Calcaneal tuberosity avulsion fracture: an unusual variant. Adapted with permission from Lee et al. Distally, it articulates with the fourth and fifth metatarsals. Bruising may develop and the patient will have difficulty walking or weight-bearing on the ankle. Bone lysis at the enthesis may be the only finding in many cases (Fig. Forced inversion of the foot is considered the mechanism of injury so that the EDB is rapidly stretched beyond its physiologic limits resulting in a tear of the muscle along with an avulsion fracture [32]. A joint capsule invests the joint cavity, and it is stabilized superiorly by the calcaneocuboid limb of the bifurcate ligament, laterally by the dorsal (dorsolateral) calcaneocuboid ligament, and inferiorly by the plantar calcaneocuboid ligament and the long plantar ligament [3638]. An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment. Comorbid conditions and increased age portend a poor prognosis with a significant association with wound complications and need for additional surgeries. Although rare, an avulsion of the medial plantar process may occur when forceful tension on the plantar fascia enthesis occurs during falling from a height while landing on the tips of the toes, from forceful contraction of the Achilles tendon against a static long plantar ligament, or from violent contraction of the abductor hallucis muscle by forced dorsiflexion of the first ray [21, 22]. Definition / Description. [38] classified these injuries into four types depending on the size of fracture and angulation of the calcaneocuboid joint with stress: type 1, no fracture and an increased angle by 510; type 2, occasional fracture flake and angulation greater than 10; type 3, osseous fragment greater than 5 mm and angulation greater than 10; and type 4, compression fracture of medial cuboid and major joint distraction. Avulsion fractures can sometimes be overlooked or where an injury to the 5th metatarsal occurs together with an ankle sprain. Foot Ankle Int. The medial, intermediate, and lateral cuneiform bones (sometimes referred to as the first, second, and third cuneiforms, respectively) serve as stabilizing structures within the medial column of the foot. wm. Pathology They tend to occur when normal physiological forces are repeatedly applied to an area of bone. A Salter 3 fracture of the apophysis in a skeletally immature patient may mimic Sever disease when it is not significantly displaced [15]. The cause is strong muscular contraction with the heel fixed to the ground and occurs only in a subset of patients who have a broad and extensive tendinous insertion [9]. Because the talus is important for ankle movement, a fracture often results in substantial loss of motion and function. Hip injury, such as from a fall. The width of the tendon at its insertion varies from 1.2 to 2.5 cm [5]. 11). Of the two types, avulsion fractures generally are more difficult to identify but are quite specific in their locations. Avulsion fracture of the calcaneus is an emergency. The flexor hallucis longus tendon lies underneath the sustentaculum and if screw placement to the sustentacular fragment is too long, this could affect the flexor hallucis longus tendon, causing fixed flexion of the big toe. MRI of Ankle and Lateral Hindfoot Impingement Syndromes. The fracture is best depicted on the anteroposterior projection of the ankle or the frontal projection of the foot, and it characteristically appears as variably sized fragments of bone arising from the dorsolateral aspect of the anterior calcaneus (Fig. Treatment of an Anterior Process of the Calcaneum fracture. J Am Acad Orthop Surg. OBJECTIVE. Playing sports comes with risks. Fig. Occurs more in smokers, diabetics and in patients with open fractures. The calcaneus is the largest bone in the foot and serves as the primary weight bearing structure in the heel. The EDB muscle is broad and thin. The two mechanisms of injury that result in a fracture of the anterior calcaneal process are compression or impaction forces and extreme tensile forces [29]. Another pitfall occurs in children. runners) Epidemiology 2% of all fractures Most frequently fractured tarsal bone [1][2] It can occur at numerous sites in the body, but some areas are more sensitive to these types of fractures than others, such as at the ankle which mostly occurs at the lateral aspect of the medial malleolus or in the foot where avulsion fractures are common at the base of the fifth metatarsal, but also at the talus and calcaneus. History of the injury will be similar to that of an ankle sprain (plantarflexor inversion). 3); type 2, beak fracture with a horizontal fracture extending into the posterior body; type 3, infrabursal avulsion by the superficial fibers of the middle third of the Achilles tendon (Fig. A small, non-displaced fracture is best treated non-operatively. Calcaneal spurs can be located at the back of the heel (dorsal heel spur) or under the sole (plantar heel spur). Anteriorly, the calcaneus is entirely covered with cartilage forming the surface that articulates with the cuboid. Check for errors and try again. fall from . The proximal attachment of the bifurcate ligament, an important stabilizer in plantar and dorsal flexion of the ankle, attaches to this process. Type I-- Nondisplaced/Non-operative treatmentType II--Two-part fracture of the posterior facet. 1). 2-Open fractures of the calcaneus--May lead to amputation & there is a high risk of infection.3-Malunion of the calcaneus 4-Peroneal tendon irritation and impingement from the lateral wall. It begins at the midcalf level and it receives muscular fibers from three muscles: the medial and lateral heads of the gastrocnemius and the soleus muscles. Do not wait, do emergency surgery. 9B 32-year-old female tennis player who inverted her foot and had dorsolateral bruising in foot. extra-articular: 25-30% Calcaneus (Heel Bone) Fractures A fracture of the calcaneus, or heel bone, can be a painful and disabling injury. A pitfall is a normal small ossicle, the os calcaneus secondarius, which is adjacent to the anterior calcaneal process mimicking this fracture; however, these ossicles, which are seen in about 25% of the population, are completely surrounded by lamellar bone [33, 34] (Fig. B, Axial proton-density MR image shows that avulsion occurred distally at cuboid attachment manifested as gap (arrow) between ligament and cuboid. Pathology. B, Sagittal T1-weighted MR image obtained 6 weeks after injury shows thickened Achilles tendon. Careful scrutiny of the cortex is necessary for making the diagnosis. Fractures of the tu-berosity are either from an avulsion or shear-compression mechanism of injury, with the latter constituting most fractures. When refering to evidence in academic writing, you should always try to reference the primary (original) source. Fig. Unable to process the form. Rehabilitation following an avulsion fracture consists of 3 phases; the acute, the recovery, and the functional phase: It can begin at 2 weeks post-operatively. Management of calcaneal tuberosity fractures. The flexor hallucis longus tendon courses in a groove underneath the sustentaculum tali. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. A systematic evaluation of the calcaneus with attention to areas of vulnerability will assist those who interpret ankle and foot radiographs in maintaining a high diagnostic accuracy for these fractures. J Foot Ankle Surg. It's important to see your healthcare provider right away if you have a . Level of Evidence: 5, Fracture Dislocations of the Tarsometatarsal Joints: End Results Correlated with Pathology and Treatment. Avulsion fracture of the calcaneal tuberosity: classification and its characteristics. Conditions in the fascia that produce pain in the heel can be attributed to either plantar fasciitis or fascial rupture. The smaller oval-shaped anterior facet lies on the superomedial surface of the anterior calcaneus. Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I, Leg Compartment Release - Single Incision Approach, Leg Compartment Release - Two Incision Approach, Arm Compartment Release - Lateral Approach, Arm Compartment Release - Anteromedial Approach, Shoulder Hemiarthroplasty for Proximal Humerus Fracture, Humerus Shaft ORIF with Posterior Approach, Humerus Shaft Fracture ORIF with Anterolateral Approach, Olecranon Fracture ORIF with Tension Band, Olecranon Fracture ORIF with Plate Fixation, Radial Head Fracture (Mason Type 2) ORIF T-Plate and Kocher Approach, Coronoid Fx - Open Reduction Internal Fixation with Screws, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Fracture Spanning External Fixator, Distal Radius Fracture Non-Spanning External Fixator, Femoral Neck Fracture Closed Reduction and Percutaneous Pinning, Femoral Neck FX ORIF with Cannulated Screws, Femoral Neck Fracture ORIF with Dynamic Hip Screw, Femoral Neck Fracture Cemented Bipolar Hemiarthroplasty, Intertrochanteric Fracture ORIF with Cephalomedullary Nail, Femoral Shaft Fracture Antegrade Intramedullary Nailing, Femoral Shaft Fracture Retrograde Intramedullary Nailing, Subtrochanteric Femoral Osteotomy with Biplanar Correction, Distal Femur Fracture ORIF with Single Lateral Plate, Patella Fracture ORIF with Tension Band and K Wires, Tibial Plateau Fracture External Fixation, Bicondylar Tibial Plateau ORIF with Lateral Locking Plate, Tibial Plafond Fracture External Fixation, Tibial Plafond Fracture ORIF with Anterolateral Approach and Plate Fixation, Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleol, Ankle Isolated Lateral Malleolus Fracture ORIF with Lag Screw, Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws, RETIRE Transtibial Below the Knee Amputation (BKA), C-arm from contralateral end of bed at ~20 to get Harris heel view with foot dorsiflexed, lateral decubitus on beanbag with feet at end of bed, operative foot elevated under stack of blankets to make flat working surface, lateral approach to calcaneus with extensile L-shaped incision, vertical limb between lateral malleolus and Achilles, 90 turn with horizontal limb 3cm above plantar surface of foot, clean out fracture lines and remove lateral wall, identify constant anteromedial fragment and build off of it with kwires, large Schantz pin into posteroinferior calcaenus for traction, lag screws 3.5mm to join lateral to medial fragments, check plate size, fill central void with allograft, and replace lateral wall, 2 wks non-weight bearing in postmold splint, 10-12 wks non-weight bearing in CAM boot, range of motion exercises and progression of weight bearing, identify fracture pattern based on xrays (AP/Lat/Oblique and Harris/Broden views) and CT scan, analyze direction and number of fracture lines (Sanders classification), evaluate joint depression, articular comminution, Bohlers angle, and angle of Gissane, if severe articular comminution may need to concurrently fuse subtalar joint, if tongue-type with mild displacement and shortening can perform closed reduction with percutaneous pinning, goal is to restore calcaneus height, width, alignment, and articular surface, need to check wounds for evidence of open fracture, assess lumbar spine xrays (10% association with L-spine fractures), document soft tissue status, associated injuries, distal neurovascular status, check for signs of compartment syndrome, identify comorbidities (diabetes) and social factors (smoking) that correlate with complications and poor outcomes, standard OR table with radiolucent end, c-arm in from contralateral side end of bed at ~20 to get Harris heel view, Calcaneus Plating System (Stryker Veriax Calcaneus System), patient lateral decubitus on beanbag with feet at end of bed, place sheets between ipsilateral and contralateral extremities to make elevated flat working surface ~1 in height, make sure body and legs are taped down (need flat surface to work on), can alternatively place patient supine with table tilted away from surgeon, thigh tourniquet placed high on thigh with webril underneath, mark out lateral malleolus and lateral border of Achilles, vertical limb of incision between lateral malleolus and Achilles 2-4cm proximal to lateral malleolus, then 90 turn with horizontal limb 3cm above plantar surface of foot, exsanguinate limb and inflate tourniquet, 15 blade through skin then tenotomy scissors to spread subcutaneous tissue in vertical direction with minimal soft tissue stripping, knife down to bone on calcaneus for full-thickness flaps, not at distal or proximal 2-3cm of incision due to peroneals and posterior tibial tendon, elevate periosteum sharply off calcaneus following contour of bone, need to follow bone closely anteriorly to not get into peroneals distally, be careful to avoid sural nerve and short saphenous vein posterior to lateral malleolus, inverting the foot will help expose the subtalar articular surface, no touch technique avoiding skin using three .062 kwires into ant/med/post aspect of talus, bend kwires with driver into two 90 angles as fixed internal retractors for subcutaneous and skin retraction, delineate fracture lines with knife and clean out using freer, curettes, and rongeur, identify lateral wall that is often broken off, remove piece, clean and mark orientation for later use, and place in saline on back table, next find constant anteromedial fragment and build off of it, checking to see how remaining fragments fit together, break apart fragments with curved osteotome and lever to regain calcaneus height, there is a central void of comminution due to bone loss, remove fragments if needed and temporarily pin into place with multiple kwires, need to restore ant/med/post facet of subtalar joint, check with fluoro Bohlers angle and angle of Gissane, kwires through bottom of calcaneus to pin constant fragment to remaining fragments, drill large Shantz pin into posteroinferior aspect of calcaneus perpendicular to bone to gain traction through fragment, bolt cutter to remove sharp end, T-handle to apply traction through pin and distract fragments, build periphery of calcanues and later fill in central void with allograft chips, tamp in gently, check AP/Lat/Harris fluoro to check calcaneus reduction in terms of height, width, alignment, and articular surface, use blue handle of lap around forefoot to pull foot into dorsiflexion for heel view, place 3.5mm lag screw to join largest pieces lateral to medial (2.7mm drill, 3.5mm screws), be careful of iatrogenic injury to FHL from long screws, check calcaneus plate sizing on Lat fluoro, fill in central void with bone chips allograft, then place lat wall fragment back into place, place bicortical nonlocking screws first in anterior and posterior aspects of plate to compress plate down to bone, place locking screws around periphery of plate, if performing simultaneous fusion of subtalar joint, place threaded guidepins for 8.0mm cannulated screws x2 through posterior facet of subtalar joint, check on fluoro Lat for placement into talar body, measure, drill calcaneus cortex, just into talar body, then place screw on power followed by hand, can use fully threaded (if significant comminution of subtalar joint) or partially threaded screws (for compression), check with fluoro on AP/Lat/Harris views, exchange screws that are too long medially to avoid tendon irritation (FHL) and damage, irrigate wounds thoroughly and deflate tourniquet, cauterize any bleeders carefully, watching out for saphenous vein, hemovac drain deep exiting superolateral from incision, subcutaneous closure with 2-0 vicryl, skin closure with 3-0 nylon horizontal mattress or Allgower-Donati stitch to reduce skin tension (diabetics, smokers), incision dressing (gauze, webril) followed by postmold splint with extra padding under heel for immobilization, remove splint and place in short-leg cast boot non-weight bearing, remove cast and place in CAM boot non-weight bearing, begin range of motion exercises to ankle and foot, advance weight-bearing status in CAM boot, wound breakdown (10-25%, worse in diabetics, smokers, open fractures), iatrogenic injury to peroneal tendons, sural nerve, saphenous vein, lateral impingement with peroneal irritation, iatrogenic injury to FHL from lateral to medial screws. The EDB avulsion fracture may also be mistakenly identified as an os peroneum, but the latter resides more inferiorly and is completely corticated. A, Frontal 3D CT image of calcaneus in cadaver shows shelflike prominence of medial plantar process (arrow) where central and lateral cords of plantar fascia inserts. Fig. Fig. Fractures of the tuberosity are either from an avulsion or shear-compression mechanism of injury, with the latter constituting most fractures. [12][13], Starts at 6 to 8 weeks post-operatively. 11A 28-year-old male hockey player with twisting injury. It indicates, "Click to perform a search". Superomedial fragment:Constant fragment.Also called sustentacular fragmentSuperolateral fragment Tuberosity fragmentSuperomedial fragment includes the sustentaculum tali and it is stabilized to the talus by ligaments. The extensile approach has delayed wound healing in about 20% of cases. Man with calcaneal fracture:Workmans compensation Heavy labor 0-degree Bohler angle: measured on lateral x-ray (Harris view and axial view)Probably will need subtalar fusion.Bohler angle is formed by a line drawn from the highest point of the anterior process of the calcaneus to the highest point of the posterior facet and a line drawn tangential to the superior edge of the tuberosity. Distally, the tendon has a concave anterior and convex posterior surface tapering to its broad enthesis on the calcaneus located at the middle third of the posterior surface of the calcaneal tuberosity. Fig. It is important to see your doctor as soon as the accident takes place to prevent more damage.. Type III usually gets more arthritis because it has more fracture fragments and may end by fusion. There are four types of avulsion fractures (Fig. Fig. Surgery is only recommended where the bone is displaced from its normal position or where more than 30% of the cubometatarsal joint is involved. mostly avulsion type fractures: anterior process, sustentaculum tali, calcaneal tuberosity. Sanders type II & type III calcaneal fractures will benefit from surgery of reduction and fixation. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. A pitfall is a fracture through a plantar fascia enthesophyte, which may occur as a result of either direct trauma or forceful tension on the plantar fascia. If the bone is not displaced, a walking boot or a walking cast can be used, which will remain in situ for 4 to 6 weeks. Painful problems of the foot, such as a bunion, callas, plantar fasciitis, or Achilles. Calcaneal avulsion fractures need urgent reduction and internal fixation to prevent skin complications. The calcaneus is a relatively long tarsal bone that has the shape of a pistol grip (Fig. The margins of this joint should be closely inspected for fractures in patients who have an inversion or plantar flexion injury of the foot or forced adduction injury of the forefoot. Most avulsion fractures occur at the attachments of the dorsal calcaneocuboid ligament (Fig. 7). Level of Evidence: 4. Calcaneal fractures are better if the patient is a female. Epidemiology. Original Editors - Niels Verbeeck as part of the Vrije Universiteit Brussel Evidence-Based Practice Project, Top Contributors - Niels Verbeeck, Kim Jackson, Admin, Pierreux Maarten, Shaimaa Eldib, Scott Cornish, Vidya Acharya, Rachael Lowe, Jan Alderweireldt, Claire Knott, Wanda van Niekerk and Lucinda hampton. The dorsal spurs are often associated with achilles Tendinopathy, while spurs under the sole are associated with Plantar fasciitis. Calcaneal tuberosity avulsion fracture. Unlike the non-operative treatment of a lateral ligament rupture, non-operative treatment of avulsion fractures does not yield satisfactory results. However, radiography remains the principal imaging modality for evaluating trauma to the calcaneus, the most frequently fractured tarsal bone. It arises from the medial process of the calcaneal tuberosity and extends distally in a fanlike configuration, dividing into five distinct bands that interconnect with the plantar plates, plantar interdigital ligaments, and the sagittal septa underneath the metatarsophalangeal joints [1618]. The characteristic radiographic appearance is a small fleck of bone separated from the donor site in the inferior surface of the calcaneal tuberosity or a break in the medial process cortex (Fig. A Narrative Review on Avulsion Fractures of the Upper and Lower Limbs. Most calcaneal fractures are occupational, and are caused by axial loading from a fall [ 2 ]. 3 59-year-old man with type 1 calcaneal avulsion fracture who felt pop and acute posterior heel pain. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. 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