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Figure 1. Anteroposterior view of the right foot.
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Figure 2. Anteroposterior view of the right ankle.
A 40-year-old man presents with severe right foot pain after tripping at his home 2 days ago. He admits the ankle rolled as he tripped and he felt a sharp pain in the foot during the fall. Over the last few days, the foot has become swollen and bruised on the lateral side. He is having difficulty bearing weight but denies numbness or tingling. Radiographs of the foot and ankle (Figures 1 and 2) show an avulsion fracture of the dorsolateral aspect of the calcaneus. What is the best treatment option?
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Avulsion fractures are common after foot and ankle inversion/eversion injuries. Identifying attachment sites of tendons and ligaments of the foot and ankle helps guide identifying particular avulsion patterns. One of the most common avulsion fractures of the calcaneus is an avulsion of the extensor digitorum brevis muscle off the dorsolateral aspect of the calcaneus. These injuries occur from an inversion ankle injury such as a fall upstairs or a slip on ice. The extensor digitorum brevis is the only muscle that originates on the dorsum of the foot and functions to extend the 4 medial toes. Other avulsion fractures of the calcaneus include an anterior process fracture caused by avulsion of the bifurcate ligament or those resulting from sudden tension on the Achilles tendon or plantar fascia.1,2
Most avulsion fractures heal uneventfully with a period of immobilization, usually in a weight-bearing boot for 4 to 6 weeks. If pain from the avulsion fracture persists beyond 4 to 6 months excision of the avulsed fragment may be considered.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
References
1. Norfray JF, Rogers LF, Adamo GP, Groves HC, Heiser WJ. Common calcaneal avulsion fracture. AJR Am J Roentgenol. 1980;134(1):119-123. doi:10.2214/ajr.134.1.119
2. Halm JA, Schepers T. Resection of small avulsion fractures of the anterior process of the calcaneus for refractory complaints. J Foot Ankle Surg. 2017;56(1):135-141. doi:10.1053/j.jfas.2016.05.004
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