5B Images of medial plantar process. assess for neuologic compromise due to swelling. Patients complain of swelling and dorsolateral pain over the sinus tarsi region. Lateral ankle injuries are extremely common, most commonly injury to anterior talofibular (ATFL) and calcaneofibular ligaments (CFL). Careful scrutiny of the cortex is necessary for making the diagnosis. This case is unusual because it is the calcaneal attachment of the CFL which is avulsed. Often they are seen in only one of the frontal or oblique views. 1 Calcaneal anatomy. Extraarticular fractures are categorized as either compressive or avulsive types. Nondisplaced fractures of the cuboid without evidence of collapse of the lateral column can be managed with non-weightbearing for 4-6 weeks in a short leg cast. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. In this article, we will show the characteristic appearance and location of these fractures, discuss the mechanisms responsible for these injuries, and illustrate potential pitfalls to consider. 4. Laterally, the calcaneus has two protuberances. 1). Fracture of the posterior calcaneal tuberosity with avulsion of the Achilles tendon insertion, without fragment separation from the tendon. 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]. Fig. 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]. Typically, avulsion injuries involving the ATFL and CFL result in fracture of the fibular tip. Sagittal T1-weighted MR image shows small fragment of bone (straight arrow) arising from anterior calcaneus process corresponding to type 1 fracture. After perfecting the examination (routine blood test, coagulation function, electrocardiogram and lung CT) and eliminating the contraindications for surgery, we performed surgery on the patient. 7). Axial loading of the foot following a fall from a height is the most common mechanism for severe calcaneal fractures. 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]. Note saucerlike defect in inferior aspect of calcaneus from bone lysis (curved arrow). The standard oblique view requires medially rotating the ankle by 45. A rupture of plantar fascia is far less common but is characterized clinically by severe focal pain inferior to the calcaneus that is associated with tenderness to palpation and an acute onset [19, 20]. According to Degan et al. MRI may be necessary to confirm the diagnosis (Fig. 2019;50(10):1781-6. Avulsion fractures of the calcaneal tuberosity are uncommon, accounting for 1.32.7% of calcaneal fractures [9]. 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. Degan T, Morrey B, Braun D. Surgical Excision for Anterior-Process Fractures of the Calcaneus. Fractures in the medial process of the calcaneus may occur as a result of compressive or tensile forces. 6). It can be differentiated by its well defined, rounded, well corticated borders [5]. Recognition and Treatment. 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. 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. A calcaneal fracture is a break of the calcaneus (heel bone). Twenty-one patients had diabetes mellitus, and 40 were nondiabetic. 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. Reload page. Fig. 2018;210(5):1123-30. 5). In general, impaction fractures tend to be larger than avulsion fractures. The EDB avulsion fracture may also be mistakenly identified as an os peroneum, but the latter resides more inferiorly and is completely corticated. Fig. 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. Bone lysis at the enthesis may be the only finding in many cases (Fig. 4); and type 4, small beak fracture avulsed from the deep fibers of the tendon [9, 10]. . Avulsion fractures of the calcaneal tuberosity are rare, accounting for only 3% of all calcaneal fractures. 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. [38] classified these injuries into four types depending on the size of fracture and angulation of the calcaneocuboid joint with stress: type 1, no fracture and an increased angle by 510; type 2, occasional fracture flake and angulation greater than 10; type 3, osseous fragment greater than 5 mm and angulation greater than 10; and type 4, compression fracture of medial cuboid and major joint distraction. This ossicle is referred to as os calcaneus secundarius and is differentiated from fracture by lack of donor site in calcaneus. Radiology 1996;199:1-12. . Eighteen of the diabetic patients had no history of significant trauma. In these patients, the fracture occurs without a history of significant trauma or overuse activity. B, Sagittal T1-weighted MR image obtained 6 weeks after injury shows thickened Achilles tendon. J Am Podiatry Assoc. 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]. Radiology 1991; 180:725 - 9. Pathology The case shows superior extensor retinaculum injury, grade I injuries of lateral ankle ligaments, and avulsion fracture of the anterior calcaneal process. You can use Radiopaedia cases in a variety of ways to help you learn and teach. There are four types of avulsion fractures (Fig. Defect in tubercle was similar in size to avulsed fragment (curved arrow) and likely its source. About half of these fractures are radiographically occult even when confirmed on MRI, whereas as many as 6% of radiographically evident fractures in adults are misdiagnosed as ankle sprains [23]. Learning objectives for this will include reviewing foot anatomy, x-ray evaluation, mechanisms of injury. This is foot trauma. Distal to the posterior subtalar joint is a depression called the calcaneal sulcus that extends medially to terminate at the sustentaculum tali. The calcaneocuboid joint is a large lateral joint in the midfoot. FHL = flexor hallucis longus. Use secondary code (s) from Chapter 20, External causes of morbidity, to indicate cause of injury. B, Oblique view of foot affords another opportunity to identify fracture (arrow). Tap on the below button when you are Online. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-77260. Andermahr et al. 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 . 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. The calcaneus is the largest bone in the foot and serves as the primary weight bearing structure in the heel. Tibiotalar Joint: Subchondral marrow edema like signal along the medial talar dome with tiny subchondral cystic changes along the tibial plafond indicating degenerative changes. Superiorly, there are three articular facets covered by hyaline cartilage. The tendon has a coiled collagen fiber pattern that spirals about 90 before its attachment [6]. 8). However, 25% of fractures in adults are extraarticular, and the incidence is even higher in children [2, 3]. B, Axial proton-density MR image shows that avulsion occurred distally at cuboid attachment manifested as gap (arrow) between ligament and cuboid. 11). Abstract. Unable to process the form. A, Frontal radiograph shows swelling in lateral foot with its epicenter just proximal to base of fifth metatarsal bone (straight arrow). 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. The lateral talar process is one of the check areas on an ankle series for any patient with lateral pain. 4B 43-year-old man who fell off horse and experienced pain and bruising in back of ankle. Fourteen had calcaneal insufficiency avulsion (CIA . An avulsion fracture occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone. Oblique view of foot shows incidental ossicle (arrow) located between calcaneus, talus, navicular, and cuboid that mimics type 1 anterior process fracture. There is small linear bone fragment located lateral to calcaneocuboid joint (curved arrow). Symptoms include nonspecific lateral ankle pain. 9A 32-year-old female tennis player who inverted her foot and had dorsolateral bruising in foot. 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. Clinically, lateral foot pain over the calcaneocuboid joint and focal soft-tissue swelling occurring proximal to the fifth metatarsal are characteristic clinical findings. . 8B Type 1 fracture versus os calcaneus secundarius in two patients. High grade "sprain" injuries consist of either intrasubstance ligament rupture, or small avulsion fractures at the ligamentous insertions. [] Fig. Bone marrow edema is seen in the posterior calcaneal tuberosity. 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 1. Anteriorly, the calcaneus is entirely covered with cartilage forming the surface that articulates with the cuboid. You can use Radiopaedia cases in a variety of ways to help you learn and teach. The calcaneus is a relatively long tarsal bone that has the shape of a pistol grip (Fig. Fractures of the tuberosity are either from an avulsion or shear-compression mechanism of injury, with the latter constituting most fractures. When the fracture is imaged sequentially, distraction and fragmentation are common later findings. Radiographs and clinical records of 61 patients with calcaneal fractures were studied. 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. Thickening and increased signal intensity are seen indicating underlying tendinosis. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Macori F, Knipe H, Foster T, et al. 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. 2. Occasionally, the middle and anterior subtalar joints form a contiguous articulation instead of two discrete joints. A systematic evaluation of the calcaneus with attention to areas of vulnerability will assist those who interpret ankle and foot radiographs in maintaining a high diagnostic accuracy for these fractures. Fig. 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. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Gilcrease-Garcia B, Calcaneofibular avulsion fracture. We monitored 12. 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. 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. Mild increased signal intensity and thickening of medial and central band of the plantar fascia in keeping with plantar fasciitis. 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]. Fig. Greenspan A. . ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. (2015) American Journal of Roentgenology. 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. 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]. It has two smaller inferior tubercles, the medial and lateral processes. 1984;74(8):398-401. They are distinct from a lateral condyle fracture which although it has a similar name, it a very different . 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. 5. The hip, elbow and ankle are the most common locations for avulsion fractures in the young athlete. Reference article, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-90885. The "critical" angle of Gissane was devised on lateral radiographs to evaluate calcaneal fractures, . The middle talar facet is an inclined oval surface on the roof of the sustentaculum. Portion of bifurcate ligament is shown (curved arrow). Types 3 and 4 fractures occur in younger people and require more-severe trauma. 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. 10A 21-year-old male basketball player who inverted his foot and had pain laterally. Conditions in the fascia that produce pain in the heel can be attributed to either plantar fasciitis or fascial rupture. 10 public playlists include this case Cas 100-200 by isabelle MSK by Mix MI by Albert Guillemette Paeds Ankle Gamuts by Dr John Karpewycz Most injuries are caused by high-energy trauma that result in intraarticular fractures [1]. AJR Am J Roentgenol. Fig. 1982;64(4):519-24. This site uses cookies. Acute Fracture of the Anterior Process of Calcaneus: Does It Herald a More Advanced Injury to Chopart Joint? Fig. 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. The posterior talar facet has a triangular shape and a convex contour and is the largest of the three facets. Fig. Fig. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. [9]). Subtalar Joint(s): Intact. Joint is stabilized dorsally, from medial to lateral, by dorsal talonavicular ligament (TN) and bifurcate ligament with its two components (calcaneonavicular and calcaneocuboid), dorsolaterally by dorsal calcaneocuboid (DCC) ligament (two-band variant is shown), and plantarly by short and long plantar ligaments. Fracture and bed curettage. Keywords: avulsion, calcaneus, foot, fracture, ligament, plantar fascia, tendon. 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. 4A 43-year-old man who fell off horse and experienced pain and bruising in back of ankle. 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. 2): type 1, simple avulsion with a variable-sized bone fragment (Fig. Heterogeneous echogenicity of the distal achilles tendon and tendinosis / partial tearing of the distal achilles tendon are seen near the calcaneal attachment. Typically, avulsion injuries involving the ATFL and CFL result in fracture of the fibular tip. 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. (Drawings by Yu JS). Small fluid in the retrocalcaneal region and diffuse subcutaneous edema are seen. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. Fractures of the calcaneus are divided into two types, noncompressive and compression. 7B 25-year-old man who fell while skiing. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. 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]. I or related party have no financial relationship to disclose. (2007) The American journal of sports medicine. [1] Symptoms may include pain, bruising, trouble walking, and deformity of the heel. Check for errors and try again. Pitfalls and Pearls in MRI of the Knee, Clinical Perspective. Patients with this fracture present with pain and swelling in the dorsolateral midfoot that is similar to those who have an anterior calcaneal process fracture. Fig. 193: . Type 1 fractures are likely insufficiency fractures, occurring in elderly patients with osteoporosis after minor trauma such as tripping. From a radiographic perspective, the calcaneus is a relatively difficult bone to visualize in its entirety. 5A Images of medial plantar process. 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. This case is unusual because it is the calcaneal attachment of the CFL which is avulsed. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Biomechanically, the central cord is the most important component of the plantar fascia. A, 22-year-old man who sustained fracture during football game. 6A 45-year-old woman who felt ripping sensation in bottom of her ankle 2 weeks ago. Check for errors and try again. A, Close-up of oblique view of foot shows linear piece of bone (arrow) just proximal to calcaneocuboid joint. The fracture also tends to extend posteriorly with a horizontal component immediately distal to the enthesis of the Achilles tendon [14]. 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. This configuration gives it the viscoelasticity that allows it to absorb and adapt to forces that can approach 612.5 times body weight during running [7, 8]. Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis, Review. The joint space is preserved. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Asiri Y, Calcaneal tuberosity avulsion fracture. 11A 28-year-old male hockey player with twisting injury. Calcaneus fractures are the most common fractured tarsal bone and are associated with a high degree of morbidity and disability. The primary fracture line is parallel to the apophyseal scar, and the fracture affects the superior cortex but not always the inferior cortex. Weight-bearing can be advanced as pain subsides. A, Lateral radiograph shows fracture (straight arrow) through enthesophyte emanating from medial plantar process. We will spend a time to discuss base of fifth fractures, stress fractures and sesamoid pathology. Maneuvers that adduct the forefoot exacerbate pain. However, surgery may be delayed to allow swelling to subside which can improve your results and reduce the risk of . 10B 21-year-old male basketball player who inverted his foot and had pain laterally. and Joseph S. Yu. Fig. Proximal aspect of ligament can be visualized to its calcaneal attachment. 2015;205(5):1061-7. (Drawings by Yu JS. 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. Complete avulsion fracture of the calcaneal tuberosity with very thin osseous fragment resulting in proximal retraction of the achilles tendon from calcaneal attachment. An avulsion fracture is caused by tension on the bifurcate ligament during forceful inversion and plantar flexion of the foot. Hirschmann A, Walter W, Alaia E, Garwood E, Amsler F, Rosenberg Z. Avulsion fractures are uncommon. Of the two types, avulsion fractures generally are more difficult to identify but are quite specific in their locations. Calcaneal fractures are relatively uncommon, comprising 1 to 2 percent of all fractures, but important because they can lead to long-term disability. The characteristic radiographic appearance is a small fleck of bone separated from the donor site in the inferior surface of the calcaneal tuberosity or a break in the medial process cortex (Fig. A lateral radiograph of the ankle offers the most optimal opportunity for identifying the fracture, which characteristically appears vertically through the process (Fig. 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. Linear dense structure is seen superior to the calcaneal tuberosity. 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. 3 59-year-old man with type 1 calcaneal avulsion fracture who felt pop and acute posterior heel pain. Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and . Avulsion fractures of the calcaneal tuberosity are rare injuries that commonly occur in elderly or osteoporotic patients ( 3 ). 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]. All diabetic patients were insulin dependent for more than 5 years and had clinically evident peripheral neuropathy. 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. [1] It may be associated with breaks of the hip or back. 7A 25-year-old man who fell while skiing. Fig. Sarah M. Yu, Joseph S. Yu. Soft tissue swelling over the lateral malleolus. Avulsion fractures of the calcaneal tuber-osity are uncommon, accounting for 1.3-2.7% of calcaneal fractures [9]. Skin incision: lateral approach to elbow. An important pitfall is a neuropathic avulsion fracture of the tuberosity in a patient with long-term diabetes mellitus [13]. Another clinical and radiographic pitfall may be a small avulsion fracture of the EDB insertion; however, in our experience, even small EDB fracture fragments contain more bone than just the cortex so they do not have the typical linear appearance of a calcaneocuboid ligament avulsion fracture. Two mechanisms for anterior calcaneal process fractures have been described 3: the commonly recognized mechanism is an injury by flexion, inversion, and distraction of the bifurcate ligament leading to an avulsion fracture of variable size from the anterior calcaneal process, infrequently, impaction by eversion and dorsiflexion of the midfoot (known as the nutcracker mechanism) is observed. Calcaneus Fracture (Broken Heel) Treatment. Radiology may show calcaneal spur formation or calcification at either the insertion of the . The extent is easily underestimated, which is why an additional CT scan is frequently made in a comminuted fracture. There is heterogeneous signal intensity within tendon and focus of low signal intensity (straight arrow) approximately 5 cm above enthesis. CONCLUSION. 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. 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. American Journal of Radiology, September 2009, Vol. Either is acceptable. 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. Alignment has been maintained. However, radiography remains the principal imaging modality for evaluating trauma to the calcaneus, the most frequently fractured tarsal bone. 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. The Achilles tendon is the strongest tendon in the body and has an average length of 15 cm. A, Lateral radiograph shows linear lucency (arrow) through anterior calcaneus process corresponding to type 2 fracture. "Calcaneal avulsion fractures: an often forgotten diagnosis." American Journal of . The 2022 edition of ICD-10-CM S92.03 became effective on October 1, 2021. Another pitfall occurs in children. 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. Lateral. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. Use the menu to find downloaded articles. There is osseous avulsion fracture of the posterior calcaneus associated with thickening and proximal retraction of the Achilles tendon. 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. 35 (7): 1144-52. Check for errors and try again. The bulbous proximal end is the calcaneal tuberosity, and it serves as the attachment of the Achilles tendon. A joint capsule invests the joint cavity, and it is stabilized superiorly by the calcaneocuboid limb of the bifurcate ligament, laterally by the dorsal (dorsolateral) calcaneocuboid ligament, and inferiorly by the plantar calcaneocuboid ligament and the long plantar ligament [3638]. 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