Clinical case. Connect with peers, learn from experts. (2020). FIGURE 3. Methods: It is useful in separating the joint fractures into two types. Rockwood and Green's fractures in adults. If this angle remains above 15 degrees, nonoperative care can be suggested. The fixation device was mounted to the bottom of the testing machine, and the synthetic band simulating the Achilles tendon was affixed to a clamp connected to the load cell. Yeungnam Univ J Med. No use, distribution or reproduction is permitted which does not comply with these terms. [Fractures of the calcaneus--new trends in management]. Careers. Fractures of the calcaneum, with an atlas illustrating the various types of fracture. (A) In type III fracture, only the superficial fibers are involved with the avulsed fracture fragment (. Received: 15 March 2022; Accepted: 17 June 2022;Published: 04 August 2022. NCI CPTC Antibody Characterization Program. We believe this technique would prove useful in surgical management of calcaneal tuberosity avulsion fractures. Acta Chir Orthop Traumatol Cech. doi:10.5435/JAAOS-20-04-253, Beavis, R. C., Rourke, K., and Court-Brown, C. (2008). Foot Ankle Surg. Surg. The most important feature of this fracture is its association with significant soft-tissue injury and potential soft-tissue complications. eCollection 2018. eCollection 2021. Methods: Thirty None of the plates was able to tolerate loads above 100N. In terms of overall stability, the best results were observed with 6.5-mm cannulated partially threaded screws, followed by 5.0 headless cannulated compression screws and 4.0-mm cannulated partially threaded screws, respectively. 2002;69(4):209-18. Main indications. The site is secure. 1979;134:214-6. Fractures of the Calcaneum. Orthopedic Surgery, 01 Dec 1969, 20(15): 1577-1578 Language: jpn Surgical management of calcaneus fractures: indications and techniques. The involved fibers of the Achilles tendon according to the fracture type. (E) 2.8-mm plate fixation. (C) 5.0 headless cannulated compression screw. Court-Brown CM, Caesar BC. Different fixation techniques are required in order to reduce and stabilize this deformity. Conclusions: Unable to load your collection due to an error, Unable to load your delegates due to an error. Means for cyclic testing at 200N were 0.30 0.26mm in Group A, 1.99 1.66mm in Group B, and 0.38 0.15mm in Group C. Significant differences could be seen between groups A and B with p = 0.001 and between groups B and C with p = 0.016. Finally, clinical cases about the surgical application and recovery are included. Br. Injury. Increased age was significantly associated with wound complications (P = .029). They result from an axial load and may demonstrate varying severity, type and location of fracture type.The type of fracture is determined by position of the foot, direction and magnitude of the force and the quality of the bone. -, Beavis RC, Rourke K, Court-Brown C. Avulsion fracture of the calcaneal tuberosity: a case report and literature review. Foot Ankle Surg. official website and that any information you provide is encrypted Visual data: Means at the load level of 100N were 0.09 0.12mm in Group A, 0.26 0.25mm in Group B, and 0.22 0.13mm in Group C. At this level, there was no statistical difference. Clipboard, Search History, and several other advanced features are temporarily unavailable. Connect with peers, learn from experts. doi:10.1177/1938640014548323, Hoelscher-Doht, S., Jordan, M. C., Bonhoff, C., Frey, S., Blunk, T., and Meffert, R. H. (2014). Combined Lag Screw and Cerclage Wire Fixation for Calcaneal Tuberosity Avulsion Fractures. What remains unclear, however, is which type of screw is least likely to result in complications such as screw pull-out or screw cut-out (Banerjee et al., 2012; Lee et al., 2012; Carnero-Martn de Soto et al., 2019). We propose a modified classification scheme that presents the four types of calcaneal avulsion fracture as described by surgical and magnetic resonance imaging (MRI) The fracture healed well following the first revision using a restrictive postoperative motion protocol (Figure 9). Type III fractures are infrabursal avulsions from the middle third of the posterior tuberosity. This measured load-to-failure and failure mode. The calcaneal beak fracture is a rare avulsion fracture of the tuber calcanei characterized by a solid bony fragment at the Achilles tendon insertion. Results: More markers were attached to the fixation device as reference points (Figure 1). Diagnosis is made radiographically with foot radiographs with CT scan often being required for surgical planning. RM is president of the International Bone and Research Association. Few injuries are more devastating or have more long-term impact on a patients life. Different traction force levels were applied through an Achilles tendon surrogate in a material-testing machine on all stabilized synthetic bones. This became most obvious under high loads. Secondary complications such as soft tissue complications and loss of fixation were noted. Calcaneoplasty coupled with an insertional Achilles tendon reattachment procedure for the prevention of secondary calcaneal impingement: a retrospective study. One specimen failed by fracture at the level of the caudal screw. Type I (20%) the fracture line may be through the tuberosity, the sustentaculum tali, or the anterior process of the calcaneus. The Treatment of Avulsion Fracture of the Calcaneal Tuberosity: A New Technique of 180-Degree Annular Internal Fixation. This site needs JavaScript to work properly. Clin Interv Aging. Cement-augmented Screw Fixation for Calcaneal Fracture Treatment: a Biomechanical Study Comparing Two Injectable Bone Substitutes. 58, 423426. Accessibility Management of Calcaneal Tuberosity Fractures. Richard Buckley, Andrew Sands. FIGURE 1. The most important feature of this fracture is its association with significant soft-tissue injury and potential soft-tissue complications. Our data confirm the biomechanical stability of 4.0- and 6.5-mm cannulated partially threaded screws with round washers. The fracture was reduced and fixed with two 1.25mm k-wires. Type V fractures are comminuted fractures with a centrally depressed fragment. AO Davos Courses 2022. (D) 2.3-mm plate fixation. If used, a combination of screws, suture anchors, or other fixation techniques and a very restrictive postoperative rehabilitation protocol is recommended. The advantage of the percutaneous operative technique is the very low risk of soft tissue trauma compared to open techniques. MeSH In addition, in cases where the fragment does not adapt well, conversion to open exposure and fixation may become necessary. Type I were usually caused due to an accidental trip causing a fall by the patient. We examined the features of each avulsed type according to several criteria including patient age, gender, anatomical variances of the Achilles tendon, the fibers involved and the mechanism of injury. Am. doi:10.3113/FAI.2008.0000, Blum, L. E., Hundal, R., Walton, D., and Hake, M. E. (2019). [Analysis and prevention of skin necrosis after operation of calcaneus fracture]. [Combined method of treating dislocated fractures of the calcaneus]. Jordan MC, Hufnagel L, McDonogh M, Paul MM, Schmalzl J, Kupczyk E, Jansen H, Heilig P, Meffert RH, Hoelscher-Doht S. Front Bioeng Biotechnol. FIGURE 2. Group B was stabilized with two cannulated 4.0mm partially threaded screws and washers (length 44mm, REF 407.644, DePuy Synthes). Biotechnol., 04 August 2022, View all J. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). See this image and copyright information in PMC. 5, 196202. Parameters measured were peak-to-peak displacement for 100, 200, and 300N in mm, stiffness (N/mm) and plastic deformation (mm), total displacement (mm), load-to-failure (N), and mode of failure (anterior fracture, caudal screw cut-out and cranial screw pull-out, caudal screw cut-out, caudal and cranial screw pull-out, pull-out of the fracture-fragment from the caudal screw, pull-out of the fracture fragment from both screws, fracture of the fracture-fragment at the caudal screw, fracture of the fracture fragment at the site of the cranial screws, and plastic deformation of the plate). 772,395) attached to the fragment (EPO-X-Y, Roxolid, Germany and staples). To our knowledge, no biomechanical study has been conducted regarding the use of 2.3- or. Three specimens in Group D and one in Group E lasted the 1,000 cycles at 100N. This rendered a sufficient statistical analysis of these groups impossible. Disclaimer, National Library of Medicine HJ: clinical case assembling and manuscript revision. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. A beak fracture was simulated in synthetic bones and assigned to five different groups of fixation: A) The screw fixation methods presented here allow percutaneous fixation with minimal soft tissue irritation. Pan Afr Med J. Gardner MJ, Nork SE, Barei DP, Kramer PA, Sangeorzan BJ, Benirschke SK. Clin. Description of Extreme tongue-type (beak) fracture of the calcaneus body. doi:10.1016/j.jos.2015.06.011, Warrick, C. K., and Bremner, A. E. (1953). 2021 May 28;8:620964. doi: 10.3389/fsurg.2021.620964. Percutaneous Fixation of Calcaneal Tuberosity Avulsion Fracture. Achilles tendon; Avulsion fracture; Calcaneal tuberosity. Innovative Fixation Technique for Avulsion Fractures of the Calcaneal Tuberosity. Load vectors may also be different under real-life conditions. Based on the results of this biomechanical study, we implemented headless cannulated compression screws in a clinical case of a calcaneal avulsion fracture with critical soft tissue findings. (B) Cracks and bursts of the fracture can occur when the screw size is not appropriate. Type III (4/20 cases) and IV (3/20 cases) fractures were likely to occur due to falling. 2021 Oct;38(4):289-307. doi: 10.12701/yujm.2021.01102. Type I is a sleeve fracture in which the shell of the cortical bone is avulsed from the posterior tuberosity. Type II fracture is the classical beak fracture, and type III fracture is the infrabursal avulsion fracture from the middle third of the posterior tuberosity. Patient-Reported Outcome Following Operative and Conservative Treatment of Calcaneal Fractures: A Retrospective Analysis of 79 Patients at Short- to Midterm Follow-Up. Means at 200N were 206N/mm 48N/mm in Group A, 121N/mm 26N/mm in Group B, and 151N/mm 29N/mm in Group C. There was a significant difference between groups A and B with p = 0.002. Classification of avulsion fracture of the calcaneal tuberosity. The next load level was 10200N for 1,000 cycles, and the third load level was 10300N for 1,000 load repeats: a static ultimate strength test was performed after cyclic testing. Foot Ankle Surg. 2022 Aug 4;10:896790. doi: 10.3389/fbioe.2022.896790. muscle strength) -Widening of calcaneal shaft through displacement of its LATERAL margin (impinges peroneal) -VARUS deformation of calcaneal tuberosity. MJ: study design, establishing the test set-up, conducting biomechanical tests, funding, and manuscript development. 8600 Rockville Pike In these and in revision cases, plate fixation may be an option. In contrast, the stability of plate fixation was disappointing. PMC 60-75% of injuries are intra-articular fractures, no significant increase in infection rates, peak incidence in women in seventh decade of life, violent contaction of the triceps surae with forced dorsiflexion, strong concentric contaction of the triceps surae with knee in full extension, intrinsic tightness of the gastrocnemius and achilles tendon, peripheral neuropathy leading to decreased pain sensation and proprioception resulting in recurrent microtrauma, increased physical activity in the setting of relative energy deficiency, primary fracture line results from oblique shear and leads to the following, includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments, dictate whether there is joint depression or tongue-type fracture, strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus, more common in osteopenic/osteoporotic bone, inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament, superolateral fragment contains the articular facets, superior articular surface contains three facets that articulate with the talus, the flexor hallucis longus tendon is medial to the posterior facet and inferior to the medial facet and can be injured with errant drills/screws that are too long, between the middle and posterior facets lies the, projects medially and supports the neck of talus, connects the dorsal aspect of the anterior process to the cuboid and navicular, calcaneal tuberosity (Achilles tendon avulsion), the primary fracture line runs obliquely through the posterior facet forming two fragments, the secondary fracture line runs in one of two planes, the axial plane beneath the facet exiting posteriorly in, when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly, behind the posterior facet in joint depression fractures, based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet, One fracture line in the posterior facet (, Two fracture lines in the posterior facet (, based on fracture morphology of the calcaneus tuberosity, tenting, ecchymosis, or lack of skin blanching with tuberosity fractures, neccessitates urgent sugical reduction and fixation to avoid posterior heel skin necrosis, must be debrided and epithelialized prior to surgical intervention, lack of heel cord continuity in avulsion fractures, lack of posterior heel skin blanching with tenting fractures, assess for compartment syndrome secondary to swelling, presence of Langer's lines and skin wrinkles suggests skin is appropriate for surgical intervention, decreased ankle plantarflexion strength with avulsion fractures, assess for neuologic compromise due to swelling, severe peripheral vascular disease may preclude surgical treatment due to poor wound healing potential, useful for evaluation of intraoperative reduction of posterior facet, with ankle in neutral dorsiflexion and ~45 degrees internal rotation, take x-rays at 40, 30, 20, and 10 degrees cephalad from neutral, visualizes tuberosity fragment widening, shortening, and varus positioning, place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees, demonstrates lateral wall extrusion causing fibular impingement, indicates partial separation of facet from sustentaculum, angle between line from highest point of anterior process to highest point of posterior facet + line tangential to superior edge of tuberosity, represents collapse of the posterior facet, angle between line along lateral margin of posterior facet + line anterior to beak of calcaneus, demonstrates posterior and middle facet displacement, demonstrates calcaneocuboid joint involvement, used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis, cast immobilization with nonweightbearing for 10 to 12 weeks, anterior process fracture involving <25% of calcaneocuboid joint, comorbidities that preclude good surgical outcome (smoker, diabetes, PVD), avoids the high wound complications seen with these fractures, minimally displaced tuberosity fractures (<1 cm of displacement) without threatened soft-tissue envelope in elderly patients with reduced function or physical capacity, begin early range of motion exercises once swelling allows, early reduction prevents skin sloughing and need for subsequent flap coverage, ideal in patients with sever peripheral vascular disease or severe soft-tissue compromise, lag screws from posterior superior tuberosity directed inferior and distal, require urgent reduction and fixation to avoid skin necrosis (disastrous consequence), open reduction allows for sufficient debridement of contaminated tissue, inability to participate in closed treatment, large extra-articular > 2 mm displacement, posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity, anterior process fracture with >25% involvement of calcaneocuboid joint, wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days, no benefit to early surgery due to significant soft tissue swelling, displaced tuberosity fractures with posterior skin compromise should be addressed urgently, number of intra-articular fragments and the, surgical treatment decreases the risk of post-traumatic arthritis, age > 50 (similar outcomes with surgical and nonsurgical treatment), initial Bhler's angle <0 (these injuries do poorly regardless of treatment), lower Bhler angles suggest greater energy absorbed, open fractures (significant soft tissue injury and engery absorbed), bilateral calcaneal fractures (significant gait problems following bilateral injuries), factors associated with most likely need for a secondary subtalar fusion, male worker's compensation patient who participates in heavy labor work with an initial Bhler angle less than 0 degrees, standard short-leg cast for calcaneal stress fractures, standard short-leg cast applied with mild equinus, windowed over posterior heel to allow for frequent skin checks, requires close follow-up to determine if pull of gastrocnemius-soleus dispaces fracture, weekly cast changes are necessary due to high incidence of skin complications, high incidence of vascular insufficiency and diabetes in this population, ideal for poor soft tissue coverage or patients with peripheral vascular disease, Steinmann pin placed into the fracture site anteromedially-to-posterolateral to leverage fragments into place, additional K-wires and Steinmann pins are placed from posterior-to-anterior and lateral-to-medial to secure remaining bone fragments, calcaneal transfixin pin can be used to distract fracture, percutaneus tamps and elevators can be used to raise the articular surface, pins are cut flush with the skin and removed 8-10 weeks post-op, can be combined with distracting external fixator, pins placed in calcaneal tuberosity, cuboid, and distal tibia, restor calcaneal height, width, and alignment, can be combined with percutaneous cannulated screws, extensile lateral L-shaped incision is most popular, vertical portion inbetween posterio fibula and achilles tendon, horizontal portion in line with 5th metatarsal base, a more inferior incision protects the sural nerve, provides access to the calcaneocuboid and subtalar joints, full-thickness skin, soft tissue, and periosteal flaps are developed, lateral calcaneal branch of peroneal artery, superior flap contains the calcaneofibular ligaments and peroneal tendon sheath, sural nerve and peroneal tendons are retracted superiorly, fracture opened and medial wall reduced going medial to lateral, reduction confirmed indirectly via fluoroscopy, tuberosity reduction is done under direct visualization, manual traction, Schanz pins, and minidistractors, height and length of tuberosity is recreated, definitive fixation with plates and screws, restore Bhler's angle and calcaneal height, minimally invasive incision that minimizes soft tissue dissesction, reduces wound complications associated with extensile lateral incision, allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall, same incision can be utilized for secondary subtalar arthrodesis or peroneal tendon debridement, patient placed in lateral decubitus position, incision made in line with the tip of the fibula and the base of the 4th metatarsal, extensor digitorum brevis retracted cephalad to expose sinus tarsi and posterior facet, Schanz pin inserted percutaneously in posteroinferior tuberosity going from lateral to medial, provides distraction and aids with reduction, fibrous debris and fat removed from sinus tarsi, small elevator or lamina spreader placed under posterior facet fragment to aid in reduction, K-wires inserted for provisional fixation aimed towards the sustentaculum, two screw are placed lateral-to-medial to engage sustentaculum and support facet, one large fully threaded screw from posterior-to-anterior to support axial length of calcaneus, low-profile plate is applied underneath a well developed soft tissue envelope with screws engaging anterolateral and tuberosity fragments, nonweight bearing for 6-8 weeks post-op with ankle range-of-motion exercises beginning 2 weeks post-op, manipulate the heel to increase the calcaneal varus deformity, manipulate the heel to correct the varus deformity with a valgus reduction, stabilize the reduction with percutaneous K-wires or open fixation as described above, arthroscopic-assisted reduction and internal fixation, improved visualization of articular surface and carilage lesions, increased swelling from fluid extravasation, can be combined with sinus tarsi approach, patient positioned in lateral decubitus position, fluoroscopy unit positioned posterior and oblique to patient, anterolateral and posterolateral portals are used to visualize posterior facet, loose bodies and cartilage fragments are removed with a shaver, Freer elevator is introduced into one of the portal sites and used to elevate the posterior facet, Schanz pin to control tuberosity fragment, cannulated screws from the posterior aspect of the calcaneal tuberosity to the anterior aspect of the calcaneus, lateral-to-medial screws placed in sustentaculum, buttress screw from the posterior aspect of the calcaneal tuberosity to the subchondral bone of the posterior facet, posterior approach for calcaneal tuberosity fractures, fracture fragment is mobilized and debrided, plantar flexion of foot aids with reduction, presence of gastrocnemius tightness may preclude reduction, Strayer procedure may be performed to aid in reduction, figure-of-8 tension-band wire passed around ends of K-wires or cannulated screws, Krackow sutures passing through bone tunnels, restricted weight bearing for 6 weeks followed by progression of weight bearing an additional 6 weeks, performed in highly comminuted Sanders IV intraarticular fractures, high rate of secondary fusion after ORIF with these injuries, avoids added treatment costs and decreases time off from work, can be performed through an extensile lateral or sinus tarsi approach, fracture reduction is perfromed in a similar fashion as ORIF, articular cartilage of the subtalar joint denuded to bleeding subchondral bone, cannulated compression screws are placed from the posterio calcaneal tuberosity to the talar dome, lateral fixation plate applied to hold reduction, increased risk in smokers, diabetics, and open injuries, may consider nonoperative treatment in these patients, tongue type fractures at high risk (>20%) for posterior skin necrosis, should be splinted in 30 degrees of planarflexion to relieve soft tissue tension, keep all hardware away from the corner of the incision, delayed wound healing is the most common complication, can be addressed with ankle bracing (gauntlet type), NSAIDs, injections, and physical therapy, may require bone block subtalar arthrodesis to address loss of calcaneal height, important when there are symptoms of anterior ankle impingement, Lateral impingement with peroneal irritation, at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment), loss of height, widening, and lateral impingement, distraction bone block subtalar arthrodesis, incongruous subtalar joint/post-traumatic DJD, results from posterior talar collapse into the posterior calcaneus, Lateral exostosis with no subtalar arthritis, Lateral exostosis with subtalar arthritis, Lateral exostosis, subtalar arthritis, and varus malunion, increased due to mechanism (fall from height), smoking, and early surgery, lateral soft tissue trauma increases the rate of complication, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. 2022 Mar;53(3):1276-1282. doi: 10.1016/j.injury.2021.12.046. Outcome measures were peak-to-peak displacement, total displacement, plastic deformation, stiffness, visual-fracture-line displacement, and mode of implant failure. Careers. 2013 Jun;34(6):773-80. doi: 10.1177/1071100713477607. eCollection 2022. 28, 11831186. Despite the absence of a washer, the 5.0 headless cannulated compression screws also demonstrated a surprisingly high stiffness and low displacement as compared to the other screws. The results of closed manipulation are poor in these fractures, usually requiring open reduction and internal fixation. Medartis provided the implant material without cost. 95144. Connect with peers, The type of fracture is determined by position of the foot, direction and magnitude of the Open all 2020 Aug 3;11:2040622320944793. doi: 10.1177/2040622320944793. Fixation of calcaneal avulsion fractures using screws with and without suture anchors: a biomechanical investigation. Jordan MC, Hufnagel L, McDonogh M, Paul MM, Schmalzl J, Kupczyk E, Jansen H, Heilig P, Meffert RH, Hoelscher-Doht S. Front Bioeng Biotechnol. Bookshelf AO Surgery Reference. HHS Vulnerability Disclosure, Help Instr Course Lect, 39:161-165, 01 Jan 1990 Cited by: 2 Classification for calcaneal avulsion fractures. Res. Detailed step by step desription of ORIF - screw fixation for Extreme tongue-type (beak) fracture of the calcaneus body located in our module on Foot Calcaneus Warrick CK, Bremner AE. In The original contributions presented in the study are included in the article/Supplementary Material; further inquiries can be directed to the corresponding author. eCollection 2022. Pathology. Clinical cases further underline our findings. This CT shows a normal foot and an axial cut of a patient with a beak fracture, showing the double line of the articular surface which demonstrates the articular split. 2. Soft-tissue principles All heel fractures have a spectrum of soft-tissue injury. 2022 Aug 4;10:896790. doi: 10.3389/fbioe.2022.896790. However, lack of biomechanical understanding of the ideal fixation technique persists. 2015 Feb 5;20:106. doi: 10.11604/pamj.2015.20.106.5709. 10 Articles, This article is part of the Research Topic, https://doi.org/10.3389/fbioe.2022.896790, https://www.frontiersin.org/articles/10.3389/fbioe.2022.896790/full#supplementary-material. -. Would you like email updates of new search results? Plate fixation was found to be significantly weaker. 8600 Rockville Pike Means for cyclic testing at 300N were 0.7 0.6mm in Group A, 3.1 2.3mm in Group B, and 1.4 1.1mm in Group C. There was a significant difference between groups A and B with p = 0.006. Occasionally, it is completely extraarticular but deserves the same operative treatment and reduction. The https:// ensures that you are connecting to the In each group, ten synthetic bone specimens of the calcaneus were used. Bioeng. [Duck beak fracture the posterior tuberosity of the calcaneus: about one case]. This unusual displaced calcaneal fracture can be intra- or extraarticular. Important outcome. We performed an innovative surgical procedure of suture fixation to the anchor screw in four cases, following which earlier postoperative rehabilitation with full weight-bearing walking and range of motion exercises was possible, and bony union was achieved without repeated displacement of the fragment in all patients. Unable to load your collection due to an error, Unable to load your delegates due to an error. We propose a modified classification scheme that presents the four types of calcaneal avulsion fracture as described by surgical and magnetic resonance imaging (MRI) findings, and evaluation of their specific features. A dangerous extraarticular subtype of a tongue-type fracture with severe displacement of the superior margin of the calcaneal tuberosity (beak fracture) is a surgical emergency. Federal government websites often end in .gov or .mil. Implant material was purchased from DePuy Synthes with a 30% research discount. -Post. government site. Despite this, we do not recommend plating of beak fractures as a first-line treatment. J. Orthop. Bethesda, MD 20894, Web Policies A very low stiffness is noticeable for groups D and E, underlining the weakness of plating. J Orthop Trauma. This method may also reduce the necessity of implant removal. (A) Lateral x-ray showing a fracture gap caused by tension of the Achilles tendon. 2022 Mar;53(3):1276-1282. doi: 10.1016/j.injury.2021.12.046. An official website of the United States government. 2008 Aug;22(7):439-45. doi: 10.1097/BOT.0b013e31817ace7e. (C and D) Postoperative x-ray after 12months demonstrating osseous healing in lateral and ap views. Harnroongroj T, Chuckpaiwong B, Angthong C, Nanakorn P, Sudjai N, Harnroongroj T. Biehl WC 3rd, Morgan JM, Wagner FW Jr, Gabriel R. Clin Orthop Relat Res. Before Hisatomi T. Seikeigeka. Hypothyroidism (P = .003), peripheral vascular disease (P = .022), and presence of more than one comorbidity (P = .005) were significantly associated with need for secondary surgical intervention. As mentioned previously, our results raise concerns about the fixation of beak-type fractures using plate osteosynthesis. This site needs JavaScript to work properly. Results for peak-to-peak displacement at different load levels. type I: simple extra-articular avulsion fracture. 1), S44S45. Most anterior process fractures of the calcaneus can be treated non-surgically. The purpose of this study was to perform a comprehensive biomechanical comparison of currently available operative fixation techniques and to demonstrate their application in selected clinical cases. The beak fracture is a rare calcaneal fracture subtype of the posterior calcaneal tuberosity (Warrick and Bremner, 1953; Carnero-Martn de Soto et al., 2019). https://doi.org/10.1053/j.jfas.2020.09.001. The surgeon must consider the patient and the fracture when making decisions about treatment.Operative management is indicated in patients with beak fractures. Fig. (C) Band mimicking the Achilles tendon to apply tension to the fragment. 59-31). 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. (A) Stiffness at 100N for all groups analyzed. FOIA This x-ray will demonstrate also whether or not this fracture extends into the subtalar joint, or is completely extraarticular, leaving the posterior facet uninvolved. Fragment pull-out occurred in 5.0-mm headless cannulated compression screws. The Achilles tendon was simulated by a braided synthetic band (kwb Germany GMBH, LC 1500daN, Art.-Nr. Three specimens failed by a simultaneous cut-out of the caudal screw and pull-out of the cranial screw. -, Khazen GE, Wilson AN, Ashfaq S, Parks BG, Schon LC. Clipboard, Search History, and several other advanced features are temporarily unavailable. Accessibility 4) with avulsion and cranial displacement of the superior margin of the calcaneal tuberosity warrant emergency reduction in order to avoid the rapid development of skin necrosis over the Achilles tendon insertion which is particularly hard to treat [16, 36]. The site is secure. Neuropathic calcaneal tuberosity avulsion fractures. FOIA and transmitted securely. 2013 Nov;44(11):1483-5. doi: 10.1016/j.injury.2013.01.033. Schematic illustration of the fixation techniques. government site. Despite this success, an open exposure and visually controlled reduction to ascertain anatomic fixation of the fragment may be necessary for more complex fractures and may be superior to percutaneous fixation (Banerjee et al., 2012; Blum et al., 2019). Bioeng. 2007;28(11):11831186. doi:10.1053/j.jfas.2014.09.038, Yu, G.-r., Pang, Q.-j., Yu, X., Chen, D.-w., Yang, Y.-f., Li, B., et al. [ 1] However, a true consensus regarding the management of these fractures has J. Dec 416, 2022, Revised distal humerus module is now online, with displacement of more than a few millimeters posteriorly, present or impending posterior soft-tissue compromise. An official website of the United States government. Group D was fixed by a lateral 2.0/2.3mm locking plate (TriLock Grid Plate 3 + 3 hole, 37mm, t1.3, APTUS, REF A-4655.69, Medartis). The results are presented as the mean with standard deviation. When such large screws cannot be applied, 4.0-mm screws also allow reasonable fixation strength. volume 35-B, 3345. Pflger P, Zyskowski M, Greve F, Kirchhoff C, Biberthaler P, Crnlein M. Front Surg. [The so-called duck beak fracture] [The so-called duck beak fracture] Hefte Unfallheilkd. The normal angle is 25 degrees to 40 degrees. The greater the impact, the greater the damage to the calcaneus. eCollection 2015. sharing sensitive information, make sure youre on a federal Please enable it to take advantage of the complete set of features! 8600 Rockville Pike Headless cannulated compression screws were inserted via priorly placed k-wires until the screw head was buried on the bone level. Conclusions: 3) In general, 2.3-mm or 2.8-mm bend plates cannot be recommended. Methods: 21, 690693. 5.0 headless cannulated compression screw, and 4.0-mm partial threaded cannulated screw can also resist high tension forces. doi:10.1097/BOT.0000000000001533, Carnero-Martn de Soto, P., Bautista-Enrique, D., Gmez-Cceres, A., Rodrguez-Len, A., Bravo-Zurita, M. J., and Santos-Maraver, M. T. (2019). The 2.3- and 2.8-mm plating groups showed a high drop-out rate at 100N tension force and failed under higher tension levels of 200N. The fracture fixation using 4.0-mm partial threaded screws showed a significantly higher repair strength and was able to withhold cyclic loading up to 300N. The lowest peak-to-peak displacement and the highest load-to-failure and stiffness were provided by fracture fixation using 6.5-mm partial threaded cannulated screws or 5.0-mm headless cannulated compression screws. Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures. process becomes displaced upward. Mitchell PM, ONeill DE, Branch E, Mir HR, Sanders RW, Collinge CA. Screw-to-bone ratio. 2009 Dec;22(12):942-3. doi: 10.1097/BOT.0000000000001582. The .gov means its official. Combined Lag Screw and Cerclage Wire Fixation for Calcaneal Tuberosity Avulsion Fractures. Drop-out occurred during the cyclic loading at 300N for one specimen in Group A, three specimens in Group B, and one specimen in Group C. Biomechanical data: Means at the load level of 100N were 0.5 0.3mm in Group A, 0.8mm 0.4mm in Group B, and 0.4mm 0.2mm in Group C. There was a significant difference between Group B and C with p = 0.023. Copyright 2022 Elsevier B.V. or its licensors or contributors. Before Normally distributed data were compared using analysis of variance and the Bonferroni correction. 2009;15(2):5861. The most important feature of this The most caudally positioned marker on the fragment was used for visual analysis of the displacement. Reposition was achieved by a pointed reduction clamp and temporarily fixed by k-wires. The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fbioe.2022.896790/full#supplementary-material, Agni, N., and Fearon, P. (2016). Despite this, results for the most promising fixation techniques require follow-up confirmation in a biomechanical setting with cadaver specimens. But the clinical advantage of these headless cannulated compression screws requires evaluation through clinical studies and cannot be confirmed by our biomechanical study. (B) Intraoperative fluoroscopy demonstrating percutaneous reduction by a pointed reduction clamp. Sci. A comparison of different synthetic bone models showed that Synbone most closely mimics the bone structure of elderly patients (Hoelscher-Doht et al., 2014; Fuchs et al., 2020). If the patient is medically safe for surgery, then immediate operative reduction is indicated to prevent this from becoming an open fracture. All data were statistically analyzed for normal distribution using the ShapiroWilk test. Epub 2020 Sep 5. Calcaneus - Extreme tongue-type (beak) fracture AuthorsAuthors Beak fracture This unusual displaced calcaneal fracture can be intra- or extraarticular. mostly avulsion type fractures: anterior process, sustentaculum tali, calcaneal tuberosity. Results were grouped into biomechanical data gained by the material testing machine and visual data by the optical system. No potential conflict of interest relevant to this article was reported. This site needs JavaScript to work properly. Composite Bone Models in Orthopaedic Surgery Research and Education. SH-D received funding from Medartis for biomechanical projects not related to this work. From a clinical point of view, the risk of soft tissue irritation can be further reduced through the use of the headless cannulated compression screws, which enables the burial of the screw head in the bone. Sustentaculum. 20, 253258. The fragment in Group A was fixed using two cannulated 6.5mm threaded screws with underlying washers (length 45mm, REF 408.431, b7, DePuy Synthes, Johnson & Johnson, United States). Treatment is nonoperative versus operative based on fracture displacement and alignment, associated soft tissue injury, and patient risk factors. Thirty-three patients who sustained extra-articular calcaneal avulsion fractures from 2002 to 2011 were retrospectively identified. Epub 2021 Dec 31. A power analysis was performed in previous tests using a power of 80% and a significance level of 5%, which showed that the sample size was adequate. Two-thirds of the bone specimen was embedded in the fixation device using calcium sulfate Ca [SO4] 2H2O, leaving the tuber calcanei free. The joint depression is notorious for the degree of joint involvement and displacement. The final test protocol encompassed a 10N preload followed by 10 setting cycles between 10 and 40N. Following this, the test started with a cyclic loading from 10 to 100N for 1,000 repetitive cycles. Locking screws from 1420mm were used. Because of marked disruption of the posterior soft tissues, if it does not present as an open fracture at the time of admission to hospital, the pressure from within on the posterior skin will soon cause it to break down and convert it into an open fracture. Orthop. Clipboard, Search History, and several other advanced features are temporarily unavailable. Unable to load your collection due to an error, Unable to load your delegates due to an error. When using conventional screws, the screw head and washer can be placed at the level of the Achilles tendon insertion, usually without interfering with the surrounding tissue. Surgical management of calcaneus fractures: indications and techniques. At 200N load, the means were 0.4 0.3mm in Group A, 2.1 2.1mm in Group B, and 0.5 0.2mm in Group C. Data showed a significant difference between groups A and B with p = 0.013. * Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis, 1951-52. Type of implant failure sorted by groups. Previous studies have shown that the biomechanical properties of synthetic bone and human specimens are similar, and our pre-tests confirmed these findings. Levels of evidence: -, Lui TH. 1953;35(1):3345. Group E was stabilized by a lateral 2.8mm locking plate (2.8 TriLock Grid Plate 3 + 3 hole, 43mm, t1.6, APTUS, REF A-4850.69, Medartis) and locking screws (1420mm) (Figures 2, 3, and Table 1). Biomechanical data: the means were 3.9 1.3mm in Group A, 6.8 1.5mm in Group B, and 4.4 1.2mm in Group C. Statistical analysis showed significant differences between groups A and B with p = 0.001 and between groups B and C with p = 0.007. Despite our poor biomechanical results, successful reports of plate fixation for beak fractures exist (Agni and Fearon, 2016). The available data indicate that elderly patients with osteopenic or osteoporotic bones are more likely to be affected by this fracture (Carnero-Martn de Soto et al., 2019; Beavis et al., 2008; Lee et al., 2012). Outcomes of operatively treated calcaneal tuberosity avulsion fractures. Please enable it to take advantage of the complete set of features! 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