Case Report

Calcaneal avulsion fractures: complications from delayed treatment

Abstract

Calcaneal fractures represent approximately 2% of all fractures, of which 25% to 40% are classified as extra- articular in nature. Most calcaneal fractures are closed injuries that are treated nonoperatively, or if treated operatively, surgery is delayed to allow subsidence of swelling. The purpose of this article is to highlight a subset of calcaneal fractures that should be addressed urgently. Calcaneal tuberosity avulsion fractures often compromise the thin posterior skin that covers the insertion of the Achilles tendon. These patients are at risk for skin breakdown of the posterior heel and tissue necrosis if they do not receive urgent treatment. This case series presents 3 posterior tuberosity calcaneal avulsion fractures that led to Skin necrosis because of a delay in treatment.

Calcaneal fractures represent approximately 2% of all fractures, of which 25% to 40% are classified as extra- articular in nature [1,2]. Tuberosity avulsion fractures are rare fractures that involve the posterosuperior aspect of the calcaneus but not the subtalar joint. Tuberosity fractures result from a contraction of the gastrocnemius-soleus complex, often occurring after a low-impact fall causing forced dorsiflexion, pulling the Achilles tendon, and causing avulsion of a fragment of bone [1,3,4]. In older literature, 2 types of tuberosity avulsions were distinguished into those that do not involve the insertion of the Achilles tendon (“beak” fracture) and those that do involve the insertion of the Achilles tendon (avulsion fracture) [5]. It is currently thought that these 2 fractures are the same entity and are due to variations in the insertion of the Achilles tendon [6,7].

Risk factors for developing these fractures include osteoporosis, osteomalacia, diabetes mellitus, peripheral neuropathy, and long-term immunosuppressive therapy [4,8,9]. Patients with calcaneal injuries may have comorbid soft tissue damage and skin blistering. Calca- neal fractures have a high incidence of skin and soft tissue injury. Fracture blisters and deep contusion are

common and play an important role in decision-making regarding treatment.

nonoperative treatment is used for patients with nondisplaced or minimally displaced fractures [2,5,10,11]. Non-weight bearing restrictions are maintained for approxi- mately 8 to 12 weeks until radiographic union is confirmed [11,12]. Operative treatment is selected for displaced fractures of the calcaneal tuberosity to restore continuity of the gastrosoleus complex [1,5,7,13,14]. Another surgical indication is to decompress the skin when the displaced fragment puts the overlying skin at risk for necrosis. This indication must be recognized when the diagnosis is made so that treatment can commence expediently. Skin necrosis often occurs if this is not recognized and treated emergently (see Figs. 1 and 2) [7].

The following case presentations illustrate the compli- cation of skin necrosis over the avulsed calcaneal fragment that occurred when fractures of this type were not treated on the day of diagnosis. The purpose of presenting these cases is to alert the physician, who is the initial evaluator to this subset of fractures. Most calcaneal fractures, both intra-articular and extra-articular, are simply splinted in the emergency department (ED) and sent out. When operative intervention is needed, it is often delayed to allow the Soft tissues to recover and lower the incidence of incisional complications.

A delayed approach in the type of avulsion fractures described in this article can lead to skin necrosis and severe wound complications [7]. When a calcaneal avulsion or beak fracture is recognized, the posterior skin of the heel must be urgently evaluated, and if it is tented or blanched, the fracture must be reduced and fixed [7,13]. This is the only way to prevent skin necrosis.

Case 1 is of a 68-year-old woman who sustained a fall at home while rising from a chair. She has a history of bilateral lower-extremity peripheral neuropathy, diabetes, renal disease resulting in a left nephrectomy, and osteoarthritis. She presented to her primary care physician, who referred her to an orthopedist. The orthopedist then referred her to an orthopedic foot and ankle specialist, who evaluated her 6 days after the injury. On physical examination, there was a visible deformity of the right heel, with thinning of the skin and altered capillary refill around the area. The skin overlying the bony deformity had

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Fig. 1 Case 1: open wound on posterior heel developed when the fracture seen in Fig. 2 was not treated expediently. The displaced fragment causes pressure on the overlying skin, leading to necrosis.

begun to necrose (see Fig. 1). Radiographs of the right heel showed a right calcaneal avulsion fracture (see Fig. 2). Operative treatment was selected to decompress the skin and to excise the open wound.

Case 2 is of a 73-year-old woman who sustained a fall at home. She has a medical history of hypertension, osteoar- thritis, and gastroesophageal reflux disease. She presented to

Fig. 2 Case 1: radiograph showing the displaced beak fracture. This Fracture pattern must be differentiated from more common patterns as a fracture that must be reduced emergently.

Fig. 3 Case 2: a larger fracture fragment in a calcaneal avulsion fracture.

an ED with an olecranon fracture and the fracture shown in Fig. 3. Her olecranon fracture was treated the next day, and the orthopedist determined that she had too much soft tissue swelling in the foot to do immediate fixation of the calcaneus. In the interim, the heel developed a full-thickness necrosis in a 1 x 4-cm area over the fragment site (Fig. 4). She was then referred to an orthopedic foot and ankle specialist for evaluation and treatment. This evaluation took place 1 month after the initial injury. The specialist observed that she was unable to plantar-flex the ankle against any resistance, and now, a 1 x 3-cm full-thickness eschar had

Fig. 4 Skin necrosis seen in case 2.

Fig. 5 Skin necrosis seen in case 3, which was not fixed until 2 days after the injury. At this time, it was too late, and the skin necrosed after the incision. This illustrates the importance of reducing the fragment as soon as it is recognized.

formed over the fracture fragment. The patient was scheduled for open reduction internal fixation of the calcaneus with random flap advancement and gastrocne- mius-soleus muscle recession.

Case 3 is of a 58-year-old woman with a medical history of hypertension, diabetes, and hyperlipidemia who presented to the ED with pain in her right heel after falling on some bleachers. Physical examination at that time showed no open wound and minimal swelling. Radio- graphs showed a right calcaneal avulsion fracture. The patient was taken to surgery 2 days after the injury. A longitudinal incision was made, and the fracture fragment was fixed with Mersiline tape. Skin closure was performed with staples. She was placed in a cast and discharged from the hospital. Upon follow-up in the office, there was evidence of skin necrosis over the incision (Fig. 5). The patient was then referred to an orthopedic foot and ankle specialist. During evaluation, a 5- to 6-cm wound was noted over the posterior aspect of the calcaneus, with exposed Achilles tendon. The tendon itself was dried out, but there was no purulence or evidence of infection around the wound. Radiographs revealed a loss of fracture fixation with 1 cm displacement. A plastic surgeon was consulted, and it was decided that a staged procedure with formal debridement would be performed with removal of the bony piece. The debridement took place 1 month from the original injury. It was followed by placement of a radial forearm free vascularized flap over the wound. No Achilles reconstruction was done at this time. Upon discharge from the hospital, the patient was treated with intravenous antibiotics for 4 to 6 weeks. The free flap around the open wound healed, and the infection has resolved. The antibiotics were discontinued, and the patient is using her ankle-foot orthosis; however, she has a dysfunctional Achilles complex.

Calcaneus fracture treatment has been studied exten- sively over the last 20 years. Because of swelling, skin contusion, and blistering, most displaced intra-articular fractures are treated initially with splinting in a compres- sive dressing, whereas definitive fixation is delayed for 2 to 3 weeks.

The patients presented in this article represent a small subset of calcaneal fractures that must be addressed in an emergent manner because of compromise of the posterior skin of the heel. This skin is very thin, and when the displaced beak fragment seen in the calcaneal avulsion fracture is left unreduced, the skin can quickly necrose over the fragment, leaving an exposed Achilles tendon and calcaneus.

The only way to prevent or minimize this complication is to reduce and fix the fracture expediently, thus decompres- sing the skin.

The initial evaluating physician must distinguish this subset of calcaneal fractures to get them treated in a timely manner. The orthopedist taking calls for the ED must be made aware of the skin at risk with this injury and given the opportunity to evaluate the injury before discharge from the emergency department. As is illustrated in these cases, delay in surgery resulted in skin necrosis. Signs of skin at risk on the day of presentation are blanching and lack of capillary refill. Treating the 2 women who had established skin necrosis required advancement of the Achilles tendon, prolonged immobilization, and antibiotics to get the wound to heal. The third woman, who was treated 2 days after the injury, when the swelling and Skin compromise were greatest, had disastrous wound breakdown requiring a free vascularized flap and was not able to have her Achilles tendon

reconstructed.

All of these complications may have been prevented with more expedient treatment. Initiating and achieving definitive fixation of the fracture expediently is the only way to minimize the chance of skin necrosis.

Matthew Hess MD Branyan Booth MD Richard T. Laughlin MD

Department of Orthopaedic Surgery Wright State University Boonshoft School of Medicine

Dayton, OH 45409, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2007.04.033

References

1. Rothberg AS. Avulsion fractures of the os calcis. J Bone Joint Surg 1939;21:218-20.
2. Sanders R, Clare M. Campbell’s operative orthopedics. 10th ed. St. Louis: Mosby; 2002 [Chapter 55].
3. Ranawat C, Positano R. Disorders of the heel, rearfoot, and ankle. 1st ed. New York: Churchill Livingstone; 1999 [Chapter 21].
4. Squires B, Allen PE, Livingstone J, Atkins RM. Fractures of the tuberosity of the calcaneus. J Bone Joint Surg [Br] 2001;83;(1):55-61.
5. Rowe CR, Sakellarides H, Freeman P, Sorbie C. Fractures of os calcis

-a long term follow-up study of one hundred forty-six patients. JAMA 1963;184:920.

1. Lowy M. Avulsion fractures of the calcaneus. J Bone Joint Surg [Br] 1969;51-B:494-7.
2. Protheroe K. Avulsion fractures of the calcaneus. J Bone Joint Surg [Br] 1969;51:118-22.
3. Hedlund L, Maki D. Calcaneal fractures in Diabetic patients. J Diabetes

Complications 1998;12;(2):81-7.

1. Martini F, Kremling E. Bilateral atraumatic avulsion fracture of the calcaneal tubercle in osteomalacia during fluoride therapy. Acta Orthop Scand 1999;70;(1):91-2.
2. Biehl III WC, Morgan JM, Wagner FW. Neuropathic calcaneal tuberosity avulsion fractures. Clin Orthop Relat Res 1993;(296): 8-13.
3. Dieterle JO. A case of so-called “open-beak” fracture of the os calcis. J Bone Joint Surg 1940;22:740.
4. Slatis P, Santavirta S, Sandelin J. Surgical treatment of chronic dislocation of the peroneal tendons. Br J Sports Med 1988;22: 16-8.
5. Brunner CF, Weber BG. Special techniques in internal fixation. 1st ed.

Berlin: Springer-Verlag; 1982.

1. McLaughlin HL. Treatment of late complications after os calcis fractures. Clin Orthop Relat Res 1963;30:111-5.