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Jurnal Ortopedi
Jurnal Ortopedi
Management of Calcaneal
Tuberosity Fractures
Abstract
Rahul Banerjee, MD
John C. Chao, MD
Ryan Taylor, MD
Akas Siddiqui, MD, MPH
Pathoanatomy and
Mechanism of Injury
The calcaneus is the most frequently
fractured tarsal bone. Fractures are
classified as intra-articular and extra-articular; 60% to 75% are intraarticular.1,6 The most common mechanism of injury for intra-articular
fractures is axial loading resulting
from either a fall from a height or a
motor vehicle collision.6,7 Extraarticular fractures, conversely, most
often result from twisting forces in
the hindfoot.8,9 A subset of extraarticular fractures, posterior calcaneal tuberosity avulsion fractures,
account for 1% to 3% of all calcaneal fractures.6,10-13
The strength of calcaneal bone
plays a major role in the etiology of
avulsions of the posterior tuberosity.
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Figure 1
A, Radiograph (left) and close-up photograph (right) of the traditionally described Achilles tendon insertion.
B, Radiograph (left) and close-up photograph (right) of a more proximal Achilles tendon insertion. (Reproduced with
permission from Lowy M: Avulsion fractures of the calcaneus. J Bone Joint Surg Br 1969;51[3]:494-497.)
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Classification
Beavis et al10 proposed a classification system for describing calcaneal
tuberosity avulsion fractures (Figure
2). Type I is a sleeve fracture, in
which a small shell of cortical bone
avulses from the tuberosity. Type II is
a beak fracture, in which an oblique
fracture line runs posteriorly from
the most superior portion of the posterior facet, but the Achilles tendon
remains attached to the fracture.
Type III is an infrabursal avulsion
fracture from the middle of the tuberosity, which Beavis et al10 described in a case report.
Patient Evaluation
The evaluation of a patient with a
calcaneus fracture begins with a
thorough history, with importance
placed on the time and mechanism of
injury. Patients with osteoporosis,
peripheral neuropathy, or diabetes,
or who are on long-term immunosuppressive therapy, are at higher
risk for avulsion fractures, and they
may not recall any history of
trauma.6,11,16,17
Physical examination should include a careful evaluation of the soft
tissues. The skin of the posterior heel
should be carefully examined to ensure identification of open fractures.
In addition, the surgeon must recognize that fracture displacement may
put pressure on the skin over the heel
and thus lead to skin necrosis (Figure
3). Clinically, this is manifested by
skin that is pale or nonblanching. A
delay in treatment is associated with
a greater risk of complications from
this problem. In a large series of 139
displaced posterior calcaneal tuberosity fractures, 29 (21%) had some
form of soft-tissue compromise;
there was a higher incidence in patients who delayed seeking medical
Figure 2
Figure 3
Management
Nonsurgical
care, had greater fracture displacement, or smoked tobacco.18 Hess
et al19 presented three calcaneal avulsion cases that resulted in wound
complications secondary to delayed
surgical treatmentspecifically, posterior heel skin breakdown with
overlying tissue necrosis.
Plain radiographs of the foot and
ankle should be obtained to evaluate
the foot and rule out other injuries.
The fracture is best visualized on a
lateral foot radiograph. Unlike other
fractures of the calcaneus, CT scans
are not necessary for definitive management.
April 2012, Vol 20, No 4
Surgical
Most displaced calcaneal tuberosity
fractures require surgery to restore
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Figure 4
the function of the gastrocnemiussoleus complex and prevent secondary soft-tissue compromise of the
posterior heel. Indications for surgery include open fractures, threatened skin, displacement >1 cm, and
inability to participate in closed
treatment.18,20 Open fractures necessitate dbridement and stabilization
of the fracture. In open fractures, reduction and stabilization of the fracture help soft-tissue healing. In cases
of threatened skin from displaced
fracture fragments, urgent reduction
of the fracture is necessary to prevent
further skin injury and possible conversion into an open fracture. If the
fracture is displaced, the function of
the calcaneus as a lever to the
gastrocnemius-soleus complex is
compromised. Without surgical reduction and fixation, the patient will
experience weakness of plantar flexion as well as difficulty climbing
stairs.6,11,13,21 In addition, the patient
is at risk for a bony protuberance
over the site of the fracture, which
can affect shoe wear.
Fracture reduction is achieved
through open exposure and direct visualization of the displaced fragment
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Figure 5
Figure 6
along with either metal or spiked ligament washers. Lag screw fixation
alone may be insufficient to resist the
pull of the triceps surae, particularly
in osteoporotic bone; therefore, supplemental fixation has been advocated in the form of suture anchors.16
Recent suture anchor designs have
demonstrated markedly increased
load to failure, especially in metaphyseal cortical and cancellous bone,
which had been a problem with
older suture anchor designs.24 One
application of suture anchors in the
repair of these fractures is to use the
anchors to directly reapproximate
the avulsed bony fragment. One limb
of suture from each suture anchor is
used to hold the fragment in place;
the other limb is woven into the
Achilles tendon with a Krackow suture.23 Robb and Davies13 described
the use of two 6.5-mm corkscrew anchors in a patient with bilateral posApril 2012, Vol 20, No 4
257
Outcomes
Limited data regarding the outcomes
of calcaneal tuberosity fractures have
been published; this may be because
of the relative rarity of these fractures. Most studies are noncontrolled retrospective case series; none
of them, to our knowledge, compares different types of fixation. The
available literature suggests that patients have better outcomes with surgical than with nonsurgical treatment.6,17 Schepers et al6 reviewed the
literature of reported calcaneal tuberosity fractures from 1852 to 2007.
Of the 66 patients with fractures
identified, 11 were treated nonsurgically, for a 64% satisfactory rate,
and 29 were treated surgically, for an
88% satisfactory rate. However,
more than half of the reported patients had no documented follow-up.
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12.
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Summary
Fractures of the calcaneal tuberosity
occur most commonly in osteoporotic elderly women or in diabetic
patients as a result of neuropathic
fracture. Open and displaced fractures tenting the skin must be identified and addressed urgently. Internal
fixation must provide stability and
be able to resist the pull of the triceps surae muscle. Although studies
with reported outcomes are limited,
surgical reduction and internal fixation of these fractures restores hindfoot anatomy and may provide the
best possible results for patients with
this injury.
References
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