A 30-year-old female recreational player presented three months after an injury to her right ankle. She was not certain about the exact mechanism but described a twisting movement as she challenged for a ball. She reported experiencing immediate pain, developing rapid swelling and being unable to walk unaided for about a week. She was seen by a physiotherapist and diagnosed with a lateral ankle sprain. While her symptoms had improved a lot she continued to have pain and swelling with activity and had not been able to get back to playing football. There was no past history of significant foot or ankle injuries.
On examination her ankle was obviously swollen. There was a mild global restriction of ankle and subtalar movements and some generalized tenderness about the lateral ankle. There was no clinical evidence of lateral ligament laxity or other significant signs
An x-ray series of the ankle from near the time of injury (as well as a second series a month later) appear normal. MR images show that there is a 1 cm ossicle at the anterior process of calcaneus. These is minor oedema associated with this. These findings are most consistent with an un-united fracture (although a developmental variant is another possibility). The CT imaging further demonstrates an un-united fracture of the anterior process of the calcaneus with no evidence of healing. The fracture margins are irregular and more in keeping with a fracture than an os calcaneum secundarium.
This player was reviewed by a subspecialist foot and ankle surgeon. Given that the symptoms have persisted for three months, and because there is no evidence of fracture healing, the plan is to manage this operatively. The intention is to reduce and fix (ORIF) the bony fragment. If this is not possible the fragment may need to be excised. The return to play timeline will be dictated by the procedure that is performed.
Anterior calcaneal process fractures are rare injuries. Fractures of the anterior calcaneus, in a sports setting, are generally avulsion fractures (from the bifurcate ligament) caused by forced inversion and plantarflexion of the foot. An impaction injury mechanism, caused by forced eversion and abduction of the foot, has also been described. Outside of sport they are often associated with other fractures or dislocations of the midfoot. These fractures can be hard to diagnose as they frequently present in a similar manner to lateral ligament sprains and because x-rays often appear normal or can be difficult to interpret (due to bone overlap obscuring the midfoot bones). When there is clinical suspicion, an oblique x-ray of the midfoot can better demonstrate this bony landmark and can assist with making the diagnosis. As this case illustrates CT and MR imaging can also be very helpful.
There are no clear guidelines in the literature to guide treatment decisions for this type of injury. Some patients can be successfully managed with non-surgical treatment involving a below the knee cast (or boot) with no weight bearing for 6 to 8 weeks. This is then followed with a progressive rehabilitation programme. This regime would be appropriate for non-displaced or minimally displaced fractures. Where there has been a delay in diagnosis and/or where there is a displaced (>2 mm) or large fragment (>1 cm) involving the calcaneo-cuboid joint surgical treatment should be considered. Surgery may also be considered for elite players as it is possible that this may give a more predictable result. In most cases open reduction and internal fixation (ORIF) is the best surgical option. When the fracture fragment is small, or if it cannot be reduced, it may be excised.
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