray.

The patient was operated under general anaesthesia. The non-union site was approached through an incision on the dorsomedial aspect of the toe. Fibrous tissue was removed and fracture ends were curetted. Following reduction, the fracture was fixed with two cross-pins (Kirschner wires). No graft was used (figure 2). A short leg plaster swab was applied for 1 month. The Kirschner wires were removed at the end of 1 month when union was evident (figure 3). A solid and well-aligned union was evident at 1-year follow-up (figure 4).

Figure 2
One month postoperative foot X-ray.
Figure 3
One month postoperative, after Kirschner wires (kws) were removed.
Figure 4
One year postoperative foot X-ray.

Treatment

We applied non-union surgery.

Outcome and follow-up

One year.

Discussion

Foot trauma is common in children. Injuries usually involve the soft tissues and nail bed. Phalangeal fractures are rare. Proximal phalanx of the great toe is most often involved. This usually results from direct trauma such as from dropping objects onto the area or deep cuts to it by a sharp object. Open fractures usually occur distally around the nail. The initial step in treatment of an open phalanx fracture is debridement and suturing of the wound, and antibiotherapy. The fracture is then reduced and immobilised with a cast or buddy taping. Full weight-bearing is allowed 4–6 weeks later.1 2

A normal gait cycle involves complex foot motions where body weight acting on the heel is gradually transferred to the forefoot. Forces acting on the great toe are twice the sum of forces acting on the other phalanxes.3 Deformities and diseases of the foot impair normal walking. Since load transfer takes place mostly on the medial side of the foot, disorders of the great toe are extremely important and need to be treated.4

Fracture union in a child is less problematic due to presence of a thick periosteum, good circulation and considerable remodelling capacity. Risk of non-union increases with open fractures, open reduction techniques, infection and inadequate reduction or stabilisation.5 Most studies on paediatric non-union have been either retrospective or case reports. There is only one report on paediatric non-union of phalanges of the foot. Kramer2 reported on a 15-year-old boy who had an intra-articular fracture of the great toe. Standard treatment of a non-union is curettage, grafting and stabilisation. In a retrospective study,1 5–8 Shrader et al1 reported 43 cases of non-union over a 15-year period. Forty-seven per cent of these fractures were around the elbow and 27% occurred following an open fracture. Fernandez et al5 treated six cases of non-union of forearm shaft fractures in children after intramedullary nailing. Behr et al6 reported seven cases of scaphoid, Cortes et al7 treated one case of non-union following subtrochanteric femoral fracture in a child. Pourtaheri8 reported one case of clavicle non-union. These cases were all treated using autograft and fixation.

In our case, the patient presented with non-union of the great toe 4 months after initial treatment. Curettage of the fracture ends and fixation with two cross-pins were performed. Although standard for the treatment of non-union, graft usage was avoided due to good perfusion of the fracture site, minimal bone defect and the young age of the patient, and considering donor site morbidity.9 Union was evident in the first month. The fracture was fully healed and the patient was symptom-free at 1-year follow-up.

Consequently, our case is rare. We believe that such non-unions may be treated without bone graft in cases where fracture ends are well perfused and bone defect is minimal. This will prevent donor site morbidity.

Learning points

  • Phalangeal fractures of the foot are very rare in children.
  • Non-union is very rare in children.
  • Such non-unions may be treated without bone graft in cases where fracture ends are well.
  • Perfused and bone defect is minimal so this will prevent donor site morbidity.

Footnotes

Contributors: FG was the writer and performed the surgery. CE was involved in the design and editing of the paper. UHG was responsible for surgery. BK participated in translation and surgery.

Competing interests: None declared.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

1. Shrader MW, Stans AA, Shaughnessy WJ et al. Nonunion of fractures in pediatric patients: 15-year experience at a level I trauma center. Orthopedics 2009;32:410 doi:10.3928/01477447-20090511-11 [PubMed]
2. Kramer DE, Mahan ST, Hresko MT Displaced intra-articular fractures of the great toe in children: intervene with caution! J Pediatr Orthop 2014;34:144–9. doi:10.1097/BPO.0000000000000110 [PubMed]
3. Shereff MJ. Complex fractures of metatarsals. Orthopaedics 1990;13:875–82. [PubMed]
4. Imade S, Miyamoto W, Sanada H et al. Nonunion in proximal phalanx of great toe treated by grafting with precisely processed autologous bone PEG. J Foot Ankle Surg 2011;50:449.52. doi:10.1053/j.jfas.2011.04.007 [PubMed]
5. Fernandez FF, Eberhardt O, Langendorfer M et al. Nonunion of forearm shaft fractures in children after intramedullary nailing. J Pediatr Orthop B 2009;18:289–95. doi:10.1097/BPB.0b013e32832f5b20 [PubMed]
6. Behr B, Heffinger C, Hirche C et al. Scaphoid nonunions in skeletally immature adolescents. J Hand Surg Eur Vol 2014;39:662–5. doi:10.1177/1753193413491041 [PubMed]
7. Cortes LE, Triana M, Vallejo F et al. Adult proximal humerus locking plate for the treatment of a pediatric subtrochanteric femoral nonunion: a case report. J Orthop Trauma 2011;25:63–7. doi:10.1097/BOT.0b013e3181f8d9c3 [PubMed]
8. Pourtaheri N, Strongwater AM Clavicle nonunion in a 10-year-old boy. Orthopedics 2012;35:442–3. doi:10.3928/01477447-20120222-36 [PubMed]
9. Loeffler BJ, Kellam JF, Sims SH et al. Prospective observational study of donor-site morbidity following anterior iliac crest bone-grafting in orthopaedic trauma reconstruction patients. J Bone Joint Surg Am 2012;94:1649–54. doi:10.2106/JBJS.K.00961 [PubMed]

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