SLR - November 2013 - Jason Kayce

Barefoot Sports Injury on Hallux: A New Classification by Injury Mechanism

Reference: Park, DY, Han KJ, Han SH, Cho JH. Barefoot Sports Injury on Hallux: A New Classification by Injury Mechanism. J Orthop Trauma. 2013 Feb 28 Epub. 

Scientific Literature Review    

Reviewed by: Jason Kayce, DPM
Residency Program:
Cambridge Health Alliance

Podiatric Relevance: Barefoot stubbing injuries to the hallux are relatively common in children, yet there is limited information within the literature regarding this type of injury. This particular study categorizes barefoot stubbing injuries to the great toe in children by injury mechanism, allowing the practitioner to differentiate benign injuries from more complex trauma necessitating surgery.

Methods: A prospective clinical series was established that involved 41 children under the age of 17 who sustained an indirect injury to the hallux during barefoot activities between January 2001 and December 2009. Inclusion criteria required both the patient and all guardians present to recall the mechanism of injury utilizing a skeletal foot model to reenact the incident. Patients were excluded who were lost to follow-up or if a third person had not directly observed the injury. A combination of radiographic data and reported mechanism of injury were utilized to create five different force vector categories: hyperabduction-flexion, hyperflexion, hyperabduction-extension, hyperextension, and hyperextension-adduction. Treatment was implemented based on severity, mechanism, and fracture pattern. When applicable, basic principles of open fracture management were met.

Results: Hyperabduction-flexion injuries were the most common (n=16). The majority of these cases displayed interphalangeal joint dislocation and skin disruption. Hyperabduction-extension injuries were the second most common (n=14) in which an avulsion fracture of the lateral volar condyle of the proximal phalanx was commonly appreciated. This avulsion fracture pattern had the worst prognosis after conservative care, as three cases developed a non-union.  

All patients in the hyperabduction-flexion, hyperflexion, hyperextension, and hyperextension-adduction groups were complication-free with AOFAS scores of 100 by eight weeks after treatment. Patients in the hyperabduction-extension displayed mixed results.

Conclusions: This prospective study provides insight to the podiatric physician in treating indirect hallux injuries among the pediatric population. The avulsion fracture of the lateral condyle of the proximal phalanx is a common sequela of a hyperabduction-extension injury.  This avulsion fragment is at high risk of non-union and should be aggressively treated, contrary to previous guidelines. Percutaneous reduction, open reduction and pinning, and removal of the avulsion fragment are viable treatment options. Limitations within this study include the small sample size and the inability to recreate the fracture patterns based on mechanism of injury within a cadaveric model. 

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