Calcaneal fractures are quite often seen in patients with axial loading injury and early recognition of the injury by the emergency physician and immediate orthopedic consultation is needed. To date, a comparison with the similar tongue-type fracture pattern of the calcaneus is not described. }, author={Matthew C. Hess and Branyan A. Booth and Richard T. Laughlin}, journal={The American journal of emergency medicine}, year={2008}, volume={26 2}, pages={ 254.e1-4 } } Comorbid conditions and increased age portend a poor prognosis with a significant association with wound complications and need for additional surgeries. Consideration should be given to fragment excision and tendon advancement as a primary treatment option in these patients. There was no more swelling of the soft tissues around the insertion of the Achilles tendon. Avulsion fractures of the calcaneal tuberosity are rare injuries that commonly occur in elderly or osteoporotic patients ( 3 ). One deep infection and two plastic surgical reconstructions were noted in this group. Calcaneal fractures are relatively uncommon, comprising 1 to 2 percent of all fractures, but important because they can lead to long-term disability. She was released from follow-up. Failure may oftentimes have more to do with host quality and fracture morphology than strength of a particular method of fixation. beak or avulsion fractures. Most often, those with orthopedic walking boots or casts will need to wear them for six to eight weeks. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. The avulsion patterns of the calcaneal tuberosity fractures are the result of several factors including the bony density level, the mechanism of injury and the fibers of the Achilles tendon that transmit the force. Lee SM, Huh SW, Chung JW, Kim DW, Kim YJ, Rhee SK: Avulsion fracture of the calcaneal tuberosity: Classification and its characteristics. A tension band wiring technique, or suture anchors can lead to a satisfactory result, being a less bulky implant, capable of resisting the tensile forces.1,17,20,21 In this case, conservative treatment consisting of a nonweightbearing short-leg cast for 2 weeks and an additional period of 7 weeks in a weightbearing cast led to clinical consolidation of the fracture. Kraal, Tim; Somford, Matthijs P.; Nijssen, Theo F.; Doets, Kees, Slotervaart Hospital, Department of Orthopaedic Surgery, Amsterdam, The Netherlands. Using CT and operative findings, a new pattern which consists of a fracture of the medial calcaneal process with a further fracture which separates the upper part of the tuberosity in the semicoronal plane is defined. 11 Schepers et al4 showed, in a review of the literature, including 66 cases of tuberosity avulsion cases, that in conservatively treated patients, 66% reached a satisfactory result, while 88% of the operatively treated patients reached a satisfactory result. This surgical technique has three main advantages: 2007;28:11831186, 17. J Bone Joint Surg. In the tuberosity group, 23 patients were treated operatively and six patients nonoperatively. Methods. Rijal L, Sagar G, Adhikari D, Joshi KN: Calcaneal tuberosity avulsion fracture: An unusual variant. . The patient was able to bear weight and wear normal shoes; however, dorsiflexion and plantarflexion of the foot was still limited without functional impairment. To our knowledge, this has not been described in the literature before. An ultrasound and a new radiograph of the calcaneus showed a 1 cm cranial displacement of the tuberosity fragment (Figure 2). In the tuberosity group, 45% of injuries were due to a low-energy fall, and 28% presented with polytrauma. All rights reserved. The tuberosity of the calcaneus primarily consists of cancellous bone with a thin cortex. Martini F, Kremling E, Sell S. Bilateral atraumatic avulsion fracture of the calcaneal tubercle in osteomalacia during fluoride therapya case report. No patients with implant failure noted in the tongue-type group. Open reduction and internal fixation is possible with the use of a lag screw, but several authors report problems with the use of this implant.8,1619 Precise complication rates cannot be found in the literature because of the rarity of this injury. A new radiograph at 4 months showed no further displacement of the tuberosity fragment and partial union (Figure 3). This type of extra-articular fracture is typically the result of twisting forces in the hindfoot. A calcaneal fracture is a break of the calcaneus (heel bone). The lower leg was immobilised with a lower leg cast and the patient was able to return home. Current Opinion in Orthopaedics (1999-2007), Clinical Orthopaedics and Related Research (1976-2007). Acta Orthopaedica Scandinavica: Vol. They do, however, reported an anecdotally lower rate of failure when tension-band wiring was combined with multiple cannulated screws and stated their investigation was likely underpowered to determine significance. British volume. . When an athlete presents with a calcaneal avulsion or beak fracture, it is pertinent to evaluate the skin of the posterior heel. Banerjee R, Chao J, Sadeghi C, et al. That the management of os calcis fractures has run the gamut of a wide variety of treatment methods since the turn of the century is mute testimony that this vexing problem remains unsolved. We did not attempt to add to the literature on a benchmark to treat these fractures. Financial Disclosure: Dr. Doets is a paid consultant for Wright Medical. 2, 6, 8, 9, 14, 15 Although surgical management is associated with better outcomes, high . Some error has occurred while processing your request. This procedure is performed through the skin with a small incision, when the pieces of bone can be realigned without a large incision. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. The trauma surgeon in our hospital was consulted and the decision was made to fix the fracture surgically. J Foot Ankle Surg 2019;58:423-426. J Bone Joint Surg. Please enable scripts and reload this page. After 1year, the patient was free of pain, and she had a 10 limitation of dorsiflexion and plantarflexion, compared to the contralateral side. By clicking accept or continuing to use the site, you agree to the terms outlined in our. Intra-articular fractures com- . The authors hypothesized that larger hematoma and more aggressive soft-tissue dissection play a role in the higher complication rate seen in displaced fractures. Categorical data are reported as number (n) and percentage (%) of total patients, whereas continuous data are reported as group mean and SD. Wolters Kluwer Health, Inc. and/or its subsidiaries. 2010;41:179183, 20. (Wiley, 1984; Schmidt, 1982; Mora, 2001; Schantz, 1987) Children younger . There are times, however, that the foot avulsion fracture can be more severe and may need an extensive amount of rest. The combination of cerclage wire and large diameter cannulated screws represents a promising option in the treatment of avulsion fractures of the calcaneal tuberosity, demonstrating good functional and radiographic results in a cohort of patients. 4 However, avulsion fractures of the posterior tuberosity are rare and account for 1-3%. Clinical orthopaedics and related research. Banerjee R, Chao JC, Taylor R, Siddiqui A: Management of calcaneal tuberosity fractures. Overall, 8 patients (35%) experienced some failure of fixation, with three patients with catastrophic implant failure requiring early revision surgery and five patients with secondary loss of reduction that eventually went onto union. This contributed to the choice of conservative treatment. Avulsion fractures of the posterior calcaneal tuberosity are rare injuries; with a prevalence of 1-3% of all calcaneal fractures, can be a painful and disabling injury, causes and treatment of an ankle avulsion sprain. Calcaneal tuberosity fractures are often described as insufficiency fractures, occurring in the elderly and osteoporotic patients after low-energy injuries.2,3,5,10,14,15 Recent series suggest more of a bimodal distribution with 45% to 71% occurring in low-energy or pathologic mechanisms.4,15 Despite commonly being a low-energy injury, soft-tissue compromise is seen in about one-half of patients on presentation.13,15 Mechanism and age were also reported as predictors of fracture pattern,12 with Beavis type 1 fractures representing low energy insufficiency injuries, and type 2 fractures representing high energy blunt trauma in younger patients. Treatment of calcaneal fractures is dictated by the type of fracture and extent of the injury. Demographics of extra-articular calcaneal fractures: including a review of the literature on treatment and outcome, A new technique for fixation of calcaneal tuberosity avulsion fractures, Calcaneal avulsion fractures: complications from delayed treatment, Avulsion fracture of the calcaneal tuberosity: a soft tissue complication from delayed treatment, Calcaneal tuberosity avulsion fracture: an unusual variant, Fractures of the calcaneal tuberosity treated with suture fixation through bone tunnels, Secondary soft tissue compromise in tongue-type calcaneus fractures. Fractures were classified by radiographic assessment into OTA classification types 82A1, 82A2, and 82B3 and type I sleeve fractures, type II beak fractures, and type III infrabursal avulsion fractures, as described by Beavis et al. J Bone Joint Surg Am 75:342-354 7. Carnero-Martin de Soto et al reported on 17 operatively treated tuberosity fractures. J Foot Ankle Surg 2018;57:191-195. 11. After the pain subsides, your healthcare provider might recommend range-of-motion (ROM) exercises monitored by a physical therapist. Get new journal Tables of Contents sent right to your email inbox, May/June 2013 - Volume 24 - Issue 3 - p 355-357, Conservative treatment of a calcaneal avulsion fracture partly consisting of a large bone spur, Other articles in this journal by Tim Kraal. Clin Orthop Relat Res. Owing to the potential risk of wound infection and infection of the osteosynthesis, the initial plan of ORIF was changed to a less invasive treatment modality. CALCANEAL AVULSION FRACTURES ,heel bone injury - Everything You Need To Know - Dr. Nabil Ebraheim. Pathology There are three mechanisms of action 4: fall during plantarflexion ankle hyperextension feet fixed on the ground with sudden muscular contraction Associations In the tongue-type group, only 5% of patients presented after a low-energy fall, 70% presented after a fall from height, and 57% experienced polytrauma. Calcaneal fractures are treated based on the type of fracture and extent of soft tissue damage. J Am Acad Orthop Surg 2012;20:253-258. Patients with planned or elective return to the operating room for removal of implant or planned staged surgical intervention (removal of Kirschner wires or patients whose initial surgical intervention consisted of irrigation and dbridement and/or temporary fixation) were recorded separately and not included in revision surgery. No patients with catastrophic implant failure or secondary loss of reduction were reported in tongue-type fractures. Greenhagen RM, Highlander PD, Burns PR. Schepers T, Ginai AZ, Van Lieshout EM, Patka P: Demographics of extra-articular calcaneal fractures: Including a review of the literature on treatment and outcome. Benjamin M, Rufai A, Ralphs JR. 1-6 Avulsion fractures of the calcaneus represent a rare subset of less than 3% of calcaneal fractures, 1, 2, 4-13 and these fractures occur more frequently in elderly patients with osteoporosis, diabetes mellitus, or autoimmune disorders. This website uses cookies. 2. [1] It usually occurs when a person lands on their feet following a fall from a height or during a motor vehicle collision. Khazen GE, Wilson AN, Ashfaq S, Parks BG, Schon LC: Fixation of calcaneal avulsion fractures using screws with and without suture anchors: A biomechanical investigation. Cranial displacement of the tuberosity fragment of 1 cm 3 weeks after the initial radiograph. A small, non-displaced fracture is best treated non-operatively. Calcaneal fractures are often open and can be complicated by osteomyelitis, septic calcaneal bursitis, sequestration, and chronic drainage. Tongue-type fractures are unusual calcaneal fractures in which the displacement of a bony fragment has the potential to tent the skin of the posterior heel. The size of the fragment can be too small, and the screws do not have enough holding power in poor quality, often osteoporotic bone.18,19. Some error has occurred while processing your request. Although complication rates are similar in tongue-type fractures of the calcaneus, implant failure and wound breakdown tend to occur more frequently in tuberosity fractures. More recently, McGonagle et al.15 found large posterior calcaneal spur formation in patients with spondyloarthritis and stated that besides tensile forces, inflammation also is an etiologic factor of spur formation. An avulsion fracture of the tuberosity of the calcaneus is a rare injury that needs to be operated on, preferably on the day of the injury. Restriction of activity. The effect of the treatment was assessed according to the ankle and hindfoot score system of American Orthopaedic Foot and Ankle Society (AOFAS) after the operation. She stopped taking bisphosphonates 1 year ago, after 5 years of use. Intra-articular calcaneal fractures are severe injuries of the hindfoot leading to a fair to poor functional outcome in the majority of the patients, compared to intra-artic calcaneAl fractures following operative and conservative treatment, which show a better functional outcome. Fractures of the tuberosity of the calcaneus. government site. Greenhagen RM, Highlander PD, Burns PR: Double row anchor fixation: A novel technique for a diabetic calanceal insufficiency avulsion fracture. By continuing to use this website you are giving consent to cookies being used. Although the last radiograph shows partial union and does not confirm full consolidation, clinical consolidation was concluded because the patient was able to perform heel raises and the strength to resist plantarflexion was equal to the contralateral side. After 100days, the fracture was fully consolidated (figure 2E) and the wound was fully healed (figure 2F). The current case underlines that the fracture should be fixated as soon as possible to prevent such complications. Knee Surg Sports Traumatol Arthrosc. Five patients (29%) had implant failure; three of these required revision, and the remaining two experienced secondary loss of reduction not requiring revision surgery. If the fracture fragment is not interfering with the function of the calcaneal cuboid joint, non-operative treatment is indicated. Learn more Bucholz RW, Court-Brown CM, Heckman JD. After institutional review board approval, a retrospective review was done of calcaneus fractures treated at a single Level 1 trauma center from 2001 to 2019. 5 The patient was satisfied with the result. Revision surgery was required in 6 patients (26%): three for catastrophic loss of fixation and three for full-thickness soft-tissue necrosis or deep infection. Although one can treat minimally displaced fractures non-operatively, it is considered an orthopedic emergency if the fracture fragment impinges upon or compromises the skin of the heel.1-3,5 The main treatments for an ankle avulsion fracture are rest and icing. 10 To prevent these skin complications, operative treatment on the day of trauma may be indicated. Anterior calcaneal process fractures are often missed fractures of the calcaneus (up to 88% are not reported on radiographic examination of the ankle) 1 leading to non-union of bone fragments, unrecognised associated ligamentous injuries, and per. Disadvantage of such a technique is that an extensive approach is necessary, leading to extra-trauma on frail skin.14. [1] It may be associated with breaks of the hip or back. Avulsion fractures can happen anywhere in the body but are most common . Spontaneous rupture of tendon of Achilles: a new clinical diagnostic test, Avulsion fracture of the calcaneal tuberosity: a case report and literature review, Management of calcaneal tuberosity fractures. Owing to delay in treatment, the fractured tuberosity led to a decubitus wound (A). In addition, tuberosity fractures were categorized as small (length < 2 cm or height < 1 cm), medium (length 2 to 3 cm or height 1 to 1.5 cm), and large (length > 3 cm or height > 1.5 cm). Rauer T, Twerenbold R, Fluckiger R, Neuhaus V: Avulsion fracture of the calcaneal tuberosity: Case report and literature review. In our experience, suture fixation was used more often in smaller and more comminuted fracture fragments not amenable to accepting multiple screws, because of a combination of fracture morphology and/or bone quality. She had been treated with prednisone for 4 years and currently is using hydroxychloroquine and adalimumab as immunosuppressive therapy. These factors combined with the limited space for fixation and large distraction forces across the fragment from the gastrocnemius soleus complex create an unfavorable environment for healing. Foot Ankle Int 2008;29:863-866. Continuous data were first assessed for normality using Shapiro-Wilk tests and then compared between groups using independent-samples T-tests and Mann-Whitney U tests for normally and nonnormally distributed samples, respectively. Avulsion fractures of the tuberosity of the calcaneus are rare injuries. J Orthop Trauma. Thirty-three patients, The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. Gitajn IL, Abousayed M, Toussaint RJ, Vrahas M, Kwon JY: Calcaneal avulsion fractures: A case series of 33 patients describing prognostic factors and outcomes. A case report is presented in which soft tissue complications occurred after a direct traumatic avulsion fracture of the calcaneal tuberosity occurred due to delayed treatment. Ten patients (34%) underwent elective removal of implants. They reported an overall complication rate of 62%, with a 24% revision rate. Beavis RC, Rourke K, Court-Brown C. Avulsion fracture of the calcaneal tuberosity: a case report and literature review. Treatment method, surgical fixation construct, duration of follow-up, and complications and review of all subsequent radiographs were recorded. In patients with deep infection, one went onto chronic osteomyelitis of the calcaneus, and another otherwise healthy patient presented again 2 months postoperatively with a deep infection and concomitant septic shoulder, which might be seeded from his calcaneus; he was treated with removal of implants and intravenous antibiotics. First, you'll be placed in a splint to keep your foot and ankle from moving. The clinical case of a 48-year-old patient who attended the Emergency Service of a second-level hospital after falling from a tree which resulted in being suspended by the lower right limb revealed signs of a calcaneal avulsion fracture, which was surgically managed via osteosynthesis with excellent clinical outcomes in follow-up. Please try again soon. (301) 949-8100. Calcaneal avulsion fractures have a high incidence of soft tissue problems, failure of fixation, and need for additional surgeries. You may be trying to access this site from a secured browser on the server. The heterogeneous nature of these injuries and fixation methods combined with the overall small number of patients in the literature make analysis of different treatment methods and appointment of a benchmark difficult. Levels of Evidence: Prognostic, Level II . Please enable scripts and reload this page. Osteosynthesis of tongue-type calcaneus fractures using a condyle bolt can be a practical and readily available solution for primary and revision scenarios in osteoporotic tongue- type calcaneUS fractures. If your fracture is stable and your joints are well-aligned, surgery may not be necessary. During the 18-year study period, 29 tuberosity fractures were identified for the study group and compared with 37 tongue-type fractures. Journal of diabetes and its complications. Good results require atraumatic exposure, anatomic reduction, rigid fixation and early mobilization. A lateral radiograph of the calcaneus at that time showed a large bony spur at the posterior calcaneal tuberosity, and in retrospect a nondisplaced insufficiency fracture of this spur (Figure 1). The mechanism of formation of bony spurs enthesophytes in the Achilles tendon. Clin Podiatr Med Surg. Loss of reduction has been shown to be a concern, and the screw itself can cause necrosis of the overlying skin.16,17 Squires et al.17 reported that they no longer use a lag screw because it separated the fragments in one patient and another patient had wound breakdown. Many of these fractures are amenable to closed and/or percutaneous . 9. 1996;118:391398, 19. We consider the avulsion fracture of the bony spur at the insertion of the Achilles tendon to be the end result of an insufficient adaptation mechanism in a patient with an auto-immune disorder and osteoporotic bone. Bilateral atraumatic avulsion fracture of the calcaneal tubercle in osteomalacia during fluoride therapy-a case report. 2010[7th edition] Philadelphia, PA Lippincott Williams and Wilkins:5385, 3. Bethesda, MD 20894, Web Policies Articles in Google Scholar by Michael Doany, MD, Other articles in this journal by Michael Doany, MD. The patient in our case fits the typical description of risk factors associated with this type of injury: an elderly woman with osteopenia, an auto-immune disorder requiring immunosuppressive therapy and some years of corticosteroid use. Treatment often involves surgery to reconstruct the normal anatomy of the heel and restore mobility so that patients can return to normal activity. Initially immobilisation in a CAM walker for four to six weeks with weightbearing as tolerated. After 60days, the fracture showed signs of consolidation (figure 2D) and the k wires could be removed. Federal government websites often end in .gov or .mil. The strength of this series is that it is the first to directly compare tuberosity with tongue-type calcaneal fractures, and it represents the second largest series reported on operatively treated calcaneal tuberosity fractures to date. HHS Vulnerability Disclosure, Help This patient was treated in a walking cast, but a heel lift was not used. Clin Rheumatol. FOIA Correspondence to Dr. Doany: [emailprotected]. We aim to provide a simple, safe, and strong internal fixation technique for avulsion fractures of the calcaneal tuberosity as one of the treatment options.Keywords: 180-degree annular internal fixation . Bouysset M, Tebib J, Well G, et al. J Bone Joint Surg. Methods: A retrospective study was done to analyze 15 patients with calcaneal tuberosity fracture who received surgical management between January 2008 and June 2011. Calcaneal avulsion fractures have a high incidence of soft tissue problems, failure of fixation, and need for additional surgeries. Patients in the tuberosity group were found to be older, with a higher incidence of diabetes, and higher Charlson comorbidity index in comparison with tongue-type fractures. No statistically significant difference was observed in complications or revisions in patients treated with cannulated screws, plate and screws, or tension-band wiring construct; however, they did not experience any failure of fixation in the tension-band wiring group. This generalization is not verified in subsequent series. Calcaneus Fractures Key Points: Fractures of the pediatric calcaneus are rare injuries and are frequently missed. 2012;51:123127, 21. Large 6.5-mm screw diameters provide the best biomechanical fixation for calcaneal beak fracture and should be implemented with precaution and in combination with a restrictive postoperative motion protocol. However, female sex was associated with secondary loss of reduction, and moreover, displacement greater than 2 cm was associated with a higher overall complication rate. Avulsion fracture of the calcaneal tuberosity without involving the subtalar facet. Five patients with tension-band wiring augmentation were described with no failure to maintain reduction in this small subgroup. Closed reduction and internal fixation with two k wires was performed (B and C). Treatment often involves surgery to reconstruct the normal anatomy of the heel and restore mobility so that patients can return to normal activity. 9 The tuberosity is pulled cranial by the Achilles tendon, after which the sharp fractured end of the tuberosity can press against the skin (figure 1A), leading to increased pressure and, eventually, decubitus (figure 2A) and necrosis of the skin.3 Open reduction and internal fixation. Phone Icon. Open Reduction and Internal Fixation of a Pediatric Apophyseal Calcaneus Fracture Using Cannulated Screws: A Case Report,We report a case of a 12-year-old boy who sustained a displaced calcaneal apophysis fracture, which was analogous to a bony avulsion of the insertion of the Achilles tendon, secondary to an awkward landing while jumping at a trampoline park. Journal of the American Academy of Orthopaedic Surgeons. Holding power of variable pitch screws in osteoporotic, osteopenic and normal bone: are all screws created equal? The fracture was planned for elective fixation 12days after the accident. Gitajn et al described 22 operatively treated tuberosity fractures. This case is illustrative for a gradually arising insufficiency of the posterior calcaneal cortex against the pulling force of the triceps surae muscle. Bone spurs can be an asymptomatic finding in the general population, but they also can be a part of an insertional Achilles tendinopathy.11,12 Benjamin et al. Semantic Scholar is a free, AI-powered research tool for scientific literature, based at the Allen Institute for AI. Avulsion fractures of the calcaneus commonly present with soft tissue compromise and have a significant rate of treatment failure and reoperation, and this injury should be identified early and approached thoughtfully, acknowledging that risks are high. Average age in the tuberosity group was 55 years (range 26 to 88), and average follow-up time was 30 months. Delay in treatment may lead to decubital wounds due to increased pressure of the fractured bone on the skin. Vyce SD, Addis-Thomas E, Mathews EE. All patients included had both clinical and radiographic follow-up. Foot Ankle Int 25:262-273 6. Two months after this treatment she was able to walk short distances, but she continued to have heel pain, although it had much decreased in time. 70, No. A 78-year-old woman was sent to our orthopaedic outpatient clinic by her rehabilitation physician who had initiated treatment of a calcaneal avulsion fracture of her left foot with a short-leg cast for 2 weeks. Fractures of the posterior tuberosity of the calcaneus represent a unique variant of hindfoot injury and are amenable to closed and/or percutaneous reduction techniques, followed by lag screw fixation. 1969;51-B:494497, 11. 4. 2008;26:14, 10. Directions. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. J Foot Ankle Surg. Our patient had a neurologic examination as part of a general geriatric examination a few months earlier, and it was concluded that despite a subjective numb feeling under her left foot, her protective sensibility was intact. What is the fastest way to heal an avulsion fracture? An ankle avulsion fracture can be stressful and very taxing on both your health and your wallet. 12. On physical examination, we saw a slender elderly woman with a body mass index of 18. Keep weight off the ankle until it has healed, and take measures to reduce swelling . Calcaneal Achilles Avulsion Fracture: Clinical Practice . Before [10] Level of evidence: 2B An inappropriately managed avulsion fractures can lead to significant, long-term functional disability. McGonagle D, Wakefield RJ, Tan AL, et al. . 2008;29:871879, 2. She was not able to walk or weight bear on her right foot. Careers, Department of Surgery, Rijnland Ziekenhuis, Leiderdorp, The Netherlands. Beavis RC, Rourke K, Court-Brown C: Avulsion fracture of the calcaneal tuberosity: A case report and literature review. Distinct topography of erosion and new bone formation in Achilles tendon enthesitis: implications for understanding the link between inflammation and bone formation in spondylarthritis. The initial treatment was a nonweightbearing short-leg cast for 2 weeks, which decreased her pain significantly. Neuropathic calcaneal tuberosity avulsion fractures. J Foot Ankle Surg 2016;55:891-893. Your healthcare provider may recommend: Casting. Treatment for an ankle avulsion fracture. A patient is presented with a calcaneal insufficiency fracture and a large bone spur on the posterior tuberosity that consolidated after conservative treatment to improve the understanding of this uncommon fracture and to report that conservative treatment can lead to a satisfactory result in patients. All the patients had unilateral acute injury, with the left foot in 7 cases . 6. Calcaneal Avulsion Fracture With. Significant differences exist between the intra- and extra-articular groups, in terms of lower age and malefemale ratio, and the literature study shows inconsistencies in treatment options, but most extra-Articular fractures are well manageable conservatively. 1. Anti-inflammatory medications. Conclusions. But even with appropriate treatment, some fractures may result in long-term complications, such as pain, swelling, loss of motion, and arthritis. Yu et al reported similar success with cannulated screwonly constructs, reporting only one loss of reduction in 10 patients; however, other authors have experienced notable rates of fixation failure with cannulated screws alone.4,13,15 In our series, purely suture-based constructs had the highest rate of catastrophic loss of reduction, whereas Gitjan et al reported no failure of fixation when a tension-band wiring construct alone with 18-gauge wire was used. The American journal of emergency medicine. Author Information. 10. Comorbid conditions and increased age portend a poor prognosis with a significant association with wound complications and need for additional surgeries. J Foot Ankle Surg 2013;52:762-765. Calcaneus Fractures - Trauma - Orthobullets orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports 1989;8:208214, 15. CONCLUSION. 13. Double row anchor fixation: a novel technique for a diabetic calanceal insufficiency avulsion fracture. A method, which includes deepening of the retromalleolar groove and at the same time maintaining the cartilagenous gliding layer is presented, which was successful on four patients, and one of the patients returned successfully to international track and road races. Background. 7 Peak incidence occurs at around 70 years of age, and women are more often affected than men.3 The first tuberosity avulsion fracture was described by Hippocrates.4, Several trauma mechanisms have been described in the literature. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Doany, Mr. Garcia, Dr. Komatsu, Dr. Divaris, Dr. Kottmeier, and Dr. Paulus. After 3 weeks of pain medication without improvement, she visited a rehabilitation physician for her painful left heel. BMI = body mass index, CCI = Charlson Comorbidity Index. CT scan (C) showing lack of articular involvement. 2. Injury characteristics are summarized in Table 2. J Biomech Eng. Our series also seems to suggest successful outcomes with cannulated screw constructs in patients amenable to accepting multiple cannulated screws and that additional soft-tissue or suture augments may be unnecessary in these patients. 2000;43:576583, 14. Her history was negative for diabetes mellitus and impaired renal function. Comorbid conditions and increased age portend a poor prognosis with a significant association with wound complications and need for additional surgeries. Acta Orthop Scand. Data is temporarily unavailable. Avulsion fractures of the posterior calcaneal tuberosity at the insertion of the Achilles tendon are uncommon injuries. Calcaneal fractures represent approximately 2% of all fractures, of which 25% to 40% are classified as extra-articular in nature. She was seen in the outpatient clinic 2days after the accident, and was planned for open reduction and internal fixation (ORIF) 10days later (12days after the fall). non-surgical treatment of calcaneal fractures in children: a long-term results comparative study. This was a retrospective study at a single level 1 trauma center between 2001 and 2019, including patients with calcaneal tuberosity avulsion fractures compared with patients with calcaneal tongue-type fractures. J Foot Ankle Surg 2012;51:666-668. Lui TH. Painful prominences of the heel. Most anterior process fractures of the calcaneus can be treated non-surgically. Rockwood and Green: fractures in adults. Avulsion fractures are often treated as ankle sprains, with the dysfunctional movement and impairments treated alongside the fracture, so it is important to individualise the treatment plan. Tuberosity fractures were classified by OTA and Beavis type, displacement, and fragment size by radiographic review (Table 3). Khazen GE, Wilson AN, Ashfaq S, et al. Statistical analysis did not define any variable to be associated with revision, including classification, displacement, fragment size, and demographic factors. Avulsion fractures of the tuberosity of the calcaneus are rare injuries. 12 Banerjee et al9 used suture fixation without suture anchors by running fiberwire sutures through 2.0 drillholes, sometimes aided by fixation with one or two (cannulated) screws. We were unable to collect patient-reported outcomes because of the long study period and retrospective nature. Treatment of an avulsion fracture typically includes resting and icing the affected area, followed by controlled exercises that help restore range of motion . Patients were treated by one of the five orthopaedic surgeons, and specific surgical indications and postoperative protocol were up to the discretion of the treating surgeon. Clin Orthop Surg 2012;4:134-138. 2011;25:685690. None of the previous studies showed superiority of a particular surgical construct, and discordant results exist describing risk factors of revision. The foot and ankle surgeon will discuss . Calcaneal fractures account for 1% to 2% of all fractures. Avulsion fractures of the tuberosity of the calcaneus should be fixated as soon as possible and minimally invasively when feasible, especially in older individuals. Calcaneal avulsion fractures have a high incidence of soft tissue problems, failure of fixation, and need for additional surgeries. A critical analysis of results and prognostic factors. Fragment size and initial displacement were not associated with revision surgery. The purpose of this study was to evaluate the incidence of complications and revision surgery, determine risk factors of revision surgery in the setting of operatively managed calcaneal tuberosity avulsion fractures, review our experience with different fixation constructs, and compare revision surgery rates between tuberosity and tongue-type fractures of the calcaneus. Hess M, Booth B, Laughlin RT. The authors commented on a lack of a benchmark surgical construct, and further analysis revealed no particular surgical construct to be associated with lower rates of failureincluding the use of washers, greater than two screws, screws greater than 4.0 mm diameter, soft-tissue augmentations, and use of tension band wire. Our experience seems to suggest that cannulated screws have a high success rate in the appropriate patient, and dynamic fixation constructs reliant solely on suture repair seem to fail at a higher rate. Hess M, Booth B, Laughlin RT: Calcaneal avulsion fractures: Complications from delayed treatment. No difference in outcomes between traumatology and foot and ankle trained surgeons was noted. The repositioned bone is held in place with screws. Although the overall complication rates were similar between our tuberosity and tongue-type groups, revision surgery and loss of reduction were significantly higher in the tuberosity group. Level of Evidence: Therapeutic Level IV. Two cases of bilateral fracture avulsions are reported to emphasize problems in diagnosis and treatment of neuropathic fractures in patients with diabetes mellitus. Lowy M. Avulsion fractures of the calcaneus. Dingemans SA, Sintenie FW, de Jong VM, Luitse JSK, Schepers T: Fixation methods for calcaneus fractures: A systematic review of biomechanical studies using cadaver specimens. Kraal, Tim; Somford, Matthijs P.; Nijssen, Theo F.; Doets, Kees. Get new journal Tables of Contents sent right to your email inbox, Creative Commons Attribution License 4.0 (CCBY), December 2021 - Volume 5 - Issue 12 - e21.00172, Avulsion Fractures of the Calcaneal Tuberosity: A Single-Center Review of Outcomes and Complications. Foot Ankle Spec 2015;8:10-17. Tuberosity group presented with soft-tissue compromise in 52%, compared with 32% in the tongue-type group (P = 0.036). Non-operative treatment often leads to misshaped heels, leading to footwear problems after long and slow healing, and impaired dorsiflexion, leading to problems with climbing stairs.3 The patient jogged weekly until the age of 76, then walked daily. Attention should be paid that one screw should be placed . Revision surgery was more common in the tuberosity group (26% versus 7%, P = 0.013). Levels of Evidence: Prognostic, Level II: Retrospective Analysis A trend correlating the time between injury and operative intervention with the incidence of complications in wounds was noted; the incidence rose in patients who underwent surgery >5 days after their injury, and patients with a higher body-mass index (BMI) took longer to heal their wounds. Radiographs and clinical records of 61 patients with calcaneal fractures were studied, finding that diabetic patients were insulin dependent for more than 5 years and had clinically evident peripheral neuropathy, while nondiabetic patients had no history of significant trauma. Mitchell PM, O'Neill DE, Branch E, Mir HR, Sanders RW, Collinge CA: Calcaneal avulsion fractures: A multicenter analysis of soft-tissue compromise and early fixation failure. Fractures of the calcaneal tuberosity treated with suture fixation through bone tunnels. The Thompson test1 was positive as it did not lead to plantar flexion of the foot. A summary of demographic characteristics is tabulated in Table 1. J Orthop Trauma 2019;33:e422-e426. official website and that any information you provide is encrypted Treatment with open reduction and . Archives of Orthopaedic and Trauma Surgery. 3 The current case highlights skin problems that can take place (figure 2A) if treatment is delayed. your express consent. There were nine males and six females, with the age ranging from 31 to 68 years (average, 51.4 years). 3. Banerjee R, Chao J, Sadeghi C, Taylor R, Nickisch F: Fractures of the calcaneal tuberosity treated with suture fixation through bone tunnels. Foot Ankle Int. The Semantic Scholar is a free, AI-powered research tool for scientific literature, based at the Allen Institute for AI. This website uses cookies. Foot Ankle Int 21(10):825-832 81 . [9] If surgery is involved, recovery may take longer. J Foot Ankle Surg. Most calcaneal fractures are closed injuries that are. Factors affecting the pull out strength of cancellous bone screws. The surgery is usually done. your express consent. By clicking accept or continuing to use the site, you agree to the terms outlined in our. 7 Also, direct penetrating or blunt trauma to the tuberosity has been described.7, Physical examination consists of inspection, palpation, functional testing and the Thompson test.1 Inspection may show pale skin or non-blanching of the skin, which is a sign of increased pressure of the fragment on the skin, potentially leading to decubitus and necrosis of the skin.3 Patients may not be able to plantar flex the foot fully and the Thompson test will often be positive.7. A new technique for the treatment of avulsion fractures of the calcaneal tuberosity is presented, which is fixed with a 180-degree microplate, which aims to provide a simple, safe, and strong internal fixation technique for avulsion fracture treatment. Calcaneal fractures in diabetic patients. J Orthop Trauma 2019;33(suppl 1):S44-S45. Secondary outcomes included soft-tissue complications and implant-related complications. When the cast or walking boot is removed, a period of rehabilitation is required. If you have any questions or would like further assistance with your ankle avulsion fracture case, do not hesitate to call us at 888-804-5044 and a avulsion injury attorney will be happy to help guide you through the process. Squires B, Allen PE, Livingstone J et al.. Fractures of the tuberosity of the calcaneus, Fixation of tendo Achilles avulsion fracture, Modified tension band wiring fixation for avulsion fractures of the calcaneus in osteoporotic bone: a review of three patients, Fixation of calcaneal avulsion fractures using screws with and without suture anchors: a biomechanical investigation. Different surgical strategies have been described as treatment option for calcaneal avulsions.3 Techniques have been described in which corkscrew suture anchors were inserted in the calcaneus, after which the sutures were run through the fracture fragment and to the Achilles tendon using the Kessler or Krakow technique.2 6 : Surgical management for avulsion fracture of the calcaneal tuberosity. Passive dorsiflexion of her left ankle was 15, slightly increased compared with 8 on the contralateral side. 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