Management of Calcaneal Tuberosity Fractures

Abstract

Fractures of the calcaneal tuberosity are relatively uncommon and are seen most frequently in elderly and diabetic patients. These injuries are typically avulsion fractures caused by concentric contraction of the gastrocnemius-soleus muscle complex. Displacement of these fractures can compromise the skin over the posterior aspect of the heel; therefore, early recognition and management are imperative. Surgical management of calcaneal tuberosity fractures requires reduction and stable fixation of the displaced fragment. When the patient has preexisting tightness of the gastrocnemius-soleus complex, successful management must also address this pathology to improve outcome.

An avulsion fracture of the calcaneal tuberosity: delay of treatment causes the ‘Achilles heel’ of optimal recovery

“…It normally acts as a lever to increase the power of the gastrocnemius–soleus complex, which inserts on the tuberosity. Of all tarsal fractures, the calcaneus is the most frequently fractured 3. In 70% of calcaneus fractures, the fracture is intra-articular 4.…”

“…Several risk factors have been described: diabetes mellitus, osteoporosis, osteomalacia, peripheral neuropathy and long-term use of immunosuppressives 3 6 7. Peak incidence occurs at around 70 years of age, and women are more often affected than men 3. The first tuberosity avulsion fracture was described by Hippocrates 4…”

“…The most referred to theory is that the foot is in plantar flexion with a loaded Achilles tendon when in expectation of a fall, and that the sudden impact and the sudden forceful dorsiflexion of the foot leads to an avulsion of the bone 3 4 6–8. In some cases, there has been no trauma at all; in these cases, there was often peripheral neuropathy due to diabetes 4.…”

“…In some cases, there has been no trauma at all; in these cases, there was often peripheral neuropathy due to diabetes 4. It is suggested that these patients did not notice the microtrauma, due to decreased pain sensation and decreased propriocepsis 3 7. Also, direct penetrating or blunt trauma to the tuberosity has been described 7…”

“…Inspection may show pale skin or non-blanching of the skin, which is a sign of increased pressure of the fragment on the skin, potentially leading to decubitus and necrosis of the skin 3. Patients may not be able to plantar flex the foot fully and the Thompson test will often be positive 7…”