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Review Article

Management of Calcaneal
Tuberosity Fractures
Abstract
Rahul Banerjee, MD
John C. Chao, MD
Ryan Taylor, MD
Akas Siddiqui, MD, MPH

Fractures of the calcaneal tuberosity are relatively uncommon and


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

Anatomy and Function


From the Department of
Orthopaedic Surgery, University of
Texas Southwestern Medical Center,
Dallas, TX (Dr. Banerjee, Dr. Chao,
and Dr. Siddiqui) and the
Department of Orthopedic Surgery,
University of Pennsylvania Hospital,
Philadelphia, PA (Dr. Taylor).
Dr. Banerjee serves as a board
member, owner, officer, or
committee member of the American
Academy of Orthopaedic Surgeons.
Dr. Siddiqui or an immediate family
member has stock or stock options
held in GlaxoSmithKline, Boston
Scientific, Angiotech
Pharmaceuticals, Baxter, Biopure,
Perrigo, Geron, Pfizer, Procter &
Gamble, and Johnson & Johnson.
Neither of the following authors nor
any immediate family member has
received anything of value from or
owns stock in a commercial
company or institution related
directly or indirectly to the subject of
this article: Dr. Chao and Dr. Taylor.
J Am Acad Orthop Surg 2012;20:
253-258
http://dx.doi.org/10.5435/
JAAOS-20-04-253
Copyright 2012 by the American
Academy of Orthopaedic Surgeons.

April 2012, Vol 20, No 4

The anatomy and position of the calcaneus contribute to its physiology in


the functioning hindfoot. The calcaneal tuberosity is composed primarily of cancellous bone encapsulated
by a relatively thin cortex. The cancellous portion consists of a complex
network of trabeculae that factors
into the overall strength of the bone.1
Furthermore, the calcaneus acts as a
lever to increase the power of the
gastrocnemius-soleus complex. This
lever provides a fulcrum in the midbody of the talus.2
The insertion of the Achilles tendon plays an important role in the
function of the posterior calcaneus.
Cadaver studies demonstrated that
the shape of the Achilles insertion on
the middle third of the posterior tuberosity contributes to the pattern of
avulsion fractures.3 Other cadaver
studies have shown that some persons have a more proximal insertion
of the Achilles tendon or a more extensive insertion into the calcaneus,
either of which may account for the

different sizes of avulsion fractures4


(Figure 1). The Achilles tendon is
subjected to the highest loads of any
structure in the bodyup to 10
times body weight during running or
jumping.5

Pathoanatomy and
Mechanism of Injury
The calcaneus is the most frequently
fractured tarsal bone. Fractures are
classified as intra-articular and extra-articular; 60% to 75% are intraarticular.1,6 The most common mechanism of injury for intra-articular
fractures is axial loading resulting
from either a fall from a height or a
motor vehicle collision.6,7 Extraarticular fractures, conversely, most
often result from twisting forces in
the hindfoot.8,9 A subset of extraarticular fractures, posterior calcaneal tuberosity avulsion fractures,
account for 1% to 3% of all calcaneal fractures.6,10-13
The strength of calcaneal bone
plays a major role in the etiology of
avulsions of the posterior tuberosity.

253

Management of Calcaneal Tuberosity Fractures

Figure 1

A, Radiograph (left) and close-up photograph (right) of the traditionally described Achilles tendon insertion.
B, Radiograph (left) and close-up photograph (right) of a more proximal Achilles tendon insertion. (Reproduced with
permission from Lowy M: Avulsion fractures of the calcaneus. J Bone Joint Surg Br 1969;51[3]:494-497.)

Calcaneal bone strength and mineral


content tend to decrease with advancing age, with women affected
more than men.6,14 As a result of
physiologic weakening of trabecular
bone with age, the peak incidence of
avulsion fractures of the posterior
calcaneal tuberosity is in women in
their seventh decade.6,11,13
The mechanism leading to an avulsion fracture of the posterior calcaneal
tuberosity is commonly a violent pull
from the gastrocnemius-soleus complex
coupled with forced dorsiflexion, usually associated with a lower energy fall
or sudden push-off from standing. A
strong, concentric contraction of the
gastrocnemius-soleus complex with the
knee in full extension has been implicated, as well.6,11,13 Avulsion fracture
of the posterior calcaneal tuberosity
has also been reported to occur secondary to direct trauma or a gunshot
blast.12 Intrinsic tightness of the gastrocnemius muscle is a risk factor for
the development of these fractures.5,15 The fractures manifest as a
2- to 3-cm avulsed fragment off the
posterosuperior portion of the posterior calcaneus tuberosity.
Peripheral neuropathy can also
play a role in these avulsion fractures. Decreased pain sensation and

254

proprioception resulting from the peripheral neuropathy can leave the


foot and ankle susceptible to recurring microtrauma from repeated
force exerted by the Achilles tendon.11 Lack of overt trauma is reason
to suspect a neuropathic fracture.
Posterior tuberosity avulsion fractures can interrupt normal anatomic
relationships and profoundly affect
hindfoot function. In addition, the
gastrocnemius-soleus complex is notably weakened when the calcaneal
tuberosity is displaced proximally.2

Classification
Beavis et al10 proposed a classification system for describing calcaneal
tuberosity avulsion fractures (Figure
2). Type I is a sleeve fracture, in
which a small shell of cortical bone
avulses from the tuberosity. Type II is
a beak fracture, in which an oblique
fracture line runs posteriorly from
the most superior portion of the posterior facet, but the Achilles tendon
remains attached to the fracture.
Type III is an infrabursal avulsion
fracture from the middle of the tuberosity, which Beavis et al10 described in a case report.

Patient Evaluation
The evaluation of a patient with a
calcaneus fracture begins with a
thorough history, with importance
placed on the time and mechanism of
injury. Patients with osteoporosis,
peripheral neuropathy, or diabetes,
or who are on long-term immunosuppressive therapy, are at higher
risk for avulsion fractures, and they
may not recall any history of
trauma.6,11,16,17
Physical examination should include a careful evaluation of the soft
tissues. The skin of the posterior heel
should be carefully examined to ensure identification of open fractures.
In addition, the surgeon must recognize that fracture displacement may
put pressure on the skin over the heel
and thus lead to skin necrosis (Figure
3). Clinically, this is manifested by
skin that is pale or nonblanching. A
delay in treatment is associated with
a greater risk of complications from
this problem. In a large series of 139
displaced posterior calcaneal tuberosity fractures, 29 (21%) had some
form of soft-tissue compromise;
there was a higher incidence in patients who delayed seeking medical

Journal of the American Academy of Orthopaedic Surgeons

Rahul Banerjee, MD, et al

Figure 2

Figure 3

A, Lateral radiograph of a displaced calcaneal tuberosity fracture. B, Clinical


photograph demonstrating corresponding skin necrosis resulting from lack of
early recognition of the fracture. (Panel A reproduced with permission from
Hess M, Booth B, Laughlin RT: Calcaneal avulsion fractures: Complications
from delayed treatment. Am J Emerg Med 2008;26[2]:254. Panel B
reproduced with permission from Banerjee R, Chao J, Sadeghi C, Taylor R,
Nickish F: Fractures of the calcaneal tuberosity treated with suture fixation
through bone tunnels. J Orthop Trauma 2011;25[11]:685-690.)

Management

Beavis classification of avulsion


fractures of the posterior calcaneal
tuberosity. (Redrawn with permission from Beavis RC, Rourke K,
Court-Brown C: Avulsion fracture of
the calcaneal tuberosity: A case
report and literature review. Foot
Ankle Int 2008;29[8]:863-866.)

After initial evaluation of the patient,


the injured foot is splinted in an
equinus position to relieve tension on
the posterior skin and the fracture.
The decision for surgery is based on
displacement of the fracture, the condition of the soft tissues, and patient
activity and ambulatory status.

Nonsurgical
care, had greater fracture displacement, or smoked tobacco.18 Hess
et al19 presented three calcaneal avulsion cases that resulted in wound
complications secondary to delayed
surgical treatmentspecifically, posterior heel skin breakdown with
overlying tissue necrosis.
Plain radiographs of the foot and
ankle should be obtained to evaluate
the foot and rule out other injuries.
The fracture is best visualized on a
lateral foot radiograph. Unlike other
fractures of the calcaneus, CT scans
are not necessary for definitive management.
April 2012, Vol 20, No 4

Nonsurgical management of calcaneal tuberosity avulsion fractures is


usually reserved for minimally displaced fractures with a nonthreatened soft-tissue envelope and in elderly patients with impaired function
or reduced physical ability. Robb
and Davies13 recommended nonsurgical treatment (ie, casting in equinus) for fractures with <1 cm of displacement.
With nonsurgical treatment, the
patient must be followed closely because an initially nondisplaced fracture may displace later as a result of
the pull of the gastrocnemius-soleus
complex. After the initial equinus

splinting, the patient is seen within 1


week for repeat radiographs and to
reevaluate the soft tissues. If no further displacement or soft-tissue compromise is noted, the patient is
placed into a short leg cast with the
foot in mild equinus.
Cast treatment in this population is
also fraught with complications because these patients may have diabetes and compromised peripheral sensation. If this method is chosen,
weekly cast changes and skin checks
are necessary. Furthermore, the cast
may be windowed over the heel to
permit direct visualization of the
skin. The cast is maintained, with
frequent changes, for 6 to 8 weeks or
until there is radiographic evidence
of healing. A CT scan may be obtained to confirm union. The cast is
then removed and physical therapy is
initiated, with a gradual increase to
full weight bearing as tolerated by
the patient.

Surgical
Most displaced calcaneal tuberosity
fractures require surgery to restore

255

Management of Calcaneal Tuberosity Fractures

Figure 4

Direct surgical exposure of the calcaneal tuberosity fragment. The Achilles


tendon is seen attached to the displaced fragment. (Reproduced with
permission from Banerjee R, Chao J, Sadeghi C, Taylor R, Nickish F:
Fractures of the calcaneal tuberosity treated with suture fixation through
bone tunnels. J Orthop Trauma 2011;25[11]:685-690.)

the function of the gastrocnemiussoleus complex and prevent secondary soft-tissue compromise of the
posterior heel. Indications for surgery include open fractures, threatened skin, displacement >1 cm, and
inability to participate in closed
treatment.18,20 Open fractures necessitate dbridement and stabilization
of the fracture. In open fractures, reduction and stabilization of the fracture help soft-tissue healing. In cases
of threatened skin from displaced
fracture fragments, urgent reduction
of the fracture is necessary to prevent
further skin injury and possible conversion into an open fracture. If the
fracture is displaced, the function of
the calcaneus as a lever to the
gastrocnemius-soleus complex is
compromised. Without surgical reduction and fixation, the patient will
experience weakness of plantar flexion as well as difficulty climbing
stairs.6,11,13,21 In addition, the patient
is at risk for a bony protuberance
over the site of the fracture, which
can affect shoe wear.
Fracture reduction is achieved
through open exposure and direct visualization of the displaced fragment

256

(Figure 4) or by minimally invasive


or percutaneous methods. In our experience, percutaneous methods are
almost never indicated; we believe
that anatomic reduction is necessary
to restore the gastrocnemius-soleus
complex.
The patient is positioned prone.
Open reduction is achieved by direct
exposure of the fracture fragment
through a posterior midline incision.
The fracture fragment edges are exposed, and the fragment is anatomically reduced and held in place with
provisional fixation, such as Kirschner wires (K-wires). Plantar flexion
of the foot aids reduction.
Alternatively, a minimally invasive
method may be used, in which a
small incision is made over the fragment and another small incision is
made on the plantar aspect of the
heel. A large pointed-reduction
clamp is inserted through these small
incisions and used to reduce and
hold the fracture. If the fracture fragment is too small or too thin for direct manipulation of the bone, sutures passed through the fragment
and into the Achilles tendon provide

a means by which to control the


fragment.
Because many patients with calcaneal tuberosity fractures have intrinsic gastrocnemius tightness, reduction may be hampered by this
preexisting condition. Concurrent
treatment of the intrinsic gastrocnemius tightness may be required to facilitate reduction and prevent failure
of fixation. Intrinsic gastrocnemius
tightness may be treated with gastrocnemius recession (ie, Strayer procedure).5,15,22 The procedure is performed through a separate incision
at the gastrocnemius-soleus junction
before reduction of the calcaneal tuberosity fracture fragment (Figure 5).
The amount of tension in the
gastrocnemius-soleus complex postoperatively should be compared with
that of the contralateral side.
Once reduction of the fragment is
achieved, fixation may be challenging because the fracture fragments
are often small. Also, these patients
often have osteoporotic bone. A variety of different methods of fixation
has been described, including the use
of tension bands, lag screws, and suture anchors.
Tension band constructs for the
fixation of displaced calcaneal tuberosity fractures have been advocated
as a method to ensure stabilization
of the fragment and to resist the
force of the triceps surae muscle.
Squires et al17 described a technique
in which the tuberosity fragment is
reduced and fixed with two K-wires
placed from superior and posterior
to inferior and anterior. A figure-of-8
tension-band wire is passed around
the ends of the K-wire over the lateral wall of the calcaneus.
If the calcaneal tuberosity fragment
is sufficiently large, fixation with lag
screws may be feasible.10,16,23 Because
screw pullout is common, we recommend the use of 4.5- or 6.5-mm partially threaded screws, which penetrate and capture the plantar cortex,

Journal of the American Academy of Orthopaedic Surgeons

Rahul Banerjee, MD, et al

Figure 5

Figure 6

Illustration of the Strayer procedure, which may be done for intrinsic


gastrocnemius tightness and to aid with reduction of the calcaneal fracture.
(Redrawn with permission from Strayer LM Jr: Recession of the
gastrocnemius: An operation to relieve spastic contracture of the calf
muscles. J Bone Joint Surg Am 1950;32[3]:671-676.)

along with either metal or spiked ligament washers. Lag screw fixation
alone may be insufficient to resist the
pull of the triceps surae, particularly
in osteoporotic bone; therefore, supplemental fixation has been advocated in the form of suture anchors.16
Recent suture anchor designs have
demonstrated markedly increased
load to failure, especially in metaphyseal cortical and cancellous bone,
which had been a problem with
older suture anchor designs.24 One
application of suture anchors in the
repair of these fractures is to use the
anchors to directly reapproximate
the avulsed bony fragment. One limb
of suture from each suture anchor is
used to hold the fragment in place;
the other limb is woven into the
Achilles tendon with a Krackow suture.23 Robb and Davies13 described
the use of two 6.5-mm corkscrew anchors in a patient with bilateral posApril 2012, Vol 20, No 4

terior calcaneal avulsion fractures


sustained after a fall. Fracture reduction was accomplished by passing all
four suture strands through the cortex of the avulsed fragment and into
the Achilles tendon, then securing
them with modified Kessler sutures.
Khazen et al16 confirmed the benefit
of suture anchors to augment lag
screw fixation in a cadaver study;
they showed that the addition of suture anchors to lag screws approximately doubled the load-to-fixation
failure compared with lag screws
alone.
We previously described a technique in which these sutures are
passed through the tuberosity fragment and Achilles tendon using a
modified Krackow suture25 (Figure
6). These sutures are then passed
through bone tunnels drilled in the
body of the calcaneus and tied
through a small incision on the plan-

Fixation of calcaneal tuberosity


fragment using suture fixation
through bone tunnels. (Reproduced
with permission from Banerjee R,
Chao J, Sadeghi C, Taylor R,
Nickish F: Fractures of the
calcaneal tuberosity treated with
suture fixation through bone
tunnels. J Orthop Trauma
2011;25[11]:685-690.)

tar aspect of the heel. This technique


may be used alone or as a supplement to lag screw fixation.
Postoperative protocols vary based
on the type of fixation used.13,17,23,25
Patients may be immobilized briefly
or placed in a removable ankle brace
to begin early range of motion.
Weight bearing is restricted for 6
weeks and then gradually advanced
over the next 6 weeks.
The most common surgical complication of fixing these avulsion fractures is failure of wound healing because the skin may already be at risk
preoperatively. Because of the poor
bone quality in most of these patients, device failure is also a concern. Fracture union is difficult to visualize on plain radiographs; CT
may be done when nonunion is a
concern. Furthermore, a nonanatomic reduction can lead to weakness in plantar flexion. Neuropathic
fractures deserve special mention because they have an even higher inci-

257

Management of Calcaneal Tuberosity Fractures

dence of infection, nonunion,


malunion, and failed fixation. Failure to immobilize a neuropathic patient, even after surgical fixation has
been accomplished, can lead to further displacement, device failure, or
loss of fixation.11

Outcomes
Limited data regarding the outcomes
of calcaneal tuberosity fractures have
been published; this may be because
of the relative rarity of these fractures. Most studies are noncontrolled retrospective case series; none
of them, to our knowledge, compares different types of fixation. The
available literature suggests that patients have better outcomes with surgical than with nonsurgical treatment.6,17 Schepers et al6 reviewed the
literature of reported calcaneal tuberosity fractures from 1852 to 2007.
Of the 66 patients with fractures
identified, 11 were treated nonsurgically, for a 64% satisfactory rate,
and 29 were treated surgically, for an
88% satisfactory rate. However,
more than half of the reported patients had no documented follow-up.

Evidence-based Medicine: Levels of


evidence are described in the table of
contents. In this article, reference 15
is a level I study. Reference 22 is a
level II study. References 4, 6, 10-13,
17-19, 21, 23, and 25 are level IV
studies.

258

12.

Cooper DE, Heckman JD: The heel of


achilles: Calcaneal avulsion fracture
from a gunshot wound. Foot Ankle
1989;9(4):204-206.

13.

Robb C, Davies MB: A new technique


for fixation of calcaneal tuberosity
avulsion fractures. J Foot Ankle Surg
2003;9:221-224.

14.

Weaver JK, Chalmers J: Cancellous


bone: Its strength and changes with
aging and an evaluation of some
methods for measuring its mineral
content. J Bone Joint Surg Am 1966;
48(2):289-298.

References printed in bold type are


those published within the past 5
years.
1.

Daftary A, Haims AH, Baumgaertner


MR: Fractures of the calcaneus: A review
with emphasis on CT. Radiographics
2005;25(5):1215-1226.

15.

DiGiovanni CW, Kuo R, Tejwani N,


et al: Isolated gastrocnemius tightness.
J Bone Joint Surg Am 2002;84(6):962970.

2.

Macey LR, Benirschke SK, Sangeorzan


BJ, Hansen ST: Acute calcaneal
fractures: Treatment options and results.
J Am Acad Orthop Surg 1994;2(1):3643.

16.

3.

Chao W, Deland JT, Bates JE, Kenneally


SM: Achilles tendon insertion: An in
vitro anatomic study. Foot Ankle Int
1997;18(2):81-84.

Khazen GE, Wilson AN, Ashfaq S, Parks


BG, Schon LC: Fixation of calcaneal
avulsion fractures using screws with and
without suture anchors: A biomechanical
investigation. Foot Ankle Int 2007;
28(11):1183-1186.

17.

Squires B, Allen PE, Livingstone J,


Atkins RM: Fractures of the tuberosity
of the calcaneus. J Bone Joint Surg Br
2001;83(1):55-61.

18.

Gardner MJ, Nork SE, Barei DP, Kramer


PA, Sangeorzan BJ, Benirschke SK:
Secondary soft tissue compromise in
tongue-type calcaneus fractures.
J Orthop Trauma 2008;22(7):439-445.

19.

Hess M, Booth B, Laughlin RT:


Calcaneal avulsion fractures:
Complications from delayed treatment.
Am J Emerg Med 2008;26(2):254, e1-e4.

20.

Lowery RB, Calhoun JH: Fractures of


the calcaneus: Part II. Treatment. Foot
Ankle Int 1996;17(6):360-366.

4.

5.

6.

Summary
Fractures of the calcaneal tuberosity
occur most commonly in osteoporotic elderly women or in diabetic
patients as a result of neuropathic
fracture. Open and displaced fractures tenting the skin must be identified and addressed urgently. Internal
fixation must provide stability and
be able to resist the pull of the triceps surae muscle. Although studies
with reported outcomes are limited,
surgical reduction and internal fixation of these fractures restores hindfoot anatomy and may provide the
best possible results for patients with
this injury.

tuberosity avulsion fractures. Clin


Orthop Relat Res 1993;296:8-13.

References

Lowy M: Avulsion fractures of the


calcaneus. J Bone Joint Surg Br 1969;
51(3):494-497.
DiGiovanni CW, Langer P: The role of
isolated gastrocnemius and combined
Achilles contractures in the flatfoot. Foot
Ankle Clin 2007;12(2):363-379, viii.
Schepers T, Ginai AZ, Van Lieshout EM,
Patka P: Demographics of extra-articular
calcaneal fractures: Including a review of
the literature on treatment and outcome.
Arch Orthop Trauma Surg 2008;
128(10):1099-1106.

7.

Lawrence SJ, Singhal M: Open hindfoot


injuries. J Am Acad Orthop Surg 2007;
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Protheroe K: Avulsion fractures of the


calcaneus. J Bone Joint Surg Br 1969;
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8.

Sanders RW, Clare MP: Fractures of the


calcaneus, in Bucholz RW, Heckman JD,
Court-Brown CM, eds: Rockwood and
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Philadelphia, PA, Lippincott Williams &
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22.

Pinney SJ, Hansen ST Jr, Sangeorzan BJ:


The effect on ankle dorsiflexion of
gastrocnemius recession. Foot Ankle Int
2002;23(1):26-29.

23.

Matherne TH, Tivorsak T, Monu JU:


Calcaneal fractures: What the surgeon
needs to know. Curr Probl Diagn Radiol
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Lui TH: Fixation of tendo Achilles


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Beavis RC, Rourke K, Court-Brown C:


Avulsion fracture of the calcaneal
tuberosity: A case report and literature
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Barber FA, Herbert MA, Beavis RC,


Barrera Oro F: Suture anchor materials,
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25.

Banerjee R, Chao J, Sadeghi C, Taylor R,


Nickisch F: Fractures of the calcaneal
tuberosity treated with suture fixation
through bone tunnels. J Orthop Trauma
2011;25(11):685-690.

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Biehl WC III, Morgan JM, Wagner FW


Jr, Gabriel R: Neuropathic calcaneal

Journal of the American Academy of Orthopaedic Surgeons