This site uses cookies. The function of this muscle is to extend the first through fourth toes and the respective metatarsophalangeal joints. Fig. Proximal aspect of ligament can be visualized to its calcaneal attachment. Fourteen had calcaneal insufficiency avulsion (CIA . Stress fractures. Pitfalls and Pearls in MRI of the Knee, Clinical Perspective. "Calcaneal avulsion fractures: an often forgotten diagnosis." American Journal of . Avulsion fractures of the calcaneus are often difficult to diagnose, but they occur in very specific locations, with characteristic radiographic appearances. 2019;50(10):1781-6. Pathology There are three mechanisms of action 4: fall during plantarflexion ankle hyperextension feet fixed on the ground with sudden muscular contraction Associations When the fracture is imaged sequentially, distraction and fragmentation are common later findings. 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. 1984;74(8):398-401. 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. 1). Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis, Review. 2): type 1, simple avulsion with a variable-sized bone fragment (Fig. A potential clinical pitfall is a stress fracture of the lateral aspect of the cuboid [41]. -. 3 59-year-old man with type 1 calcaneal avulsion fracture who felt pop and acute posterior heel pain. American Journal of Radiology, September 2009, Vol. 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. 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]. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. Clinically, lateral foot pain over the calcaneocuboid joint and focal soft-tissue swelling occurring proximal to the fifth metatarsal are characteristic clinical findings. J Am Podiatry Assoc. Hirschmann A, Walter W, Alaia E, Garwood E, Amsler F, Rosenberg Z. In this case, the fracture line runs along the apophyseal scar, which is c. Types 3 and 4 fractures occur in younger people and require more-severe trauma. 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]. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Often they are seen in only one of the frontal or oblique views. 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 Learning objectives for this will include reviewing foot anatomy, x-ray evaluation, mechanisms of injury. Calcaneal stress fractures [Figures 17 - 20] are nearly as common as metatarsal stress fractures. 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]. Extraarticular fractures are categorized as either compressive or avulsive types. Defect in tubercle was similar in size to avulsed fragment (curved arrow) and likely its source. Bone marrow edema is seen in the posterior calcaneal tuberosity. [1] It usually occurs when a person lands on their feet following a fall from a height or during a motor vehicle collision. A, Lateral radiograph shows linear lucency (arrow) through anterior calcaneus process corresponding to type 2 fracture. 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]. 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. Fig. In fact, this fracture constitutes the most common avulsion fracture affecting the calcaneus [26]. Conditions in the fascia that produce pain in the heel can be attributed to either plantar fasciitis or fascial rupture. Duddy R, Donahue W, Cavolo D. Anterior Calcaneal Process Fractures. 11A 28-year-old male hockey player with twisting injury. . 10B 21-year-old male basketball player who inverted his foot and had pain laterally. The bulbous proximal end is the calcaneal tuberosity, and it serves as the attachment of the Achilles tendon. Unable to process the form. The flexor hallucis longus tendon courses in a groove underneath the sustentaculum tali. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. Fig. 7A 25-year-old man who fell while skiing. The structural integrity of these ligaments as well as the plantar fascia is necessary for proper function of the calcaneocuboid joint [39]. Fig. Small fluid in the retrocalcaneal region and diffuse subcutaneous edema are seen. The fibers of the central cord envelop the aponeurosis of the flexor digitorum brevis muscle. Eighteen of the diabetic patients had no history of significant trauma. Abstract. Fig. Pathology FHL = flexor hallucis longus. 2018;210(5):1123-30. Reportedly, the percentage of unrecognized fractures in children is three to four times higher [4]. This fracture is named triplane because it occurs in the coronal, sagittal and axial plane. It forms the anterior facet superiorly and the calcaneocuboid joint anteriorly. Figure 1 Left lateral ankle . 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. Occasionally, the middle and anterior subtalar joints form a contiguous articulation instead of two discrete joints. assess for neuologic compromise due to swelling. In this type, the bony fragment can be variable in size. The calcaneus is a relatively long tarsal bone that has the shape of a pistol grip (Fig. neurologic. 9B 32-year-old female tennis player who inverted her foot and had dorsolateral bruising in foot. All diabetic patients were insulin dependent for more than 5 years and had clinically evident peripheral neuropathy. The patient placed an MR-compatible marker on skin overlying site of focal pain. You can use Radiopaedia cases in a variety of ways to help you learn and teach. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. Lateral radiograph shows superiorly displaced bone fragment (curved arrow) and donor site defect in superior aspect of calcaneal tuberosity (straight arrow). Typically, avulsion injuries involving the ATFL and CFL result in fracture of the fibular tip. Axial loading of the foot following a fall from a height is the most common mechanism for severe calcaneal fractures. We will spend a time to discuss base of fifth fractures, stress fractures and sesamoid pathology. It has two smaller inferior tubercles, the medial and lateral processes. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Please wait while the data is being loaded.. Visit https://www.ajronline.org/pairdevice on your desktop computer. [] 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. Symptoms include nonspecific lateral ankle pain. Soft tissue swelling over the lateral malleolus. 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. Talonavicular Joint: Mild degenerative changes. 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. Anteriorly, the calcaneus is entirely covered with cartilage forming the surface that articulates with the cuboid. 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. Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. 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. Tibiotalar Joint: Subchondral marrow edema like signal along the medial talar dome with tiny subchondral cystic changes along the tibial plafond indicating degenerative changes. 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. 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 Multiple other views have also been described but are less frequently utilized. Use the menu to find downloaded articles. 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]. B, 30-year-old man who did not have trauma. Fluid in the retrocalcaneal and retroachillealbursae are noted suggestive of traumatic bursitis. In this case, the fracture line runs along the apophyseal scar, which is compatible with type 1 avulsion fracture. Reload page. Sarah M. Yu, Joseph S. Yu. A, Close-up of oblique view of foot shows linear piece of bone (arrow) just proximal to calcaneocuboid joint. We will review talar fractures, calcaneal, midfoot fractures. 1 Calcaneal anatomy. Fractures of the tu-berosity are either from an avulsion or shear-compression mechanism of injury, with the latter constituting most fractures. Fractures of the tuberosity are either from an avulsion or shear-compression mechanism of injury, with the latter constituting most fractures. They are distinct from a lateral condyle fracture which although it has a similar name, it a very different . 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]. 8A Type 1 fracture versus os calcaneus secundarius in two patients. Incidental note of os subfibulare and os trigonum. Calcaneal fractures are relatively uncommon, comprising 1 to 2 percent of all fractures, but important because they can lead to long-term disability. Unable to process the form. Linear dense structure is seen superior to the calcaneal tuberosity. The lateral talar process is one of the check areas on an ankle series for any patient with lateral pain. 35 (7): 1144-52. Greenspan A. B, Oblique view of foot affords another opportunity to identify fracture (arrow). Calcaneal fractures are the most common tarsal fracture and can occur in a variety of settings. Check for errors and try again. 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. Careful scrutiny of the cortex is necessary for making the diagnosis. 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. This case is unusual because it is the calcaneal attachment of the CFL which is avulsed. Anterior calcaneal process fracture. An avulsion fracture is caused by tension on the bifurcate ligament during forceful inversion and plantar flexion of the foot. 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. The standard oblique view requires medially rotating the ankle by 45. The hip, elbow and ankle are the most common locations for avulsion fractures in the young athlete. and Joseph S. Yu. . 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. Fig. The extent is easily underestimated, which is why an additional CT scan is frequently made in a comminuted fracture. 9A 32-year-old female tennis player who inverted her foot and had dorsolateral bruising in foot. King Faisal Specialist Hospital and Research Center. 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. Most injuries are caused by high-energy trauma that result in intraarticular fractures [1]. 1982;64(4):519-24. 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 . Fig. 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. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Asiri Y, Calcaneal tuberosity avulsion fracture. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. There is mild thickening of the achilles tendon shadow and opacification of the Kager's fat pad. Injury. 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 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. Find the code on the page and enter it above. 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. A calcaneal fracture (also termed lover's or Don Juan fracture) usually develops after a fall from height. The fracture also tends to extend posteriorly with a horizontal component immediately distal to the enthesis of the Achilles tendon [14]. However, radiography remains the principal imaging modality for evaluating trauma to the calcaneus, the most frequently fractured tarsal bone. 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. The calcaneus is the largest bone in the foot and serves as the primary weight bearing structure in the heel. Left lateral ankle radiograph shows a calcaneal avulsion fracture with the fragment pulled cephalad by the Achilles tendon. 2015;205(5):1061-7. The Achilles tendon is the strongest tendon in the body and has an average length of 15 cm. We monitored 12. AJR Am J Roentgenol. Keywords: avulsion, calcaneus, foot, fracture, ligament, plantar fascia, tendon. 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. 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. 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. Patients complain of swelling and dorsolateral pain over the sinus tarsi region. 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. 10A 21-year-old male basketball player who inverted his foot and had pain laterally. 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. [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. X-Ankle Pathology Calcaneal fracture When a calcaneal fracture is suspected, both an axial and lateral image should be made. ADVERTISEMENT: Supporters see fewer/no ads. Thickening and increased signal intensity are seen indicating underlying tendinosis. . [1] Symptoms may include pain, bruising, trouble walking, and deformity of the heel. 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. Andermahr et al. Skin incision: lateral approach to elbow. Fig. There is osseous avulsion fracture of the posterior calcaneus associated with thickening and proximal retraction of the Achilles tendon. References Ng J, Rosenberg Z, Bencardino J, Restrepo-Velez Z, Ciavarra G, Adler R. US and MR Imaging of the Extensor Compartment of the Ankle. Pitfalls in Shoulder MRI: Part 1Normal Anatomy and Anatomic Variants, Perspective. 5B Images of medial plantar process. The joint space is preserved. Figure 2 Lateral X-ray of the calcaneus, the avulsion fracture of the calcaneal tuberosity was displaced again, and the internal fixation failed. Radiology may show calcaneal spur formation or calcification at either the insertion of the . There are no specific guidelines for the management of these injuries due to the rarity of its presentation. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The anterior part of the calcaneus is tapered distally. The middle talar facet is an inclined oval surface on the roof of the sustentaculum. Twenty-one patients had diabetes mellitus, and 40 were nondiabetic. If the lateral view is equivocal, an oblique projection of the foot may be diagnostic [24]. Reference article, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-90885. A, Lateral radiograph shows fracture (straight arrow) through enthesophyte emanating from medial plantar process. 2 Classification for calcaneal avulsion fractures. Medially, the calcaneus is concave and relatively smooth. 2. Avulsion fractures of the calcaneal tuberosity are rare injuries that commonly occur in elderly or osteoporotic patients ( 3 ). 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. In these fractures, closed manipulation often fails to achieve adequate reduction, and open reduction and internal fixation is required in most cases ( 2, 3 ). The 2022 edition of ICD-10-CM S92.03 became effective on October 1, 2021. Superiorly, there are three articular facets covered by hyaline cartilage. 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. 10). The calcaneocuboid joint is a large lateral joint in the midfoot. 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