In these patients, the fracture occurs without a history of significant trauma or overuse activity. Avulsion (displaced) Oblique and Transverse (displaced) Comminuted (displaced) Fracture-dislocation (Transolecranon) Presentation Symptoms pain well localized to posterior elbow Physical exam palpable defect indicates displaced fracture or severe comminution inability to extend elbow indicates discontinuity of triceps (extensor) mechanism Imaging Calcaneal avulsion fracture is an important topic. Unable to process the form. In week 2, isometric exercises for the dorsiflexors, plantarflexors, invertors, and evertors of the foot, along with active ankle ROM movements can be started. In the Zone 1 fracture, during the foot inversion, the forces exerted by peroneus brevis or lateral band of the plantar fascia cause avulsion fracture of tuberosity with or without the involvement of the tarsometatarsal articulation. Avulsion fractures of the calcaneal tuberosity are rare, accounting for only 3% of all calcaneal fractures. Talus is attached to constant fragment. That is usually the journal article where the information was first stated. I give my consent to Physiopedia to be in touch with me via email using the information I have provided in this form for the purpose of news, updates and marketing. The characteristics of an avulsion fracture differ from those of a ligament rupture. 6B 45-year-old woman who felt ripping sensation in bottom of her ankle 2 weeks ago. The cuboid makes up the midfoot's contribution to the lateral column of the foot and serves mainly as a lateral column spacer block. Fig. An avulsion fracture is caused by tension on the bifurcate ligament during forceful inversion and plantar flexion of the foot. A, Postsplint radiograph obtained 2 days after injury depicts ossific fragment (arrow) in Achilles tendon approximately 5 cm above enthesis. The Ottawa Ankle Rules can be used to localise the exact area of pain. 4. This classification is based on the number of intraarticular fracture lines and their location on semicoronal CT images. 5A Images of medial plantar process. Occurs in female runners. Physiopedia articles are best used to find the original sources of information (see the references list at the bottom of the article). The primary fracture line is parallel to the apophyseal scar, and the fracture affects the superior cortex but not always the inferior cortex. Initially immobilisation in a CAM walker for four to six weeks with weightbearing as tolerated. Pitfalls and Pearls in MRI of the Knee, Clinical Perspective. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (5): 1496-1497. 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]. Biomechanically, the central cord is the most important component of the plantar fascia. Portion of bifurcate ligament is shown (curved arrow). B, Oblique view of foot affords another opportunity to identify fracture (arrow). At 8-12 weeks: strengthening exercises for the dorsiflexors, plantarflexors, invertors, evertors, long flexors and extensors of the toes are recommended. 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. 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. 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. This ossicle is referred to as os calcaneus secundarius and is differentiated from fracture by lack of donor site in calcaneus. The flexor hallucis longus tendon courses in a groove underneath the sustentaculum tali. Calcaneal stress fractures can cause intense pain and make walking more difficult. Avulsion fracture of the calcaneus is an emergency. A calcaneal spur, or commonly known as a heel spur, occurs when a bony outgrowth forms on the heel bone. These should be repaired in order to preserve meniscal biomechanics and protect from future chondral. Intra articular: (70-75%) Rowe Classification: Types I-III do not involve the subtalar joint. If the bone is not displaced, a walking boot or a walking cast can be used, which will remain in situ for 4 to 6 weeks. 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]. A decrease in this angle indicates the collapse of the posterior facet. Read more, Physiopedia 2022 | Physiopedia is a registered charity in the UK, no. A, Frontal radiograph shows swelling in lateral foot with its epicenter just proximal to base of fifth metatarsal bone (straight arrow). Fig. Lee SM, Huh SW, Chung JW, Kim DW, Kim YJ, Rhee SK. Medially, it articulates with the navicular nad lateral cuneiform. They also occur in patients with osteoporosis, renal osteodystrophy and hyperparathyroidism. Most injuries are caused by high-energy trauma that result in intraarticular fractures [1]. Avulsion fracture of the calcaneus is an emergency. Chopart fracture-dislocations occur at the midtarsal (Chopart) joint in the foot, i.e. runners) Epidemiology 2% of all fractures Most frequently fractured tarsal bone Avulsion fracture of the calcaneus is an emergency. "Bucket handle meniscal tears can be diagnosed on MRI as a double PCL sign on sagittal imaging. OBJECTIVE. Copyright 2022 Lineage Medical, Inc. All rights reserved. Medially, the calcaneus is concave and relatively smooth. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Patients complain of swelling and dorsolateral pain over the sinus tarsi region. They have a higher rate of malunion/non-union 4. 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. 9B 32-year-old female tennis player who inverted her foot and had dorsolateral bruising in foot. [2] [9] [10]. 8). Breederveld, Fractures of the fifth metatarsal; diagnosis and treatment, Injury, Int. [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. 2-Open fractures of the calcaneus--May lead to amputation & there is a high risk of infection.3-Malunion of the calcaneus 4-Peroneal tendon irritation and impingement from the lateral wall. A history of the injury is taken, such as mechanism, immediate pain levels, and swelling. Bruising may develop and the patient will have difficulty walking or weight-bearing on the ankle. When refering to evidence in academic writing, you should always try to reference the primary (original) source. The fibers of the central cord envelop the aponeurosis of the flexor digitorum brevis muscle. For joint depression fracture, wait for swelling to go down before surgery. Original Editors - Niels Verbeeck as part of the Vrije Universiteit Brussel Evidence-Based Practice Project, Top Contributors - Niels Verbeeck, Kim Jackson, Admin, Pierreux Maarten, Shaimaa Eldib, Scott Cornish, Vidya Acharya, Rachael Lowe, Jan Alderweireldt, Claire Knott, Wanda van Niekerk and Lucinda hampton. Reportedly, the percentage of unrecognized fractures in children is three to four times higher [4]. MRI may be necessary to confirm the diagnosis (Fig. The middle talar facet is an inclined oval surface on the roof of the sustentaculum. Key Points: Fractures of the pediatric calcaneus are rare injuries and are frequently missed. 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]. The way it occurs is often similar to that of an ankle sprain, where the foot is flexed in an . Positive squeeze test could mean there is a stress fracture of the calcaneus.Get an MRI if x-ray is negative Will see a fracture in T1 as a linear streak or a band of low signal intensity in the posterior calcaneal tuberosity. From a radiographic perspective, the calcaneus is a relatively difficult bone to visualize in its entirety. Proximal fifth metatarsal fractures: anatomy, classification, treatment and complications. funny responses to hackers ldap null bind. 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. Definition: Fracture of the calcaneus bone Mechanism Traumatic axial loading is the most common cause (eg fall from height) Can also occur in MVCs when the accelerator/brake pedal impacts the foot Stress fractures seen with overuse from repetitive impact (e.g. runners) Epidemiology 2% of all fractures Most frequently fractured tarsal bone The most common etiology is a forceful axial load to the hindfoot, frequently occurring during a fall. Arthritis of the hip, knee, or foot. Knee Pain, Metatarsalgia & Gout Symptom Checker: Possible causes include Osteoarthritis. It's important to see your healthcare provider right away if you have a . Calcaneocuboid joint fractures-60% Bilateral fractures of calcaneus -10% Peroneal tendon subluxation: may be detected on axial CT scan. Radiological image of calcaneus fracture ( lateral view) A calcaneus fracture is a heel bone fracture. B, Foot radiograph shows that fragment of bone (arrow) is located in dorsal and lateral region of anterior calcaneal body. Lateral radiograph shows linear break in medial plantar process (arrow). MRI of Ankle and Lateral Hindfoot Impingement Syndromes. 1173185, Fracture Dislocations of the Tarsometatarsal Joints: End Results Correlated with Pathology and Treatment Level of evidence: 2A, Haraguchi N, Toga H, Shiba N, Kato F, Avulsion fracture of the lateral ankle ligament complex in severe inversion injury: incidence and clinical outcome, Am J Sports Med. B, Axial proton-density MR image shows that avulsion occurred distally at cuboid attachment manifested as gap (arrow) between ligament and cuboid. Sagittal T1-weighted MR image shows small fragment of bone (straight arrow) arising from anterior calcaneus process corresponding to type 1 fracture. When the fracture is imaged sequentially, distraction and fragmentation are common later findings. The commonly fractured bones are the calcaneus, cuboid and navicular.. The Achilles tendon is the strongest tendon in the body and has an average length of 15 cm. B, 30-year-old man who did not have trauma. Do not wait, do emergency surgery. Types 3 and 4 fractures occur in younger people and require more-severe trauma. Surgery is only recommended where the bone is displaced from its normal position or where more than 30% of the cubometatarsal joint is involved. Distally, it articulates with the fourth and fifth metatarsals. Foot Ankle Int. 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]. A Prospective, Randomized, Controlled Multicenter Trial. The anterior process of the calcaneus is a prominence on the heel bone (calcaneus) that is located in front and to the outside of the ankle (Figure 1). Adapted with permission from Lee et al. Occasionally, the middle and anterior subtalar joints form a contiguous articulation instead of two discrete joints. Note saucerlike defect in inferior aspect of calcaneus from bone lysis (curved arrow). In these fractures, closed manipulation often fails to achieve adequate reduction, and open reduction and internal fixation is required in most cases ( 2, 3 ). 7). Fractures of the tuberosity are either from an avulsion or shear-compression mechanism of injury, with the latter constituting most fractures. 1 Calcaneal anatomy. Fractures of the calcaneus could be open or closed. Ankle fractures are very common injuries to the ankle which generally occur due to a twisting mechanism. The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3.. Zone 3 fractures refer to proximal diaphyseal fractures, distal to the fourth and fifth metatarsal base articulation caused by excessive bearing of the region or chronic overloading as in stress fractures[4]. The EDB avulsion fracture may also be mistakenly identified as an os peroneum, but the latter resides more inferiorly and is completely corticated. Fractures of the tu-berosity are either from an avulsion or shear-compression mechanism of injury, with the latter constituting most fractures. Palpation may also be useful. The medial cord is very thin and invests the abductor hallucis muscle. Factors associated with poor outcome are:Age (older than 50 years) Smoking Early surgery History of a fallHeavy manual labor Obesity Males Bilateral injury Workmans compensation Peripheral vascular disease. 10). Calcaneal avulsion fracture is an important topic. 2007 Jul;35(7):1144-52, Duke G. Pao, Theodore E. Keats, Robert G. Dussault, Avulsion Fracture of the Base of the Fifth Metatarsal Not Seen on Conventional Radiography of the Foot: The Need for an Additional Projection, AJR 2000;175:549552, Level of Evidence: 2B Haraguchi N, Toga H, Shiba N, Kato F, Avulsion fracture of the lateral ankle ligament complex in severe inversion injury: incidence and clinical outcome, Am J Sports Med. 3. According to Lawrence and Bottes Classification, three types of proximal fifth metatarsal fractures based on the mechanism of injury, location, treatment options, and prognosis. Calcaneal avulsion fracture is an important topic. The fracture also tends to extend posteriorly with a horizontal component immediately distal to the enthesis of the Achilles tendon [14]. ju. Fig. A lateral radiograph of the ankle offers the most optimal opportunity for identifying the fracture, which characteristically appears vertically through the process (Fig. Most fractures heal well, but following a strict immobilisation period normal arthrokinematics, strength of the lower extremity muscles, proprioception, and functional movement for chosen sport/activities need to be regained. Associated conditionsSpine fractures-10% Compartment syndrome of the foot -10% : if neglected will lead to claw toe due to contracture of the intrinsic flexor muscles. Blood Supply and Neuroanatomic Findings At birth, the entire meniscus is vascular; by age 9 months, the inner one third has become avascular. The primary fracture line divides the calcaneus into two main fragments. Fig. There is heterogeneous signal intensity within tendon and focus of low signal intensity (straight arrow) approximately 5 cm above enthesis. It accounts for 25% to 50% of all broken bones and is most commonly seen in older females and young males. 5. Types 1 and 2 fractures usually are avulsive, whereas most type 3 fractures are compressive. [4] Zone 2 fractures refer to the fractures at the metaphysis-diaphysis junction, extending into the fourth-fifth intermetatarsal facet, caused by forced forefoot adduction with the hindfoot in plantar flexion. It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. 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. Fig. Vrije Universiteit Brussel Evidence-Based Practice Project, http://www.med-info.nl/images/images_trauma/Trauma_voet_MT5_Jones_groot.jpg, http://orthopedics.about.com/od/brokenbones/a/avulsion.htm, http://www.foothealthfacts.org/footankleinfo/fifth-metatarsal_fractures.htm. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Gaillard F, Knipe H, Knipe H, et al. fall from . Pathology. 2012;51 (5): 666-8. 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]. Beavis RC, Rourke K, Court-Brown C. Avulsion fracture of the calcaneal tuberosity: a case report and literature review. Complications1-Wound-related complications are the most common complications (20%). Calcaneal fractures are better if the patient is a female. CONCLUSION. This phase involves ongoing strength and conditioning of the lower limb, increasing neuromuscular control and utilising sport/activity-specific training. The proximal attachment of the bifurcate ligament, an important stabilizer in plantar and dorsal flexion of the ankle, attaches to this process. Surgery decreases the risk of post-traumatic arthritis. wm. When this occurs, the heel can widen, shorten, and become deformed. 2012;20 (4): 253-8. Copyright 2022 Lineage Medical, Inc. All rights reserved. Sanders type II & type III calcaneal fractures will benefit from surgery of reduction and fixation. Avulsion fractures of the calcaneal tuberosity are rare injuries that commonly occur in elderly or osteoporotic patients ( 3 ). Occasionally, the fibular trochlea may present with a separated ossification center appearing similar to a fracture on an ankle radiograph but appearing completely corticated on a frontal foot radiograph [35]. 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]. Avulsion fractures of the calcaneal tuber-osity are uncommon, accounting for 1.3-2.7% of calcaneal fractures [9]. 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. Be aware that the sural nerve is in the vicinity of the surgical area. A Salter 3 fracture of the apophysis in a skeletally immature patient may mimic Sever disease when it is not significantly displaced [15]. 7B 25-year-old man who fell while skiing. 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. A, Lateral radiograph shows fracture (straight arrow) through enthesophyte emanating from medial plantar process. 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. Rehabilitation following an avulsion fracture consists of 3 phases; the acute, the recovery, and the functional phase: It can begin at 2 weeks post-operatively. A calcaneal stress fracture is one or more small breaks in your heel bone (calcaneus). Pathology They tend to occur when normal physiological forces are repeatedly applied to an area of bone. Subchondral insufficiency fracture refers to a type of stress fracture that occurs below the chondral surface on a weight-bearing surface of a bone due to mechanic failure of subchondral cancellous bone. The dorsal spurs are often associated with achilles Tendinopathy, while spurs under the sole are associated with Plantar fasciitis. The extensile approach has delayed wound healing in about 20% of cases. Superiorly, there are three articular facets covered by hyaline cartilage. Kicking. It arises from the medial process of the calcaneal tuberosity and extends distally in a fanlike configuration, dividing into five distinct bands that interconnect with the plantar plates, plantar interdigital ligaments, and the sagittal septa underneath the metatarsophalangeal joints [1618]. Other imaging methods are recommended such as MRI, CT Scan or scintigrams. talonavicular and calcaneocuboid joints which separate the hindfoot from the midfoot.. If you believe that this Physiopedia article is the primary source for the information you are refering to, you can use the button below to access a related citation statement. Fractures in the medial process of the calcaneus may occur as a result of compressive or tensile forces. In general, impaction fractures tend to be larger than avulsion fractures. Level of Evidence: 5, Fracture Dislocations of the Tarsometatarsal Joints: End Results Correlated with Pathology and Treatment. In part, this is likely related to the regional vascular anatomy of the calcaneus [11]. 6A 45-year-old woman who felt ripping sensation in bottom of her ankle 2 weeks ago. More than 90% of calcaneal fractures are extraarticular in children younger than 7 years, and 60% of such fractures are extraarticular in children 814 years old [4]. [1][2] It can occur at numerous sites in the body, but some areas are more sensitive to these types of fractures than others, such as at the ankle which mostly occurs at the lateral aspect of the medial malleolus or in the foot where avulsion fractures are common at the base of the fifth metatarsal, but also at the talus and calcaneus. Reference article, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-1042. An avulsion fracture of the base of the 5th metatarsal is usually treated conservatively. It has two smaller inferior tubercles, the medial and lateral processes. The typical cause of injury is an inversion of the foot, generating tension along with the plantar aponeurosis insertion. 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. Check for errors and try again. Weeks 6-8: active and passive ROM exercises for the ankle and the subtalar joint with Isometric and isotonic exercises. Falling on an outstretched hand. 2 Classification for calcaneal avulsion fractures. In fact, this fracture constitutes the most common avulsion fracture affecting the calcaneus [26]. GTPS can be caused by: Overuse or stress on the hip from exercising or standing for long periods. She recovered and then became an advocate for breast. Calcaneal tuberosity avulsion fracture Last revised by Dr Henry Knipe on 20 May 2020 Edit article Citation, DOI & article data Avulsion fractures of the calcaneal tuberosity are rare, accounting for only 3% of all calcaneal fractures. 4B 43-year-old man who fell off horse and experienced pain and bruising in back of ankle. 11A 28-year-old male hockey player with twisting injury. Zwitser *, R.S. [12][13], Starts at 6 to 8 weeks post-operatively. Level of Evidence: 2B, E.W. Avulsion may occur from sudden tension on the Achil- Having one leg that is longer than the other. 1). Young females less than 40 years of age. 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. Distal to the posterior subtalar joint is a depression called the calcaneal sulcus that extends medially to terminate at the sustentaculum tali. 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. Calcaneal tuberosity avulsion fracture. Keywords: avulsion, calcaneus, foot, fracture, ligament, plantar fascia, tendon. Copyright 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. Taking the example of avulsion fractures at the 5th metatarsal; It is divided into 3 parts: the tuberosity, the metaphysis, and the head. 5). Fig. The Role of Imaging in Diagnosing Diseases of the Distal Radioulnar Joint, Triangular Fibrocartilage Complex, and Distal Ulna, MR Imaging of Disorders of the Achilles Tendon, Review. 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]. It indicates, "Click to perform a search". Conclusions: Calcaneal avulsion fractures have a high incidence of soft tissue problems, failure of fixation, and need for additional surgeries. B, Axial CT image shows that avulsion fracture (oval) corresponds to proximal attachment of dorsal calcaneocuboid ligament. Swelling Tenderness with medial and lateral compression of the hindfoot. If the lateral view is equivocal, an oblique projection of the foot may be diagnostic [24]. Type II or beak fractures are . 4A 43-year-old man who fell off horse and experienced pain and bruising in back of ankle. Fig. Fig. An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment. Exercises for proprioception and proximal strength and control. This type of fracture commonly occurs during a high-energy event such as a car crash or a fall from a ladder when the heel is crushed under the weight of the body. The video will appear on the video dashboard once complete. 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. The peak incidence occurs in younger males [ 2 ]. If an avulsion fracture is present, there will be immediate pain over the outside aspect of the foot and associated with significant swelling and localised tenderness over the 5th metatarsal. Careful scrutiny of the cortex is necessary for making the diagnosis. For joint depression fracture, wait for swelling to go down before surgery. Treatment of an Anterior Process of the Calcaneum fracture. The calcaneocuboid joint is a large lateral joint in the midfoot. Calcaneal spurs can be located at the back of the heel (dorsal heel spur) or under the sole (plantar heel spur). The primary fracture line is caused by an axial load injury. The calcaneus is the largest bone in the foot and serves as the primary weight bearing structure in the heel. It indicates, "Click to perform a search". This decrease in vascularity contin-ues to. 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. Definition: Fracture of the calcaneus bone Mechanism Traumatic axial loading is the most common cause (eg fall from height) Can also occur in MVCs when the accelerator/brake pedal impacts the foot Stress fractures seen with overuse from repetitive impact (e.g. 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. Playing sports comes with risks. The plantar fascia is a dense connective tissue band that resides in the inferior aspect of the foot and is composed of three cords: medial, central, and lateral cords. 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. A small, non-displaced fracture is best treated non-operatively. Because the talus is important for ankle movement, a fracture often results in substantial loss of motion and function. For joint depression fracture, wait for swelling to go down before surgery. According to Lee et al, this injury can be classified into four types (modification of the original classification system proposed by Beavis et al)4,5: Typically, treatment is with open reduction - internal fixation(ORIF), although minimally displaced fractures may be treated with closed reduction. It's because contact sports involve movements that stress your limbs, such as: Suddenly changing direction. A, 22-year-old man who sustained fracture during football game. Definition / Description. These injuries require immediate intervention usually. An inappropriately managed avulsion fractures can lead to significant, long-term functional disability. An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment. History of the injury will be similar to that of an ankle sprain (plantarflexor inversion). Become a friend on facebook:http://www.facebook.com/drebraheimFollow me on twitter:https://twitter.com/#!/DrEbraheim_UTMC, 2023 Bobby Menges Memorial HSS Limb Reconstruction Course. 2): type 1, simple avulsion with a variable-sized bone fragment (Fig. Do not wait, do emergency surgery. 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]. Calcaneus Fractures - Trauma - Orthobullets orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports Andermahr et al. Symptoms of an ankle avulsion fracture are very similar to an ankle sprain and it is very difficult to differentiate without an X-ray or an MRI scan. Type VI Highly comminuted May require primary subtalar arthrodesis. Calcaneus fractures in children younger than 10 years of age, are usually extra-articular. However, radiography remains the principal imaging modality for evaluating trauma to the calcaneus, the most frequently fractured tarsal bone. 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. The calcaneus is a relatively long tarsal bone that has the shape of a pistol grip (Fig. 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]. Injuries were the Achilles tendon pulls off a piece of bone (avulsion fracture) can lead to soft tissue injury and are an orthopaedic emergency as skin death (necrosis) can occur rapidly. 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. CONCLUSION. It is important to see your doctor as soon as the accident takes place to prevent more damage.. The function of this muscle is to extend the first through fourth toes and the respective metatarsophalangeal joints. The width of the tendon at its insertion varies from 1.2 to 2.5 cm [5]. Level of Evidence: 4. Type III usually gets more arthritis because it has more fracture fragments and may end by fusion. There are four types of avulsion fractures (Fig. Lateral radiograph shows superiorly displaced bone fragment (curved arrow) and donor site defect in superior aspect of calcaneal tuberosity (straight arrow). Maneuvers that adduct the forefoot exacerbate pain. Calcaneal avulsion fractures need urgent reduction and internal fixation to prevent skin complications. 4 (2): 134-8. fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. 10A 21-year-old male basketball player who inverted his foot and had pain laterally. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Proximal aspect of ligament can be visualized to its calcaneal attachment. The smaller oval-shaped anterior facet lies on the superomedial surface of the anterior calcaneus. Two dedicated musculoskeletal radiologists . A magnifying glass. The bone will be removed or fixed with osteosynthesis material. There is a strong association with diabetes, where they may occur spontaneously and are thought to be due to peripheral neuropathy. Fractures of the anterior process of the calcaneus occur following an acute injury to the foot. There is small linear bone fragment located lateral to calcaneocuboid joint (curved arrow). Treatment should be based on the size of the fragment and extent of injury to the calcaneocuboid joint. May be seen as an avulsion fracture of the fibula on x-rays. 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. A, Close-up of oblique view of foot shows linear piece of bone (arrow) just proximal to calcaneocuboid joint. Diagram depicts key anatomic components of calcaneus in lateral, superior, and medial projections. 2023 Bobby Menges Memorial HSS Limb Reconstruction Course. Avulsion fracture of the calcaneal tuberosity: classification and its characteristics. Due to the high traction forces by these structures, tuberosity avulsion fractures commonly occur in an inversion injury (between the red and purple areas), figure1: source:http://www.med-info.nl/images/images_trauma/Trauma_voet_MT5_Jones_groot.jpg, 5 to 6% of all fractures in primary settings, a yearly incidence of approximately 67 in 100,000 accounts for fifth metatarsal fracture[3]. 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. 7A 25-year-old man who fell while skiing. Man with calcaneal fracture:Workmans compensation Heavy labor 0-degree Bohler angle: measured on lateral x-ray (Harris view and axial view)Probably will need subtalar fusion.Bohler angle is formed by a line drawn from the highest point of the anterior process of the calcaneus to the highest point of the posterior facet and a line drawn tangential to the superior edge of the tuberosity. Type I-- Nondisplaced/Non-operative treatmentType II--Two-part fracture of the posterior facet. Patient has a simple fracture pattern. 1. The primary fracture line goes from anterolateral to posteromedial. This phase can be further divided into 3 stages:Weeks 0-6: active ROM exercises for the toes and the MPT joints, strengthening exercises for the ankle and foot are still premature, however. Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis, Review. Being overweight. 9A 32-year-old female tennis player who inverted her foot and had dorsolateral bruising in foot. Another pitfall occurs in children. A, Lateral radiograph shows linear lucency (arrow) through anterior calcaneus process corresponding to type 2 fracture. The cuboid acts as a static supporting structure within the lateral column of the foot. The severity an ankle avulsion fracture can result in anything from a minor issue to something that requires surgery. The majority are displaced intraarticular fractures (60 to 75 percent) [ 2 ]. Calcaneal Tuber Fracture The Achilles tendon attaches to the back portion of the calcaneus. Because these fractures may be extremely difficult to detect, either CT or MRI is required to confirm the diagnosis in many cases, particularly when pain becomes chronic [23, 27, 28]. FHL = flexor hallucis longus. CeCT and 18 F-FDG PET were performed within 28 d before treatment initiation, and BS was within 50 d, according to the protocol. Proximally, the cuboid has a saddle shaped articulation with the calcaneus. J Foot Ankle Surg. Extraarticular fractures are categorized as either compressive or avulsive types. Epidemiology. Fig. B, Sagittal T1-weighted MR image obtained 6 weeks after injury shows thickened Achilles tendon. Pain is usually felt in the ankle immediately post-injury with an immediate onset of swelling. The medial, intermediate, and lateral cuneiform bones (sometimes referred to as the first, second, and third cuneiforms, respectively) serve as stabilizing structures within the medial column of the foot. Comorbid conditions and increased age portend a poor prognosis with a significant association with wound complications and need for additional surgeries. Peroneus Brevis attaches at the lateral side of the tuberosity (red area in figure 1), with peroneus tertius attaching at the dorsal side of the most proximal compartment of the metaphysis. Most calcaneal fractures are occupational, and are caused by axial loading from a fall [ 2 ]. Dr. Ebraheims educational animated video describes fracture of the calcaneus - heel bone. Open reduction and internal fixation of the calcaneus is generally delayed for 1-2 weeks to allow for improvement of the soft tissue swelling, except with fractures of the posterior tuberosity (avulsion fracture) which can cause skin tenting and urgent reduction is recommended. It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. Your video is converting and might take a while Feel free to come back later to check on it. J. While cuboid and cuneiform fractures are uncommon . [9]). It is the initial striking surface of the foot during ambulation. Avulsion fractures of the calcaneus are often difficult to diagnose, but they occur in very specific locations, with characteristic radiographic appearances. Painful problems of the foot, such as a bunion, callas, plantar fasciitis, or Achilles. Traditionally, a burst fracture of the calcaneus was known as "Lovers Fracture" as the injury would occur as a suitor would jump off a lover's . 2. mostly avulsion type fractures: anterior process, sustentaculum tali, calcaneal tuberosity. Fig. The morphologic features of this bone are complex, and its many different surface contours function either as attachments to tendons, muscles, and ligaments or as sites of articulations. Hip injury, such as from a fall. Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8:. This phase can include passive range of motion exercises and cryotherapy and is based on the reduction of pain, inflammation, and oedema, while keeping muscle atrophy of the lower limb to a minimum. 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. Occurs more in smokers, diabetics and in patients with open fractures. 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. Bone lysis at the enthesis may be the only finding in many cases (Fig. [14], Get Top Tips Tuesday and The Latest Physiopedia updates, The content on or accessible through Physiopedia is for informational purposes only. Management of calcaneal tuberosity fractures. The flexor hallucis longus tendon lies underneath the sustentaculum and if screw placement to the sustentacular fragment is too long, this could affect the flexor hallucis longus tendon, causing fixed flexion of the big toe. Tongue-type fracture may benefit from closed reduction and percutaneous fixation or open reduction and internal fixation. Intra-articular fractures of the calcaneus. 2008;29 (8): 863-6. 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. The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma. Complication rate is high. A compression test or squeeze test. Fig. 8A Type 1 fracture versus os calcaneus secundarius in two patients. Fig. A twisting injury to the ankle and foot may cause an avulsion fracture at any of these locations. 9). Pathology There are three mechanisms of action 4: fall during plantarflexion ankle hyperextension Stress fracture of the calcaneus may be misdiagnosed as plantar fasciitis. Type I (20%) the fracture line may be through the tuberosity, the sustentaculum tali, or the anterior process of the calcaneus. 6). Most avulsion fractures occur at the attachments of the dorsal calcaneocuboid ligament (Fig. Fig. rp. [5][6][7], An X-ray may be ordered by the surgeon. 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]. 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]. Joint depression type usually needs open reduction.Some surgeons advocate conservative treatment of the calcaneus.Subtalar distraction arthrodesis plus insertion of a bony block and rigid internal fixationThe lateral calcaneal artery provides blood supply to the lateral flap associated with the calcaneal extensile approach. An ankle avulsion fracture is a bone chip caused by a ligament or tendon that tears away a part of the bone. [11], Avulsion fractures are often treated as ankle sprains, with the dysfunctional movement and impairments treated alongside the fracture, so it is important to individualise the treatment plan. Begins once the goals of the acute phase have been met. This type of fracture often occurs during a high-energy event, such as a car collision or a fall from a significant height. B, 27-year-old male baseball player with acute heel pain after pushing off base while accelerating. Calcaneal avulsion fractures need urgent reduction and internal fixation to prevent skin complications. These fractures often occur because of repetitive, long-term stress on the bone, such as from jogging. Care Injured 41 (2010) 555562, Essentials of Orthopaedics for Physiotherapist, Ebnezar. Crutches may be used to avoid weight bearing on the injured foot. Talk to our Chatbot to narrow down your search. The foot is usually dislocated medially and superiorly as it is plantarflexed and inverted, usually as a result of a high-energy impact, e.g. Contact sports like lacrosse, boxing and football, for example, are the most common causes of avulsion fractures. Pitfalls in Shoulder MRI: Part 1Normal Anatomy and Anatomic Variants, Perspective. cy Conditions in the fascia that produce pain in the heel can be attributed to either plantar fasciitis or fascial rupture. Avulsion fractures of the calcaneal tuberosity are uncommon, accounting for 1.32.7% of calcaneal fractures [9]. 10B 21-year-old male basketball player who inverted his foot and had pain laterally. Check the full list of possible causes and conditions now! Do not wait, do emergency surgery. A magnifying glass. The anterior part of the calcaneus is tapered distally. Anteriorly, the calcaneus is entirely covered with cartilage forming the surface that articulates with the cuboid. This occurs as tendons can bear more load than the bone. rethinking narcissism test x ben abbott net worth x ben abbott net worth Treatment can be nonoperative or operative depending on fracture displacement, ankle stability, presence of syndesmotic injury, and patient activity demands. It forms the anterior facet superiorly and the calcaneocuboid joint anteriorly. Plantar fasciitis is the most common cause of heel pain, a degenerative process that results in fibrofatty degeneration, microtears, and collagen necrosis in the fascial enthesis. Laterally, the calcaneus has two protuberances. The structural integrity of these ligaments as well as the plantar fascia is necessary for proper function of the calcaneocuboid joint [39]. Fractures of the calcaneus: open reduction and internal fixation from the medial side a 21-year prospective study. Leaping. (2012) Clinics in orthopedic surgery. 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]. A broken wrist or distal radius fracture is an extremely common type of fracture . 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]. However, 25% of fractures in adults are extraarticular, and the incidence is even higher in children [2, 3]. (Drawings by Yu JS). The Sanders classification system is used to assess intraarticular calcaneal fractures, which are those involving the posterior facet of the calcaneus. Clinically, lateral foot pain over the calcaneocuboid joint and focal soft-tissue swelling occurring proximal to the fifth metatarsal are characteristic clinical findings. 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]. Type III--Three-part fracture of the posterior facet. Type 1 fractures are likely insufficiency fractures, occurring in elderly patients with osteoporosis after minor trauma such as tripping. Calcaneal avulsion fractures need urgent reduction and internal fixation to prevent skin complications. Bone spurs on the hip. 2007 Jul;35(7):1144-52. Older children are more likely to have intra-articular . An important pitfall is a neuropathic avulsion fracture of the tuberosity in a patient with long-term diabetes mellitus [13]. Oblique view of foot shows incidental ossicle (arrow) located between calcaneus, talus, navicular, and cuboid that mimics type 1 anterior process fracture. http://www.epainassist.com/sports-injuries/ankle-injuries/ankle-avulsion-fracture-symptoms-causes-treatment, http://www.podiatrytoday.com/article/6565, https://www.physio-pedia.com/index.php?title=Avulsion_Fractures_of_the_Ankle&oldid=260943. J Am Acad Orthop Surg. (Drawings by Yu JS. Operative Compared with Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures. Fig. Narayanasamy S, Krishna S, Sathiadoss P, Althobaity W, Koujok K, Sheikh AM. Assessment of Bone Lesions. 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. The posterior talar facet has a triangular shape and a convex contour and is the largest of the three facets. A Narrative Review on Avulsion Fractures of the Upper and Lower Limbs. 4); and type 4, small beak fracture avulsed from the deep fibers of the tendon [9, 10]. 5B Images of medial plantar process. 11). T2 will find an increased signal. An important calcaneal fracture is an avulsion of the origin of the extensor digitorum brevis (EDB) muscle [24, 32]. Men do worse with calcaneal fractures than women. The EDB muscle is broad and thin. 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. This occurs as tendons can bear more load than the bone. Full weight-bearing exercises are also permitted. Of the two types, avulsion fractures generally are more difficult to identify but are quite specific in their locations. xi. Fig. 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]. Fractures Of The Calcaneus - Everything Fractures Of The Calcaneus - Everything You Need To Know - Dr. Nabil Ebraheim. A talus fracture is a break in one of the bones that forms the ankle. Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I, Leg Compartment Release - Single Incision Approach, Leg Compartment Release - Two Incision Approach, Arm Compartment Release - Lateral Approach, Arm Compartment Release - Anteromedial Approach, Shoulder Hemiarthroplasty for Proximal Humerus Fracture, Humerus Shaft ORIF with Posterior Approach, Humerus Shaft Fracture ORIF with Anterolateral Approach, Olecranon Fracture ORIF with Tension Band, Olecranon Fracture ORIF with Plate Fixation, Radial Head Fracture (Mason Type 2) ORIF T-Plate and Kocher Approach, Coronoid Fx - Open Reduction Internal Fixation with Screws, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Fracture Spanning External Fixator, Distal Radius Fracture Non-Spanning External Fixator, Femoral Neck Fracture Closed Reduction and Percutaneous Pinning, Femoral Neck FX ORIF with Cannulated Screws, Femoral Neck Fracture ORIF with Dynamic Hip Screw, Femoral Neck Fracture Cemented Bipolar Hemiarthroplasty, Intertrochanteric Fracture ORIF with Cephalomedullary Nail, Femoral Shaft Fracture Antegrade Intramedullary Nailing, Femoral Shaft Fracture Retrograde Intramedullary Nailing, Subtrochanteric Femoral Osteotomy with Biplanar Correction, Distal Femur Fracture ORIF with Single Lateral Plate, Patella Fracture ORIF with Tension Band and K Wires, Tibial Plateau Fracture External Fixation, Bicondylar Tibial Plateau ORIF with Lateral Locking Plate, Tibial Plafond Fracture External Fixation, Tibial Plafond Fracture ORIF with Anterolateral Approach and Plate Fixation, Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleol, Ankle Isolated Lateral Malleolus Fracture ORIF with Lag Screw, Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws, RETIRE Transtibial Below the Knee Amputation (BKA), C-arm from contralateral end of bed at ~20 to get Harris heel view with foot dorsiflexed, lateral decubitus on beanbag with feet at end of bed, operative foot elevated under stack of blankets to make flat working surface, lateral approach to calcaneus with extensile L-shaped incision, vertical limb between lateral malleolus and Achilles, 90 turn with horizontal limb 3cm above plantar surface of foot, clean out fracture lines and remove lateral wall, identify constant anteromedial fragment and build off of it with kwires, large Schantz pin into posteroinferior calcaenus for traction, lag screws 3.5mm to join lateral to medial fragments, check plate size, fill central void with allograft, and replace lateral wall, 2 wks non-weight bearing in postmold splint, 10-12 wks non-weight bearing in CAM boot, range of motion exercises and progression of weight bearing, identify fracture pattern based on xrays (AP/Lat/Oblique and Harris/Broden views) and CT scan, analyze direction and number of fracture lines (Sanders classification), evaluate joint depression, articular comminution, Bohlers angle, and angle of Gissane, if severe articular comminution may need to concurrently fuse subtalar joint, if tongue-type with mild displacement and shortening can perform closed reduction with percutaneous pinning, goal is to restore calcaneus height, width, alignment, and articular surface, need to check wounds for evidence of open fracture, assess lumbar spine xrays (10% association with L-spine fractures), document soft tissue status, associated injuries, distal neurovascular status, check for signs of compartment syndrome, identify comorbidities (diabetes) and social factors (smoking) that correlate with complications and poor outcomes, standard OR table with radiolucent end, c-arm in from contralateral side end of bed at ~20 to get Harris heel view, Calcaneus Plating System (Stryker Veriax Calcaneus System), patient lateral decubitus on beanbag with feet at end of bed, place sheets between ipsilateral and contralateral extremities to make elevated flat working surface ~1 in height, make sure body and legs are taped down (need flat surface to work on), can alternatively place patient supine with table tilted away from surgeon, thigh tourniquet placed high on thigh with webril underneath, mark out lateral malleolus and lateral border of Achilles, vertical limb of incision between lateral malleolus and Achilles 2-4cm proximal to lateral malleolus, then 90 turn with horizontal limb 3cm above plantar surface of foot, exsanguinate limb and inflate tourniquet, 15 blade through skin then tenotomy scissors to spread subcutaneous tissue in vertical direction with minimal soft tissue stripping, knife down to bone on calcaneus for full-thickness flaps, not at distal or proximal 2-3cm of incision due to peroneals and posterior tibial tendon, elevate periosteum sharply off calcaneus following contour of bone, need to follow bone closely anteriorly to not get into peroneals distally, be careful to avoid sural nerve and short saphenous vein posterior to lateral malleolus, inverting the foot will help expose the subtalar articular surface, no touch technique avoiding skin using three .062 kwires into ant/med/post aspect of talus, bend kwires with driver into two 90 angles as fixed internal retractors for subcutaneous and skin retraction, delineate fracture lines with knife and clean out using freer, curettes, and rongeur, identify lateral wall that is often broken off, remove piece, clean and mark orientation for later use, and place in saline on back table, next find constant anteromedial fragment and build off of it, checking to see how remaining fragments fit together, break apart fragments with curved osteotome and lever to regain calcaneus height, there is a central void of comminution due to bone loss, remove fragments if needed and temporarily pin into place with multiple kwires, need to restore ant/med/post facet of subtalar joint, check with fluoro Bohlers angle and angle of Gissane, kwires through bottom of calcaneus to pin constant fragment to remaining fragments, drill large Shantz pin into posteroinferior aspect of calcaneus perpendicular to bone to gain traction through fragment, bolt cutter to remove sharp end, T-handle to apply traction through pin and distract fragments, build periphery of calcanues and later fill in central void with allograft chips, tamp in gently, check AP/Lat/Harris fluoro to check calcaneus reduction in terms of height, width, alignment, and articular surface, use blue handle of lap around forefoot to pull foot into dorsiflexion for heel view, place 3.5mm lag screw to join largest pieces lateral to medial (2.7mm drill, 3.5mm screws), be careful of iatrogenic injury to FHL from long screws, check calcaneus plate sizing on Lat fluoro, fill in central void with bone chips allograft, then place lat wall fragment back into place, place bicortical nonlocking screws first in anterior and posterior aspects of plate to compress plate down to bone, place locking screws around periphery of plate, if performing simultaneous fusion of subtalar joint, place threaded guidepins for 8.0mm cannulated screws x2 through posterior facet of subtalar joint, check on fluoro Lat for placement into talar body, measure, drill calcaneus cortex, just into talar body, then place screw on power followed by hand, can use fully threaded (if significant comminution of subtalar joint) or partially threaded screws (for compression), check with fluoro on AP/Lat/Harris views, exchange screws that are too long medially to avoid tendon irritation (FHL) and damage, irrigate wounds thoroughly and deflate tourniquet, cauterize any bleeders carefully, watching out for saphenous vein, hemovac drain deep exiting superolateral from incision, subcutaneous closure with 2-0 vicryl, skin closure with 3-0 nylon horizontal mattress or Allgower-Donati stitch to reduce skin tension (diabetics, smokers), incision dressing (gauze, webril) followed by postmold splint with extra padding under heel for immobilization, remove splint and place in short-leg cast boot non-weight bearing, remove cast and place in CAM boot non-weight bearing, begin range of motion exercises to ankle and foot, advance weight-bearing status in CAM boot, wound breakdown (10-25%, worse in diabetics, smokers, open fractures), iatrogenic injury to peroneal tendons, sural nerve, saphenous vein, lateral impingement with peroneal irritation, iatrogenic injury to FHL from lateral to medial screws. 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