The treatment of foot fractures presents specific challenges in pediatric patients. Accordingly, this author presents a comprehensive guide to diagnosing and treating calcaneal fractures, stress fractures, metatarsal fractures and other common injuries in this patient population. Physicians must handle fractures in children uniquely because the physiologic and biomechanical responses are different than what one would see in a mature skeleton. With the increase in activity and organized sport participation of children today, the incidence and complexity of foot trauma in this population have increased. Most fractures in children require only immobilization for treatment, which is often the stated guiding principle for the management of foot trauma in children.1 Closed reduction should be the starting point for treatment of all extra-epiphyseal fractures in children. Severe displacement in the non-articular, extra-epiphyseal fracture is the rare indication for open reduction in a child. Anatomic reduction is an important goal. There are fundamental differences in the child’s foot in comparison with that of the adult. Ogden noted that there is a greater percentage of cartilage with increased elasticity associated with growing cartilage and bone in children.2 This allows for dissipation of significant amounts of applied energy across the foot, producing different types of injuries in the pediatric patient. In this population, one must consider the potential for long lasting, growth-related damage to the child with a fracture and the possibility of early degenerative joint changes. In recent years, some have advocated a more aggressive surgical approach to certain injuries such as calcaneal fractures in children, most notably in the German literature.3 Further advances in imaging allowing easier identification of subtle changes such as soft tissue swelling, cartilaginous disruptions and subchondral bone bruising have also changed the assessment and management of these conditions. Salter-Harris injuries to the growth plate constitute a large topic. As these injuries are frequently covered in various publications, I will not discuss those injuries in this particular article.
Pertinent Insights On Treating Talar FracturesFractures of the talus are relatively rare in children and the reported incidence is 0.01 to 0.08 percent.4 Talar fractures in children generally have minimal displacement and cast immobilization is usually sufficient to allow healing. This is particularly true for children under the age of 8 when the talar anlage offers enhanced healing potential. In a child over the age of 10, the course of healing is more similar to that present in adults. The location of talar fractures often signals the mechanism of fracture. A talar neck fracture is most often associated with a fall from a height. A crush injury is more likely to produce a fracture in the talar body. In the case of a lawnmower injury, a resultant open fracture is more likely. Note that talar fractures often occur in conjunction with other injuries. This is in part because a force as high as twice that needed to fracture a calcaneus or navicular is needed to fracture a talus.5 In 64 percent of adults with talar fractures, Hawkins noted there was an associated musculoskeletal injury as well so clinicians should have a high index of suspicion for other trauma in the presence of talar fractures.6 Plain film X-rays may not show a talar fracture, especially in the first decade of life. If clinical suspicion of a fracture is present but the X-ray is negative, a computed tomography (CT) scan is indicated to evaluate the injury further. Magnetic resonance imaging (MRI) may be useful to evaluate cartilaginous disruptions in a child under the age of 10.
What You Should Know About Talar Neck FracturesOne should use the Hawkins system when classifying talar neck fractures. A type I fracture is a non-displaced fracture of the talar neck. Type II is a displaced fracture without subtalar subluxation or dislocation. Type III represents a dislocation or subluxation of the ankle and subtalar joint. In children, the type I fracture of the talar neck is the most common. One can best treat these injuries with closed reduction and a non-weightbearing short leg cast for six to eight weeks. To consider whether a fracture of this type is non-displaced, look for <5 mm of displacement and <5 degrees of talar neck malalignment. In type II talar neck fractures, in which there is displacement without subluxation or dislocation, there is most often a distal fragment located dorsal and medial. A closed reduction under sedation or general anesthesia in which the surgeon reduces the fracture with gentle plantarflexion and pronation is usually sufficient. These patients should wear an above-knee cast with the ankle in plantarflexion. A subsequent below-knee cast for four weeks may return the ankle to neutral to complete the healing. Hawkins type III talar neck fractures require open reduction with fixation and clinicians usually consider these injuries orthopedic emergencies.
Key Pearls On Fractures Of The Talar Body And DomeFractures of the talar body and dome are rare in children. When they are present, anatomic reduction of the displaced fracture can reduce the likelihood of subsequent degenerative arthritis. In regard to fractures of the lateral process, initially physicians miss these fractures in 46 percent of patients.7 Failure to identify and treat this fracture may be a risk factor for subtalar arthrosis. These fractures may be on the rise in children because of the growing popularity of snowboarding.7 One study showed that 34 percent of talar fractures in snowboarders involved the lateral process.8 The mechanism involves ankle dorsiflexion with involvement of the rearfoot leading to injury to the lateral process.9 It is best to evaluate these injuries on a CT scan. Clinical symptoms include pain and tenderness largely over the anterior talofibular ligament leading, in some cases, to misdiagnosis as a lateral ankle sprain. Treatment is a non-weightbearing cast if the fracture is non-displaced. If the fracture is displaced, open reduction with fixation is required. In the event intraarticular fragments remain, the potential for osteoarthritis exists.
How To Manage Osteochondral Fractures Of The TalusOsteochondral fractures of the talus usually result from twisting injuries to the ankle, which produce shearing and impact forces on the talar dome. Consider the possibility of these lesions when pain persists six to eight weeks after an ankle sprain. At the time of the injury, a plain film X-ray may not show any lesions as osteochondral lesions are cartilaginous and not readily evident. A child with lingering symptoms after an ankle sprain should have MRI to identify these potential lesions. There is a higher incidence of osteochondral lesions in patients with grade 4 sprains and in those undergoing lateral ankle ligament reconstructions. Most often, dorsiflexion and inversion injuries produce anterior and lateral osteochondral lesions whereas plantarflexion and inversion injuries are associated with posterior and laterally located insults.10 Treatment options for osteochondral lesions include activity modification, injection, arthroscopic repair, resection, debridement and microfracture drilling. More recently, surgeons have successfully used osteochondral allografts, autogenous grafting, autologous chondrocytes and transplantation.11 Among the newest techniques is the DeNovo procedure (Zimmer). This is a cadaveric allograft of juvenile particulated articular cartilage. Outcomes are generally better for defects <150 mm2.
What About Calcaneal Fractures?Fractures of the calcaneus represent 0.005 percent of all fractures in children under 15 years of age.12 The incidence in adults is 1 to 2 percent of all fractures.12 That said, the calcaneus is the most frequently fractured tarsal bone in children.13 In a study by Brunet, conservative treatment led to an excellent outcome with a good long-term functional result in 17 children with 19 calcaneal fractures.15 Brunet postulated that children under 10 with a damaged articular surface and depressed Bohler’s angle could achieve anatomic congruence through remodeling. Mora and colleagues supported this finding.16 Generally, the cause of a calcaneal fracture in a child is low-energy trauma. In young children, a simple fall may cause a calcaneal fracture. In older children and adolescents, the traumatic incident is usually a fall from a significant height.2,16 Consider a buckle-type calcaneal fracture in the differential diagnosis of a child who avoids weightbearing or walks with a limp. In addition to falls, calcaneal fractures in children may be the result of an accident involving some form of motorized vehicle. Motor vehicle accidents and trauma associated with recreational vehicle use are responsible. Clinicians should suspect these injuries when local or generalized swelling is present, when there is an inability to ambulate and significant pain. The presence of a subfascial bleed, fracture blisters and persistent inability to bear weight 24 to 48 hours after injury suggest a foot fracture. Consider the possibility of a spinal compression fracture when a calcaneal fracture is present in a child.13 One should also consider concurrent fractures of the tibial plateau and the talus.6
A Guide To Imaging And Classifying Calcaneal FracturesIn children below the age of 3, an X-ray may be equivocal. Evidence of a fracture may lag behind, making diagnosis difficult. One can best evaluate the cartilaginous nature of many injuries in this age group on MRI. When a fracture is visible on plain film X-ray, the Bohler’s angle provides ready evidence of the insult. This is the angle formed by the anterior and posterior facets, and the superior margin of the calcaneal tuberosity. Joint depression is visible when comparing the Bohler’s angle on a lateral view of the injured foot with the contralateral, uninvolved foot. Gissane’s crucial angle reveals a fracture when the lateral process of the talus is sitting on the calcaneus. A bone scan may be useful when needing to confirm suspicion of a fracture not visible on other imaging. Evidence of a fracture can be visible on bone scans within seven hours of injury. Also useful is the fact that a negative bone scan 72 hours after injury excludes bone involvement. Computed tomography scans may be the most useful imaging modality in in this population. Fine cuts at 2 to 3 mm widths are ideal. Buckingham and colleagues favor CT scans for calcaneal fracture diagnosis in children.17 Children are generally less susceptible to calcaneal fractures even though they are more likely than adults to endure falls from a height. The Schmidt classification is useful for calcaneal fractures in children.13 Types 1 through 3 are extraarticular fractures and types 4 and 5 are intraarticular. There is a type 6 fracture, which involves significant bone loss, soft tissue injury and loss of the Achilles tendon insertion.
What You Should Know About Treating Calcaneal FracturesAccording to Jarvis and Munoz, non-operative, non-weightbearing casting for four to six weeks is the treatment of choice for a pediatric calcaneal fracture with less than 4 mm disruption of the three subtalar facets, no subtalar subluxation secondary to widening, and no fibular impingement from the lateral cortex of the calcaneus.1 Clinicians can provide conservative treatment for tongue-type fractures if the posterior gap is less than 1 cm and the Achilles tendon has not been significantly shortened by proximal displacement of the fragment. Open reduction internal fixation is indicated in adolescents (average age 13) with displaced, intra-articular calcaneal fractures. Pickle and coworkers reported good results in 30 patients.18 Six patients had seven calcaneal fractures. Four of seven patients were pain-free. The remaining three had minor pain with sports or when they were on hard floors. Jarvis and Munoz noted the following key principles of managing a calcaneal fracture.1 • Rule out other injuries known to be associated with calcaneal fractures such as fractures of the spine. • Determine the full nature and extent of the injury through imaging. • Add special views and alternative images to aid in decision-making. • Restore the Bohler’s angle and heel height. • Reduce heel width to as close to normal as possible. • Reduce or rebuild fragments of the posterior facet of the subtalar joint, and reduce the sustentaculum tali fragment. • Provide sufficient fixation to ensure maximum healing.
What About Midtarsal Joint Fractures?Traumatic injuries to the navicular, cuboid and cuneiform are rare in children.19 The relatively low body mass and anatomically short lever arm across the midfoot make the mechanics of these injuries less likely in this population. When they do occur, these injuries are most often avulsion or stress injuries. Clinicians can address these injuries with the use of walking casts for up to four weeks pending re-evaluation.
Salient Insights On Lisfranc FracturesLisfranc joint fractures or dislocations are also rare in children.20 In the direct form, the mechanism of injury involves an insult from an object falling on the foot. In the indirect form, there is ballistic plantarflexion or abduction with the foot in a toe-walking position the patient sustains while trying to land from a fall, often from a considerable height. The typical injury here is a child jumping from a height and landing on his toes. A third mechanism is that of heel-to-toe compression. This child is in a kneeling position when impact load strikes the heel from above.21 Typically, there is resultant lateral dislocation of the second, third, fourth or fifth metatarsal, and a fracture of the second metatarsal base. Yet another mechanism for this injury is the fixed forefoot position. In this scenario, the patient falls backward while a heavy weight is pinning the forefoot to the ground. The heel resting on the ground becomes a fulcrum for the injury to the forefoot. When these rare injuries do occur in children, the three indirect injuries I described above are likely mechanisms. In adults, these injuries are more often from motor vehicle accidents, crush injuries and falls from heights.
Current Diagnostic Insights For Tarsometatarsal InjuriesWhen it comes to tarsometatarsal injuries, there is swelling dorsally over the tarsometatarsal joints. The presence of plantar ecchymosis of the plantar midfoot suggests trauma to the soft tissue of this region, most notably the tarsometatarsal ligaments. Consider the presence of ecchymosis in this location highly suggestive of a Lisfranc injury.22 A Hardcastle Type B (partial incongruity) injury is the most common tarsometatarsal injury in a child.23 It is characterized by partial incongruity of the tarsometatarsal joints, either medially or laterally. There may be medial displacement of the first metatarsal from the medial cuneiform resulting from disruption of the Lisfranc ligament or a fracture at the base of the metatarsal that remained attached to the Lisfranc ligament. One can evaluate this injury on plain film X-rays if normal relationships of the lesser tarsus and metatarsus are present. Establish whether there is a disruption of the normal arrangement of the lateral border of the first metatarsal in line with the medial cuneiform on AP film. On oblique X-rays, the medial aspect of the second metatarsal should line up with the medial aspect of the middle cuneiform. Bilateral weightbearing comparative X-rays may reveal a diastasis between the base of the second metatarsal and the medial cuneiform that is not apparent with non-weightbearing. A fracture of the base of the second metatarsal strongly suggests a tarsometatarsal dislocation. A cuboid fracture with the aforementioned second metatarsal fracture further suggests such dislocation.
Treating Lisfranc InjuriesIn patients with <2 mm displacement, perform closed reduction with the patient’s foot elevated and use a posterior splint followed by a below-knee cast for four to six weeks once swelling reduces. For fractures >2 mm, closed reduction with percutaneous pinning under anesthesia is recommended. Open reduction is indicated for fractures in which one cannot achieve anatomic reduction.1 Rupture of the Lisfranc ligament most likely warrants repair in the young patient as opposed to a fusion in order to preserve as much motion as possible. In older adults, a fusion is sometimes required if degenerative joint disease has occurred.
Expert Pointers On Metatarsal FracturesFractures of the metatarsals are the most common fractures of the foot in children.19,24 In children under the age of 5, the first metatarsal is involved 75 percent of the time. After the age of 10, the majority of injuries involve only the fifth metatarsal. The mechanism of injury is either direct with falling objects or a crush injury (motor vehicle accident and bicycle falls most likely), or indirect with axial loading involving inversion, eversion or a combination of both. In the presence of a crush injury, swelling may be significant and one should consider the possibility of compartment syndrome. This possibility is more likely in the presence of multiple injuries. These additional major injuries may sometimes contribute to a delay in evaluating distal injuries. Trauma to the proximal portion of the metatarsals should suggest the possibility of simultaneous injury to the lesser tarsus. On plain films, AP, lateral and oblique views are recommended. A lateral view can be useful to assess dorsal or plantar displacement of any fragments. Anatomically, the watershed area between the proximal branch of the nutrient artery and the metaphyseal vessel (corresponding to zone 2) is at risk for possible delayed or non-union. The apophysis (os vesalianum) appears by the age of 9 and unites with the base of the fifth metatarsal anywhere between the ages of 12 to 15. It is sagittal in orientation, placing it parallel to the metatarsal shaft. This may help in distinguishing it from a fracture of the fifth metatarsal.
How To Treat Metatarsal FracturesIf significant soft tissue swelling is present, avoid using a circumferential cast at the time of triage. Start with a posterior splint in slight equinus with elevation. Later place the child in a below-knee cast for three to six weeks with weightbearing depending on the degree of displacement. Closed reduction with conscious sedation is necessary for a completely displaced fracture in an older child. Also attempt this if the fracture is angled >20 degrees and especially if the apex of the fracture is dorsal. If the reduction is unstable, one may use a percutaneous K-wire in younger children. Considerable lateral displacement and even dorsal angulation of the metatarsal neck can be acceptable in younger patients. For fractures of the fifth metatarsal base, one may employ appropriate zone-based management. Zone 1. These are usually avulsion fractures caused by the tendon of the abductor digiti minimi muscle or the lateral plantar aponeurosis. These fractures occur proximal to the fourth and fifth metatarsal articulation. The blood supply is good here and there is a very high percentage of patients who go on to good healing.1 Place the child in a below-knee cast for three to six weeks. Most are asymptomatic after three to six weeks but evidence of healing on X-ray may lag behind. If the child has a symptomatic non-union, consider a small lag screw fixation. Consider open reduction internal fixation for tuberosity fractures if displacement is > 3 mm. Zone 2. This includes the Jones fracture characterized by an oblique fracture at the proximal metaphyseal-diaphyseal junction located 1.5 cm from the tuberosity. The typical age group for this injury is 15 to 20. In this age group, 70 percent of base fractures are Jones fractures and 17 percent are tuberosity fractures. The mechanism is usually a combination of vertical loads and frontal shear at the juncture of a stable proximal metaphysis and a mobile distal diaphysis. Zone 2 injuries occur in the so-called “watershed” region at the metaphyseal-diaphyseal juncture. The blood supply here is reduced and non-operative healing rates are closer to 80 to 85 percent.1 When Zone 2 injuries are acute in nature, one should employ a short leg non-weightbearing cast for six weeks. Serial X-rays are useful to monitor healing. When there is evidence of callus and decreased tenderness to the area, protected weightbearing in a hard-sole shoe for an additional four weeks is appropriate.25 Torg and colleagues reported successful healing in 14 of 15 adults treated with non-weightbearing casts, but only four who were allowed to bear weight went on to union.24 In an active individual, screw fixation is often recommended to speed the time of healing and reduce the risk of re-fracture after a return to sports. In chronic cases, with symptoms present for more than a few months and evidence of uneven healing, attempt six weeks of non-weightbearing casting. These cases often require surgical intervention. Zone 3. These injuries are often stress fractures in athletes. Treat acute zone 3 injuries with a non-weightbearing short leg cast for six weeks, progressing to protected weightbearing. For chronic zone 3 injuries, consider an intramedullary screw fixation and graft similar to that recommended for the Jones fracture.
When Fractures Of The Phalanges OccurFractures of the phalanges in children are relatively rare. Family members or primary care physicians often treat them. The cause is generally a direct event such as a fall or an indirect event such as a stub against an unyielding surface. First line treatment is usually a buddy splinting of adjacent toes with a rigid soled shoe to limit sagittal plane toe motion during healing. In rare cases, closed manipulation with or without traction and then taping are required. In older children with displaced phalangeal fractures a percutaneous pin may be needed after reduction for stability. Remove the pin at approximately six weeks with progressive return to weightbearing. Intra-articular fractures of the proximal phalanx of the hallux may include Salter Harris types II, III or IV injuries. Surgeons should reduce and pin those involving more than 30 percent of the joint surface and with displacement of >3 mm. Growth arrest and stiffness are possible complications of these injuries. Distal phalangeal injuries may be open fractures because of the proximity to the nail matrix. The Seymour lesion occurs when the skin and nail fold at the dorsum of the toe are disrupted. The potential for osteomyelitis warrants irrigation and debridement. Any fracture should have reduction and protection with splinting and hard soled shoes. In rare occasions, a below-knee walking cast is required. Antibiosis for seven to 10 days should be adjunctive. In cases of established osteomyelitis of the phalange, debridement and IV antibiosis are recommended.
How To Address Lawnmower InjuriesOne study reported 160,000 lawnmower injuries annually with 2,000 occurring in children.26 The child is either the operator or a bystander during the incident.27,28 Riding mowers are more likely to be associated with injury than push mowers, resulting in more devastating injuries.27 Children under the age of 14 have the greatest risk of lawnmower injury and children under 6 have the greatest risk of death from such injuries, and they occur most often in the warmer months.29 These injuries are both highly destructive and preventable. One should thoroughly assess the area of the injury. Take the patient urgently to the operating room for debridement and irrigation. Administer IV antibiosis on triage. It may be useful to stage debridement at 48 hours to determine the true point of viability after such a devastating injury. If an ablative procedure is needed, it is generally advisable to preserve as much length as possible. Avoid trans-diaphyseal ablation to prevent stump overgrowth issues. Other options include delayed closures, split-thickness skin grafting and microsurgical free flap transfers.27,30,31,32 Advances in bone transport with ring fixation and other external fixators, including stump lengthening procedures, now facilitate better functioning with as short an amputation as possible.
Understanding Stress Fractures In ChildrenCommon locations for stress fractures are the tibial, fibular, tarsal and metatarsal regions. The cause is usually a sudden increase in physical activity in a maturing adolescent involved in intensive training for a sport. The mechanism is resorption and demineralization at the site of stress followed by a reparative process evidenced by periosteal layering of new bone. Low-risk stress fractures are compression injuries. In the foot, these are commonly in the first through fourth metatarsals and calcaneus. These tend to heal more easily as compressive forces are working in favor of rapid healing. High-risk stress fractures are under tension. In the foot, these include the talus, navicular, proximal fifth metatarsal and sesamoids. In these cases, the tension forces acting on them may work against rapid healing. Exams reveal pain on weightbearing but less than what one may encounter with acute fractures. Pain is often only during a specific activity. There is minimal swelling and local tenderness, which is marked and discreet. Early X-rays are not helpful as bone callus is not visible until two to four weeks after the injury. Bone scans are more sensitive but are generally not necessary to institute treatment. Authors have implicated incorrect training, changes in footwear, increased activity and a Morton’s foot type as risk factors leading to an increase in stress on the second and third metatarsals.32 High-risk sports for stress fractures in the foot in children are running, football, gymnastics and ballet and ice skating (fibula stress fractures). With some sports, there are predilections for certain injuries. In sprinters and dancers, stress fractures occur more frequently in the metatarsals. Football players tend to get them in the base of the fifth metatarsal. Basketball players may get them in the navicular. Middle- and long-distance runners are more likely to sustain tibia and fibular stress fractures. Treatment should include cessation of sport activity and protective devices to encourage healing. If pain is present only during sports, one may consider a relative restriction of activity based on symptoms. In more severe cases, prescribe below-knee immobilization, moving to activity restriction and then a gradual return to the sport after eight to 12 weeks. Make an effort to correct training errors and biomechanical malalignments that may have contributed to the problem.
In ConclusionThis article provides an overview of fundamental principles in the management of pediatric foot fractures and trauma. I have emphasized key differences in these injuries when they occur in children in distinction to when they occur in adults. Dr. Volpe is a Professor in the Department of Orthopedics and Pediatrics at the New York College of Podiatric Medicine in New York City. He is in private practice in New York City and Farmingdale, N.Y. References 1. Jarvis J, Munoz P. Fractures and Dislocations of the Foot. In: Beaty JH (ed.): Rockwood and Wilkins Fractures in Children, sixth edition. Lippincott Williams & Wilkins, Philadelphia, 2006, pp. 1129-1180. 2. Ogden JA. The foot. In Skeletal Injury in the Child. Springer, New York, 2000. 3. Crawford AH. Fractures and Dislocations of the Foot and Ankle. In Green NE, Swiontkowski MF (eds): Skeletal Trauma in Children. WB Saunders, Philadelphia, 1994, pp. 449-516. 4. Robert IE, Jackson M, Bridgman SA. Orthopaedic fractures: trends in randomized controlled trials. Injury. 2001; 32(10):779-82. 5. Peterson L, Romanus B, Dahlberg E. Fracture of the column tali: an experimental study. J Biomech. 1976; 9(4):277-79. 6. Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am. 1970; 53(5):991-95. 7. Leibner ED, Simanovsky N, Abu-Sneinah K, et al. Fractures of the lateral process of the talus in children. J Pediatr Orthoped B. 2001; 10(1):68-72. 8. Nicholas R, Hadley J, Paul C, Janes P. Snowboarder’s fracture: fracture of the lateral process of the talus. J Am Board Family Pract. 1974; 56:263. 9. Kirkpatrick DP, Hunter RE, James PC. The snowboarders foot and ankle. Am J Sports Med. 1998; 26(2):271-77. 10. Hawkins LG. Fractures of the lateral process of the talus: a review of thirteen cases. J Bone Joint Surg Am. 2003; 93:449-80. 11. Berndt AL, Harty M. Transchondral fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Am. 1959; 41-A:998-1020. 12. Giannini S, Vannin F. Operative treatment of osteochondral lesions in the talar dome: current concepts review. Foot Ankle Int. 2004; 25(3):168-75. 13. Van Frank E, Ward JC, Englehardt P. Bilateral calcaneal fractures in childhood: case report and review of the literature. Arch Orthop Trauma Surg. 1998; 118(1-2):111-12. 14. Schmidt TL, Weiner DS. Calcaneal fractures in children: an evaluation of the nature of the injury in 56 children. Clin Orthop. 1982; 171:150-55. 15. Brunet JA. Calcaneal fractures in children. J Bone Joint Surg. 2000; 82(2):211-16. 16. Mora S, Thordarson DB, Zionts LE. Pediatric calcaneal fractures. Foot Ankle Int. 2001; 22(6):471-77. 17. Buckingham R, Jackson M, Atkins R. Calcaneal fractures in adolescents CT classification and results of operative management. Injury. 2003; 34(4):454-59. 18. Pickle A, Benaroch TE, Guy P, Harvey EJ. Clinical outcome of pediatric calcaneal fractures treated with open reduction and internal fixation. J Pediatr Orthoped. 2004; 24(2):178-80. 19. Wilson DW. Injuries of the tarso-metatarsal joints. J Bone Joint Surg Br. 1972; 54(4):677-86. 20. Wiley JJ. Tarso-metatarsal joint injuries in children. J Pediatr Orthoped. 1981; 1(3):255-60. 21. Ross G, Cronin R, Hauzenblas J, Juliano P. Plantar ecchymosis sign: a clinical aid to diagnosis of occult lisfranc tarsometatarsal injuries. J Orthoped Trauma. 1996 10(2):119-22. 22. Quenu E, Kuss G. Etude sur les luxations du metataese (luxations metatarsotariennes) du diastasis entre le 1er et la 2e metatarsien. Rev Chir. 1909; 39:281-336. 23. Owen RJT, Hickey FG, Finlay DB. A study of metatarsal fractures in children. Injury. 1995; 26(8):537-38. 24. Torg JS, Balduini FC, Zelko RR. Fractures of the base of the fifth metatarsal distal to the tuberosity: classification and guidelines for non-surgical and surgical management. J Bone Joint Surg. 1984; 66(2):209-14. 25. Alonso JE. Lawn mower injuries in children, a preventable impairment. J Orthoped Trauma. 1989; 3(2):168. 26. Vosburgh CL, Gruel CG, Herndon WA. Lawn mower injuries of the pediatric foot and ankle: observations on prevention and management. J Pediatr Orthop. 1995; 15(4):504-09. 27. Ross PM. Mutilating lawn mower injuries in children. J Am Med Assoc. 1976; 236(5):480-81. 28. Newman R, Miles R. Hazard analysis: injuries associated with riding type mowers. U.S. Consumer Products Safety Division, Washington, DC, 1981. 29. Dormans JP, Azzoni M, Davidson RS, Drummond DS. Major lower extremity lawn mower injuries in children. J Pediatr Orthoped. 1995; 15(1):78-82. 30. Love SM, Grogan DP, Ogden JA. Lawn-mower injuries in children. J Orthoped Trauma. 1988; 2(2):94-101. 31. Horowitz JH, Nichter LS, Kenney JG. Lawn mower injuries in children: lower extremity reconstruction. J Trauma. 1985; 25(12):1138. 32. Drez D, Young JC, Johnston RD, Parker WD. Metatarsal stress fractures. Am J Sports Med. 1980; 8(2):123-25. For further reading, see “Key Insights On Diagnosing Heel Pain In Kids” in the March 2004 issue of Podiatry Today or “Keys To Diagnosing And Treating Calcaneal Apophysitis” in the November 2009 issue.