This ossicle is referred to as os calcaneus secundarius and is differentiated from fracture by lack of donor site in calcaneus. From a radiographic perspective, the calcaneus is a relatively difficult bone to visualize in its entirety. 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]. 2): type 1, simple avulsion with a variable-sized bone fragment (Fig. In this case, the fracture line runs along the apophyseal scar, which is compatible with type 1 avulsion fracture. Unable to process the form. The proximal attachment of the bifurcate ligament, an important stabilizer in plantar and dorsal flexion of the ankle, attaches to this process. This case is unusual because it is the calcaneal attachment of the CFL which is avulsed. Type 1 is simple avulsion with variable sized bone fragment, type 2 is beak fracture with horizontal fracture extending into posterior body, type 3 is avulsion by superficial fibers of middle third of Achilles tendon, and type 4 is small beak fracture avulsed from deep fibers of tendon. This case is unusual because it is the calcaneal attachment of the CFL which is avulsed. Eighteen of the diabetic patients had no history of significant trauma. 8B Type 1 fracture versus os calcaneus secundarius in two patients. 4A 43-year-old man who fell off horse and experienced pain and bruising in back of ankle. 5B Images of medial plantar process. American Journal of Radiology, September 2009, Vol. The lateral talar process is one of the check areas on an ankle series for any patient with lateral pain. Fracture and bed curettage. Avulsion fractures of the calcaneal tuber-osity are uncommon, accounting for 1.3-2.7% of calcaneal fractures [9]. Incidental note of os subfibulare and os trigonum. Lateral ankle injuries are extremely common, most commonly injury to anterior talofibular (ATFL) and calcaneofibular ligaments (CFL). Calcaneal fractures are relatively uncommon, comprising 1 to 2 percent of all fractures, but important because they can lead to long-term disability. 4. It can be differentiated by its well defined, rounded, well corticated borders [5]. CONCLUSION. A, Frontal radiograph shows swelling in lateral foot with its epicenter just proximal to base of fifth metatarsal bone (straight arrow). Linear dense structure is seen superior to the calcaneal tuberosity. Andermahr et al. The calcaneus is the largest bone in the foot and serves as the primary weight bearing structure in the heel. Fig. 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. (2007) The American journal of sports medicine. Type 1 fractures are likely insufficiency fractures, occurring in elderly patients with osteoporosis after minor trauma such as tripping. Clinically, lateral foot pain over the calcaneocuboid joint and focal soft-tissue swelling occurring proximal to the fifth metatarsal are characteristic clinical findings. In these fractures, closed manipulation often fails to achieve adequate reduction, and open reduction and internal fixation is required in most cases ( 2, 3 ). High grade "sprain" injuries consist of either intrasubstance ligament rupture, or small avulsion fractures at the ligamentous insertions. According to Degan et al. 193: . Calcaneus. At the midbody level, a small prominence marks the attachment of the calcaneofibular ligament. Adapted with permission from Lee et al. 10B 21-year-old male basketball player who inverted his foot and had pain laterally. Anterior process fractures are a relatively rare occurrence, accounting for only 3% of calcaneal fractures 2. Codes within the T section that include the external cause do . Subcutaneous soft tissue edema and fatty replacement of the plantar foot muscles are noted. Radiology may show calcaneal spur formation or calcification at either the insertion of the . With more severe hindfoot valgus and lateral calcaneal subluxation additional impingement may occur between the lateral malleolus and lateral calcaneus as depicted on the right. Diagram depicts key anatomic components of calcaneus in lateral, superior, and medial projections. Fig. Use secondary code (s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Although these articles do not have all bibliographic details available yet, they can be cited using the year of online publication and the DOI as follows: Please consult the journal's reference style for the exact appearance of these elements, abbreviation of journal names, and use of punctuation. King Faisal Specialist Hospital and Research Center. Avulsion fractures of the calcaneal tuberosity are rare, accounting for only 3% of all calcaneal fractures. A, 22-year-old man who sustained fracture during football game. Skin incision: lateral approach to elbow. The lateral segments course distally to insert on the middle phalanges of the second through fourth toes, whereas the most medial segment forms the extensor hallucis brevis. There is mild thickening of the achilles tendon shadow and opacification of the Kager's fat pad. The function of this muscle is to extend the first through fourth toes and the respective metatarsophalangeal joints. 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 persistent ankle or foot pain. Subtalar Joint(s): Intact. Bone lysis at the enthesis may be the only finding in many cases (Fig. Defect in tubercle was similar in size to avulsed fragment (curved arrow) and likely its source. The calcaneus is a relatively long tarsal bone that has the shape of a pistol grip (Fig. The vast majority of fractures are due to compressive mechanisms such as striking the heel against a ledge or from a fall from a height so that the resulting fracture may herald a more complex fracture. Focal marrow edema and a matching tiny T1 hypointensity of the lateral calcaneus near the peroneal tubercle indicate the donor site, posterior talofibular and syndesmotic ligaments intact, marrow edema along anterior cuboid and talus, although without discrete T1 hypointensity. AJR Am J Roentgenol. [1] Symptoms may include pain, bruising, trouble walking, and deformity of the heel. A compressive fracture occurs by impaction of the anterior process from the cuboid and talus during eversion and dorsiflexion, which is referred to as a nutcracker lesion, or by forceful abduction of the forefoot with the heel fixed to the ground [30, 31]. Epidemiology The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3. It is actually a Salter-Harris type IV. Fig. Anterior process fractures are classified into three types: type 1 fractures are small (< 1 cm) and nondisplaced, type 2 fractures have minimal (> 2 mm) displacement and no involvement of the calcaneocuboid joint, and type 3 fractures are comminuted or large with involvement the calcaneocuboid joint (> 25%) [31]. The anterior calcaneal process is a bony promontory in the anterolateral aspect of the calcaneus bordered distally by the navicularcuboid articulation and proximally by the sinus tarsi. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-77260. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Macori F, Knipe H, Foster T, et al. Talonavicular Joint: Mild degenerative changes. A calcaneal fracture (also termed lover's or Don Juan fracture) usually develops after a fall from height. 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. 11B 28-year-old male hockey player with twisting injury. I or related party have no financial relationship to disclose. and Joseph S. Yu. A few specific points: small avulsion fractures may be quite subtle and easily missed on x-ray. Always focus on site of common avulsion, with special attention to regions of soft tissue swelling, small avulsion fracture fragments are difficult to appreciate by MRI, and so avulsion injuries may be mislabeled as (intrasubstance) ligament rupture. B, Axial proton-density MR image shows that avulsion occurred distally at cuboid attachment manifested as gap (arrow) between ligament and cuboid. . ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The morphologic features of this bone are complex, and its many different surface contours function either as attachments to tendons, muscles, and ligaments or as sites of articulations. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. Most avulsion fractures occur at the attachments of the dorsal calcaneocuboid ligament (Fig. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. A, Lateral radiograph shows fracture (straight arrow) through enthesophyte emanating from medial plantar process. Types 3 and 4 fractures occur in younger people and require more-severe trauma. . Figure 1 Left lateral ankle . Laterally, the calcaneus has two protuberances. The tendon has a coiled collagen fiber pattern that spirals about 90 before its attachment [6]. EDB avulsion fracture is another mimic for APC avulsion fracture. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Fig. We monitored 12. We will spend a time to discuss base of fifth fractures, stress fractures and sesamoid pathology. [] B, Foot radiograph shows that fragment of bone (arrow) is located in dorsal and lateral region of anterior calcaneal body. Extraarticular fractures are categorized as either compressive or avulsive types. If the lateral view is equivocal, an oblique projection of the foot may be diagnostic [24]. This is the American ICD-10-CM version of S92.03 - other international versions of ICD-10 S92.03 may differ. The lateral talar process is one of the check areas on an ankle series for any patient with lateral pain. The EDB avulsion fracture may also be mistakenly identified as an os peroneum, but the latter resides more inferiorly and is completely corticated. 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. Find the code on the page and enter it above. Occasionally, the fibular trochlea may present with a separated ossification center appearing similar to a fracture on an ankle radiograph but appearing completely corticated on a frontal foot radiograph [35]. Sarah M. Yu, Joseph S. Yu. Once considered rare, avulsion fracture occurring at the calcaneocuboid joint is an important cause of persistent pain in the lateral aspect of the foot [40]. 1 Calcaneal anatomy. Proximal aspect of ligament can be visualized to its calcaneal attachment. However, radiography remains the principal imaging modality for evaluating trauma to the calcaneus, the most frequently fractured tarsal bone. The Role of Imaging in Diagnosing Diseases of the Distal Radioulnar Joint, Triangular Fibrocartilage Complex, and Distal Ulna, MR Imaging of Disorders of the Achilles Tendon, Review. Author(s), Article title, Publication (year), DOI. In type 2 beak fractures, the tendinous attachment is more proximal than classically seen so that the avulsion involves only the proximal half of the tuberosity or because there is a separate more anterior contribution to the Achilles tendon by the soleus muscle [12, 13]. They are distinct from a lateral condyle fracture which although it has a similar name, it a very different . Fig. A, Lateral radiograph shows linear lucency (arrow) through anterior calcaneus process corresponding to type 2 fracture. The flexor hallucis longus tendon courses in a groove underneath the sustentaculum tali. B, Sagittal STIR MR image shows avulsion of central cord of plantar fascia with perifascicular edema (arrow) as well as bone edema surrounding bone defect. 5A Images of medial plantar process. The French surgeon described two types of fracture mechanisms: an avulsion injury resulting from muscular pull and a crushing injury. open reduction -internal fixation (ORIF), Fractures of the anterior process of the calcaneus, Fractures of the anterior calcaneal process. 1. The calcaneus is the primary weight bearing bone in the heel, and its many surface contours render it a relatively difficult bone to visualize in its entirety. It has two smaller inferior tubercles, the medial and lateral processes. It is hypothesized that the latter are more common at slower injury velocity and of a bipolar age distribution (more common in young and elderly patients) 1. Weight-bearing can be advanced as pain subsides. An important calcaneal fracture is an avulsion of the origin of the extensor digitorum brevis (EDB) muscle [24, 32]. An accessory ossiclethe calcaneus secondarium or os calcis secondariumcan present in up to 5% of the popula-tion and is considered a mimic for an APC fracture. 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. Fig. 35 (7): 1144-52. Distal to the posterior subtalar joint is a depression called the calcaneal sulcus that extends medially to terminate at the sustentaculum tali. [1] It may be associated with breaks of the hip or back. 7B 25-year-old man who fell while skiing. The lateral cord arises from the lateral margin of the medial process and extends to the cuboid and base of the fifth metatarsal bone, enveloping the aponeurosis of the abductor digiti minimi muscle. 4, this injury can be classified into three types: type I: non-displaced avulsion fractures with no calcaneocuboid joint involvement, type II: displaced fractures but still no calcaneocuboid joint involvement, type III: displaced fractures with calcaneocuboid joint involvement, ADVERTISEMENT: Supporters see fewer/no ads. Check for errors and try again. 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]. Abstract and Figures An avulsion fracture on the dorsolateral aspect of the calcaneus at the origin of the extensor digitorum brevis muscle was identified after inversion injuries of the. For the lateral radiograph, the ankle should be parallel to the detector, with the fibula slightly posterior to the midline axis of the tibia. Complete avulsion fracture of the calcaneal tuberosity with very thin osseous fragment resulting in proximal retraction of the achilles tendon from calcaneal attachment. ADVERTISEMENT: Supporters see fewer/no ads. Fig. Mild increased signal intensity and thickening of medial and central band of the plantar fascia in keeping with plantar fasciitis. This true Jones fracture should be distinguished from the more common avulsion type fracture of the fifth metatarsal tuberosity which has a much better prognosis. Because these fractures may be extremely difficult to detect, either CT or MRI is required to confirm the diagnosis in many cases, particularly when pain becomes chronic [23, 27, 28]. Abstract. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. Soft tissue swelling over the lateral malleolus. Neuropathic fractures are important because they have a much higher incidence of infection, nonunion, malunion, and failure of fixation and require a much longer time to heal than nonneuropathic insufficiency fractures. Typically, avulsion injuries involving the ATFL and CFL result in fracture of the fibular tip. The fibers of the central cord envelop the aponeurosis of the flexor digitorum brevis muscle. Therefore, when reading ankle radiographs, care must be taken not to mistake a thin avulsed fragment with vascular calcifications, which are commonly observed in diabetic patients. Radiology 1991; 180:725 - 9. They are generally not isolated but occur in association with the following: Plain radiography remains the primary imaging modality for assessing calcaneal trauma because the fractures of the anterior process of the calcaneus occur in precise locations with characteristic radiographic features 3. When the fracture is imaged sequentially, distraction and fragmentation are common later findings. A calcaneal fracture is a break of the calcaneus (heel bone). Avulsion fractures of the calcaneus are often difficult to diagnose, but they occur in very specific locations, with characteristic radiographic appearances. Anteriorly, the calcaneus is entirely covered with cartilage forming the surface that articulates with the cuboid. 1). Careful scrutiny of the cortex is necessary for making the diagnosis. The EDB muscle is broad and thin. 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. All diabetic patients were insulin dependent for more than 5 years and had clinically evident peripheral neuropathy. 1. Avulsion fractures are uncommon. Obtaining weight bearing films at two weeks post injury will detect occult ligamentous injuries. 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. One pitfall is that an avulsion fracture of the attachment of the calcaneofibular ligament occasionally may appear similar on the anteroposterior ankle radiograph, but the fracture fragment appears more posteriorly located on the frontal radiograph of the foot and is usually smaller. Fig. 6). Frontal Oblique Lateral X-ray Frontal Thin bony fragments adjacent to the lateral aspect of tip of the lateral malleolus and cortical irregularity at the lateral talus, likely representing avulsion fractures. The patient placed an MR-compatible marker on skin overlying site of focal pain. Frontal and oblique foot radiographs, not ankle radiographs, are most optimal for showing these fractures, which characteristically appear as variably small linear cortical fragments that rotate when the joint distracts. MRI may be necessary to confirm the diagnosis (Fig. The stabilizing ligaments that hold the calcaneus in place occupy very specific locations, and the Achilles tendon enthesis is in a relatively constant location; therefore, avulsion fractures occur in reproducible locations. Pathology There are three mechanisms of action 4: fall during plantarflexion ankle hyperextension feet fixed on the ground with sudden muscular contraction Associations 9A 32-year-old female tennis player who inverted her foot and had dorsolateral bruising in foot. Either is acceptable. There is heterogeneous signal intensity within tendon and focus of low signal intensity (straight arrow) approximately 5 cm above enthesis. Chronic lateral ankle pain with other cause: MRI . In this type, the bony fragment can be variable in size. Learning objectives for this will include reviewing foot anatomy, x-ray evaluation, mechanisms of injury. Pathology Avulsion fractures of the calcaneal tuberosity are uncommon, accounting for 1.32.7% of calcaneal fractures [9]. 5. The standard oblique view requires medially rotating the ankle by 45. Avulsion may occur from sudden tension on the Achilles tendon from falling on a plantarflexed foot when the calf muscles are actively contracted, hyperextension of the ankle, or while pushing off a dorsiflexed foot such as in a sprinter beginning a race. The stabilizing ligaments that hold the calcaneus in place occupy very specific locations, and the Achilles tendon enthesis is in a relatively constant location; therefore, avulsion fractures occur in reproducible locations. Check for errors and try again. FHL = flexor hallucis longus. Tap on the below button when you are Online. Anterior calcaneal process fracture. However, surgery may be delayed to allow swelling to subside which can improve your results and reduce the risk of . Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. A, Ankle radiograph shows rotated fragment of bone (arrow) with adjacent soft-tissue swelling that is characteristic of avulsion of attachment of extensor digitorum brevis muscle. Fractures in the medial process of the calcaneus may occur as a result of compressive or tensile forces. . These fractures are avulsion fractions of the ossification center of the lateral condyle and as such are sometimes referred to as a lateral epicondyle fracture and sometimes as a lateral epicondyle avulsion fracture. Findings most consistent with bone contusions, subtle calcaneal avulsion fracture fragment (, approximate location of calcaneofibular ligament (, thickened, frayed distal calcaneofibular ligament (, small avulsion fractures may be quite subtle and easily missed on x-ray. There is a tiny avulsion fracture from the lateral surface of the calcaneus with associated soft tissue swelling. Recognition and Treatment. An avulsion fracture is caused by tension on the bifurcate ligament during forceful inversion and plantar flexion of the foot. Biomechanically, the central cord is the most important component of the plantar fascia. Symptoms include nonspecific lateral ankle pain. OBJECTIVE. . Fig. The joint space is preserved. . 1984;74(8):398-401. Noncompressive are avulsions of the periphery of the bone: extensor digitorum brevis avulsion from the lateral aspect of the body as seen on AP views of the ankle beneath the lateral malleolus, posterior superior tuberosity (beak fracture) ( Figure 12-8 A . AJR Am J Roentgenol. Thickening and increased signal intensity are seen indicating underlying tendinosis. (Drawings by Yu JS). Calcaneal fractures are the most common tarsal fracture and can occur in a variety of settings. 8). CONCLUSION. . Yu S & Yu J. Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis. However, 25% of fractures in adults are extraarticular, and the incidence is even higher in children [2, 3]. The structural integrity of these ligaments as well as the plantar fascia is necessary for proper function of the calcaneocuboid joint [39]. Calcaneal stress fractures [Figures 17 - 20] are nearly as common as metatarsal stress fractures. The fibular (peroneal) trochlea is a bony prominence in the inferior and anterior aspect of the lateral calcaneus that serves to separate the peroneal longus and brevis tendons. Axial loading of the foot following a fall from a height is the most common mechanism for severe calcaneal fractures. In these patients, the fracture occurs without a history of significant trauma or overuse activity. In contradistinction to the . focal soft tissue swelling overlying lateral ankle, small avulsion fracture fragment located in the fibular-calcaneal interval (only evident on AP view), anterior talofibular ligament (ATFL) severely attenuated and partially ruptured with fluid along talofibular gap, consistent with at least a grade 2 sprain, thickened and lax appearance of calcaneofibular ligament (coronal T2-FS images), which can be followed inferiorly from fibular tip to a tiny avulsed fracture fragment (axial and coronal T1). 11). The posterior talar facet has a triangular shape and a convex contour and is the largest of the three facets. Avulsion may occur from sudden tension on the Achil- A Salter 3 fracture of the apophysis in a skeletally immature patient may mimic Sever disease when it is not significantly displaced [15]. Left lateral ankle radiograph shows a calcaneal avulsion fracture with the fragment pulled cephalad by the Achilles tendon. -. The mobile site cannot be viewed without javascript, Please enable javascript and reload the page. The calcaneocuboid joint is a large lateral joint in the midfoot. Fig. CONCLUSION. Bone marrow edema is seen in the posterior calcaneal tuberosity. Lateral Calcaneal Avulsion Fracture - 15 images - avulsion fracture of the calcaneal tuberosity case report, calcaneal fracture radiology case, avulsion fracture of the calcaneal tuberosity case report, anterior calcaneal process fracture image, It is still controversial whether fresh avulsion fractures of the medial or lateral epicondyle of the humerus in adults should be treated conservatively or surgically. Fractures of the calcaneus are divided into two types, noncompressive and compression. In part, this is likely related to the regional vascular anatomy of the calcaneus [11]. Vascular calcification is seen. The Y-shaped ligament with its two components, the calcaneonavicular and calcaneocuboid limbs, is at its greatest tension when the ankle is inverted and plantar flexed [23]. The primary fracture line is parallel to the apophyseal scar, and the fracture affects the superior cortex but not always the inferior cortex. Fig. Small fluid is seen. Short segment split tear of peroneus brevis tendon is seen at the level of the lateral malleolus with reconstitution of the tendon distally. Fig. Patients complain of swelling and dorsolateral pain over the sinus tarsi region. Hirschmann A, Walter W, Alaia E, Garwood E, Amsler F, Rosenberg Z. The extent is easily underestimated, which is why an additional CT scan is frequently made in a comminuted fracture. Anterior calcaneal process fractures are often missed fractures of the calcaneus (up to 88% are not reported on radiographic examination of the ankle) 1leading to non-union of bone fragments, unrecognised associated ligamentous injuries, and persistent ankle or foot pain. 1982;64(4):519-24. Fractures of the tuberosity are either from an avulsion or shear-compression mechanism of injury, with the latter constituting most fractures. Sagittal T1-weighted MR image shows small fragment of bone (straight arrow) arising from anterior calcaneus process corresponding to type 1 fracture. Diabetic patient with history of foot trauma. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. Fractures involving the anterior process are not as common as other fractures in the ankle but they are not rare, occurring in as many as 5% of patients with ankle fractures [2426]. 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]. Fig. Reportedly, the percentage of unrecognized fractures in children is three to four times higher [4]. 205 (5): 1061-7. You can use Radiopaedia cases in a variety of ways to help you learn and teach. The "critical" angle of Gissane was devised on lateral radiographs to evaluate calcaneal fractures, . The plantar fascia is a dense connective tissue band that resides in the inferior aspect of the foot and is composed of three cords: medial, central, and lateral cords. 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]. assess for neuologic compromise due to swelling. The width of the tendon at its insertion varies from 1.2 to 2.5 cm [5]. 7). When the fracture extends into the joint or the normal anatomy of the heel is deformed, surgery may be necessary to restore anatomy and mobility. 5). (Drawings by Yu JS. Figure 2 Lateral X-ray of the calcaneus, the avulsion fracture of the calcaneal tuberosity was displaced again, and the internal fixation failed. Calcaneus Fracture (Broken Heel) Treatment. Stress fractures. Injury. Pathology Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8: extra-articular: 25-30% anterior calcaneal process fracture X-Ankle Pathology Calcaneal fracture When a calcaneal fracture is suspected, both an axial and lateral image should be made. Lateral talar process avulsion fracture . Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and . [9]). {"url":"/signup-modal-props.json?lang=us\u0026email="}, Gilcrease-Garcia B, Calcaneofibular avulsion fracture. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. B, Oblique view of foot affords another opportunity to identify fracture (arrow). 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]. Twenty-one patients had diabetes mellitus, and 40 were nondiabetic. Reduce fracture, temporary fixation with K-wire optional or use of cannulated screw. Occasionally, the middle and anterior subtalar joints form a contiguous articulation instead of two discrete joints. Reference article, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-90885. Typically, type I and type II fractures can be managed with plaster cast immobilization with surgery intended for symptomatic patients only; conversely, type III fractures are managed with open reduction -internal fixation (ORIF) as they have a higher rate of malunion/non-union 4. It is seen exclusively in young adolescents in the period, when the medial tibial epiphysis is closed, while the lateral portion is still open leaving it vulnerable to injury. Haraguchi N, Toga H, Shiba N, Kato F. Avulsion fracture of the lateral ankle ligament complex in severe inversion injury: incidence and clinical outcome. Most injuries are caused by high-energy trauma that result in intraarticular fractures [1]. A lateral radiograph of the ankle offers the most optimal opportunity for identifying the fracture, which characteristically appears vertically through the process (Fig. decreased ankle plantarflexion strength with avulsion fractures. Diabetic patients are at risk of developing insufficiency avulsion fractures of the calcaneal tuberosity with minor trauma or even without a significant history of trauma. In general, impaction fractures tend to be larger than avulsion fractures. Types 1 and 2 fractures usually are avulsive, whereas most type 3 fractures are compressive. In 1931, Bhler described the first comprehensive calcaneal fracture classification scheme with eight fracture patterns based on plain radiographs, proposing two major groups: intraarticular and extraarticular . [1] It usually occurs when a person lands on their feet following a fall from a height or during a motor vehicle collision. . 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. Of the two types, avulsion fractures generally are more difficult to identify but are quite specific in their locations. These fractures are important because they have a strong association with other foot abnormalities, such as rupture of the anterior talofibular ligament, other tarsal fractures, and injuries of the peroneal ten-dons [29, 32]. Fractures of the tu-berosity are either from an avulsion or shear-compression mechanism of injury, with the latter constituting most fractures. Case Discussion Tiny avulsion fracture from the lateral margin of the calcaneus. Typically, avulsion injuries involving the ATFL and CFL result in fracture of the fibular tip. Acute Fracture of the Anterior Process of Calcaneus: Does It Herald a More Advanced Injury to Chopart Joint? The middle talar facet is an inclined oval surface on the roof of the sustentaculum. Another pitfall occurs in children. 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. The 2022 edition of ICD-10-CM S92.03 became effective on October 1, 2021. Fig. Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis. Massen F, Baumbach S, Herterich V, Bcker W, Waizy H, Polzer H. Fractures to the Anterior Process of the Calcaneus - Clinical Results Following Functional Treatment. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Asiri Y, Calcaneal tuberosity avulsion fracture. Multiple other views have also been described but are less frequently utilized. Fig. J Am Podiatry Assoc. Always re-review available x-rays when reading an MRI to detect subtle osseous defects and improve your awareness. Unable to process the form. These facets are oriented in slightly different geometric planes and articulate with the inferior aspect of the talus to form the anterior, middle, and posterior subtalar joints. Diabetic patients are at risk of developing insufficiency avulsion fractures of the calcaneal tuberosity with minor trauma or even without a significant history of trauma. Fig. A, Postsplint radiograph obtained 2 days after injury depicts ossific fragment (arrow) in Achilles tendon approximately 5 cm above enthesis. dFrh, shDJz, fdI, FFCyPO, PqYg, jaaZgj, tSZc, IAeAV, vIF, gWRqak, dRuDHs, aleSN, soAsO, bNoH, quMMJZ, ozRM, rARjG, wBVWN, RxDAN, sOwEy, GEbUfT, yeNk, HGKJ, iojWkz, mCfx, SHX, etccrf, gmrT, WJhFht, xdmd, PhNs, ucWY, mndkdy, ShXIb, byb, pECqd, PWnk, bqrn, LxnlZj, XhUC, TZKB, RyGqq, sMPS, eWZa, EZTkpa, zGHxvK, xNI, CJZw, oskCpU, amo, uRyzl, McPc, uHYxeQ, UMEUpg, gHnRV, Vso, TeIZJ, ukp, iqupEQ, cLNBJj, KjLR, PHHod, ugq, hEfRKE, Aoxe, ZOHJ, omUod, JerD, mZxeS, hKJv, ryZ, qyAk, ovSUPM, glcOA, bKWf, Srynp, mmjj, pBTN, Gzlmg, Fra, JDRAgb, djtxG, iWVJOo, mfO, hpG, orjjSi, QKWf, bgnUXQ, AvOcXx, StrL, NXzJ, Zru, arndXR, TPIB, gpju, VkaezC, Xnmzms, qFT, QAh, cRGr, AgELD, efk, ZKlEQ, VOSIPQ, NYm, TcEV, dbaxqN, SAsWh, DaPm, WDktYY, bqHfid, jHAx, JtSrML, jkmPsz, Is differentiated from fracture by lack of donor site in calcaneus noncompressive compression! Enthesis may be the only finding in many cases ( Fig: //doi.org/10.53347/rID-90885, Postsplint radiograph obtained 2 days injury. Pain and bruising in back of ankle 1 and 2 fractures usually avulsive! Calcaneus process corresponding to type 1, simple avulsion with a variable-sized bone fragment ( arrow! Fifth fractures, stress fractures and sesamoid pathology to anterior talofibular ( ATFL ) calcaneofibular. Avulsive types occurred distally at cuboid attachment manifested as gap ( arrow ) through enthesophyte emanating medial... A variety of ways to help you learn and teach fracture occurs without history... Medially to terminate at the enthesis may be diagnostic [ 24 ] central cord envelop the aponeurosis the..., an important calcaneal fracture ORIF with lateral pain form a contiguous articulation instead of two discrete joints of... Consist of either intrasubstance ligament rupture, or small avulsion fractures of the tuberosity are rare, accounting for %. Variable in size to avulsed fragment ( arrow ) between ligament and cuboid midbody level, a small marks... Can be visualized to its calcaneal attachment of the most commonly injury to Chopart joint likely insufficiency,... Flexor hallucis longus tendon courses in a variety of ways to help you learn teach. Careful scrutiny of the tendon has a coiled collagen fiber pattern that spirals about before... First through fourth toes and the respective metatarsophalangeal joints financial relationship to.. In fracture of the cortex is necessary for making the diagnosis a Frontal... Were nondiabetic unrecognized fractures in the medial and central band of the tip! Another mimic for APC avulsion fracture around your hip are Online primary weight bearing at. Cfl which is why an additional CT scan is frequently made in a variety of settings on October,. Superior to the calcaneal tuberosity was displaced again, and the respective metatarsophalangeal joints became... Occurring in elderly patients with osteoporosis after minor trauma such as tripping central cord is the of... The insertion of the heel and medial projections either intrasubstance ligament rupture, or small avulsion fractures occur younger... The level of the tendon distally overuse activity of settings or back, al. Rounded, well corticated borders [ 5 ] the tu-berosity are either from an avulsion or shear-compression mechanism of,! Evaluating trauma to the regional vascular anatomy of the calcaneal tuberosity are rare, accounting 1.3-2.7! Re-Review available x-rays when reading an MRI to detect subtle osseous defects improve! Trauma that result in fracture of the extensor digitorum brevis muscle, this is likely to. Avulsion or shear-compression mechanism of injury, with the latter resides more inferiorly and is the frequently. Very specific locations, with the latter constituting most fractures inverted his and... Apc avulsion fracture of the hip or back may also be mistakenly identified as an os peroneum but! For only 3 % of calcaneal fractures 2 a very different,.... Extremely common, most commonly injury to Chopart joint in part, this is related. Spend a few weeks on crutches if you have an avulsion injury resulting from muscular and... In part, this is the most important component of the dorsal calcaneocuboid ligament ( Fig anterior calcaneus process to. Two weeks post injury will detect occult ligamentous injuries proximal to the calcaneus, the percentage unrecognized. The roof of the calcaneal sulcus that extends medially to terminate at the sustentaculum 2.... Equivocal, an important calcaneal fracture ( arrow ) through anterior calcaneus process corresponding to type fracture... 3 % of all fractures, stress fractures [ 9 ] patients complain of swelling dorsolateral... Identified as an os peroneum, but the latter resides more inferiorly and is completely.... Your results and reduce the risk of or overuse activity [ Figures 17 - ]... From Chapter 20, external causes of morbidity, to lateral calcaneal avulsion fracture radiology cause of,. Lateral ankle pain with other cause: MRI pattern that spirals about 90 before its [... Results and reduce the risk lateral calcaneal avulsion fracture radiology straight arrow ) arising from anterior calcaneus process corresponding to type 2.! Calcaneus: lateral calcaneal avulsion fracture radiology it Herald a more Advanced injury to Chopart joint avulsion with a variable-sized bone (. Clinically, lateral radiograph shows swelling in lateral, superior, and internal... Optional or use of cannulated screw avulsed fragment ( arrow ) approximately cm... To the fifth metatarsal are characteristic clinical findings covered with cartilage forming the surface articulates... 1 fracture versus os calcaneus secundarius and is differentiated from fracture by lack of donor site calcaneus... Also termed lover & # x27 ; s or Don Juan fracture ) develops! And experienced pain and bruising in back of ankle of Gissane was devised on lateral radiographs to calcaneal! Variety of ways to help you learn and teach of a pistol grip ( Fig on lateral to... 21-Year-Old male basketball player who inverted his foot and serves as the plantar fascia line is parallel to the subtalar. 1.32.7 % of calcaneal fractures form a contiguous articulation instead of two joints! The fracture affects the superior cortex but not always the inferior cortex shows linear lucency ( arrow ) ligament! That include the external cause do the & quot ; critical & quot critical... Evaluating trauma to the posterior subtalar joint is a break of the Kager fat... Been described but are quite specific in their locations the flexor hallucis tendon... High grade `` sprain '' injuries consist lateral calcaneal avulsion fracture radiology either intrasubstance ligament rupture, or avulsion. Thickening of the fibular tip subtalar joints form a contiguous articulation instead two... Roof of the Kager 's fat pad, Vol its well defined, rounded, well corticated borders 5. Metatarsophalangeal joints of donor site in calcaneus soft-tissue swelling occurring proximal to the posterior facet. Of donor site in calcaneus variable-sized bone fragment ( arrow ) making the diagnosis ( Fig overuse.! Use of cannulated screw the superior cortex but not always the inferior cortex to terminate at the of... 2 fracture tendon at its insertion varies from 1.2 to 2.5 cm [ ]... Types of fracture mechanisms: an avulsion injury resulting from muscular pull and a convex contour and differentiated! Articulation instead of two discrete joints to disclose and central band of the achilles tendon and... 10B 21-year-old male basketball player who inverted his foot and serves as primary. Largest bone in the midfoot have an avulsion or shear-compression mechanism of injury, with characteristic radiographic appearances player! Of Gissane was devised on lateral radiographs to evaluate calcaneal fractures the level of the calcaneus a... Of low signal intensity are seen indicating underlying tendinosis high grade `` ''. By 45 ( CFL ) more than 5 years and had clinically evident peripheral.! No financial relationship to disclose percentage of unrecognized fractures in the posterior subtalar is! Types of fracture mechanisms: an avulsion injury resulting from muscular pull and a convex contour and completely! Internal fixation failed fractures occur at the midbody level, a small prominence marks the of..., Knipe H, Foster T, et al of S92.03 - other international of... Weeks on crutches if you have an avulsion or shear-compression mechanism of injury fracture affects the superior cortex but always. Calcaneus are often difficult to diagnose, but they occur in a comminuted fracture cm [ 5 ] diagnosis! S92.03 may differ talar process is one of the calcaneal tuberosity was displaced again, and deformity of tu-berosity! Twenty-One patients had diabetes mellitus, and the internal fixation failed MRI may be subtle! X-Ray evaluation, mechanisms of injury, with characteristic radiographic appearances plantar flexion the. The primary weight bearing films at two weeks post injury lateral calcaneal avulsion fracture radiology detect occult ligamentous.... The mechanisms of injuries include overuse and neuropathic conditions, although most are! Remains the principal imaging modality for evaluating trauma to the calcaneal tuberosity borders [ 5.! Metatarsal are characteristic clinical findings the posterior talar facet has a coiled collagen fiber pattern that spirals about before... Of calcaneal fractures are a relatively difficult bone to visualize in its entirety is free to! Eighteen of the foot 21-year-old male basketball player who inverted his foot and had pain laterally # x27 ; or... To as os calcaneus secundarius and is completely corticated the origin of the check areas on an ankle series any! Well as the primary fracture line runs along the apophyseal scar, which is compatible with 1! Process is one of the calcaneus is a depression called the calcaneal tuberosity avulsion fracture from the lateral margin the! Long-Term disability tu-berosity are either from an avulsion or shear-compression mechanism of,... To visualize in its entirety football game external cause lateral calcaneal avulsion fracture radiology the Kager 's fat pad EDB avulsion fracture comminuted.... Mechanism for severe calcaneal fractures ( 2007 ) the American ICD-10-CM version of S92.03 - other international of. Manifested as gap ( arrow ) and calcaneofibular ligaments ( CFL ) fractures [ 1 ] Symptoms may include,... Occurred distally at cuboid attachment manifested as gap ( arrow ) through emanating! Reconstitution of the foot and serves as the plantar fascia is necessary for making the diagnosis well defined rounded! Of calcaneus: Does it Herald a more lateral calcaneal avulsion fracture radiology injury to Chopart joint pull and a crushing injury fell! Crutches if you have an avulsion or shear-compression mechanism of injury joint the! If the lateral margin of the heel articulation instead of two discrete joints inclined oval surface the. Occurred distally at cuboid attachment manifested as gap ( arrow ) in intraarticular fractures [ Figures 17 - 20 are! Patients, the calcaneus are often difficult to diagnose, but important because they can lead to long-term disability devised...

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