Calcaneus fractures: a threa”>Case Report

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American Journal of Emergency Medicine

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Tongue-type calcaneus fractures: a threat to skin

Abstract

Calcaneal fractures account for 60% of all tarsal bone fractures. Tongue-type calcaneus fractures are longitudinal fractures that exit the calcaneal tuberosity posteriorly and involve a portion of the articular surface. They are often superiorly displaced because of the insertion of the Achilles tendon and pull of the gastroc-soleus complex. Skin compromise complicates a large percentage of these injuries because of the thin layer of soft tissue and superficial nature of the fracture. Early recognition by the emergency physician and prompt operative repair prevent further injury and obviate the need for surgical soft tissue coverage or potential amputation.

A 21-year-old man presented to the emergency department after sustaining an injury to his right heel while playing basketball. He reported landing on his heel after jumping, with immediate pain to his posterior right foot. He was seen at an outside hospital, had radiographs, and was told that he had a fracture of his heel. After immobilization in a short-leg posterior mold splint with the ankle in a neutral position, he was given instructions to follow up with an Orthopedic surgeon.

He had no insurance, so he was unable to see an orthopedic surgeon. The patient presented to our urban, county emergency department 10 days after the injury. At that time, he was still non-

Fig. 1. Clinical picture of the heel before surgery. Note the hemorrhagic blistering of the skin.

weight bearing and ambulating with crutches. On physical examina- tion after splint removal, he had significant tenderness over his posterior foot. The soft tissue of the heel was significant for hemorrhagic blistering and partial Skin necrosis (Fig. 1). His neurovascular examination was normal. Radiographs of his foot were obtained and showed a tongue-type calcaneus fracture with significant superior displacement that was tenting the skin posteriorly causing significant soft tissue tension (Fig. 2).

The orthopedic service was consulted, and the patient was consented for emergent open reduction and internal fixation of his calcaneal fracture. He underwent the procedure on the day of his emergency department presentation. One week after the surgery, he was found to have only superficial skin necrosis that began to granulate with daily dressing changes. No further soft tissue intervention was planned at that time.

Calcaneal fractures are the most commonly diagnosed tarsal bone fractures in emergency medicine, accounting for 60% of all tarsal fractures [1]. They frequently occur after a high-energy axial load to the heel, but can occur after relatively minor trauma [2,3]. Tongue- type calcaneal fractures, in contrast to the more common joint depression patterns, are longitudinal fractures that involve the calcaneal tuberosity and a portion of the posterior articular facet. Superior and dorsal displacement of the calcaneal tuberosity fragment is common because of rotation of the fracture fragment from the pull of the gastroc-soleus complex. This displacement can potentially tent the relatively thin skin of the posterior heel and place it under significant tension, eventually leading to partial- or full-thickness necrosis [3-5]. Gardner et al [2] documented posterior

Fig. 2. Lateral radiograph of the foot demonstrating a tongue-type calcaneus fracture. Note the proximity of the fracture fragment to the skin.

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skin compromise at presentation in 21% of 139 tongue-type fractures over a 5-year period. Soft tissue coverage or amputation was needed in 29% of these patients. Greater displacement of the fracture segment and a nonfall mechanism increased the likelihood of soft tissue compromise. In those patients with threatened posterior skin, further soft tissue intervention was avoided with early reduction and immobilization.

Most calcaneal fractures are splinted in the emergency setting with the ankle in a neutral position and kept immobilized by the orthopedist for several weeks to allow swelling to subside. In contrast, tongue-type calcaneus fractures should be splinted in plantar flexion to minimize soft tissue tension with emergent orthopedic consultation for open reduction and internal fixation to minimize soft tissue devitalization.

Neeraj Chhabra MD

Department of Emergency Medicine Cook County (Stroger) Hospital, Chicago, IL 60612, USA

Scott C. Sherman MD

Department of Emergency Medicine Cook County (Stroger) Hospital, Chicago, IL 60612, USA

Department of Emergency Medicine Rush Medical College, Chicago, IL, USA

E-mail address: [email protected]

Jan P. Szatkowski MD

Department of Orthopedic Surgery Cook County (Stroger) Hospital, Chicago, IL 60612, USA

http://dx.doi.org/10.1016/j.ajem.2013.02.029

References

1. Simon RR, Sherman SC. Emergency orthopedics. 6th ed.New York: McGraw-Hill; 2011.
2. Gardner MJ, Nork SE, Barei DP, Kramer PA, Sangeorzan BJ, Benirschke SK. Secondary soft tissue compromise in tongue-type calcaneus fractures. J Orthop Trauma 2008;22(7):439-45.
3. Hess M, Booth B, Laughlin R. Calcaneal avulsion fractures: complications from delayed treatment. Am J Emerg Med 2008;26:54e1-4.
4. Squires B, Allen PE, Atkins RM. Fractures of the tuberosity of the calcaneus. J Bone Joint Surg 2001;83(1):55-61.
5. Watson TS. Soft tissue complications following calcaneal fractures. Foot Ankle Clin 2007;12:107-23.