Foot and Ankle cases 34
A 33-year-old man jumped off a 6-ft ledge, injuring his right ankle. He presented to the emergency department shortly thereafter, unable to bear weight on the right foot. The ER physician confirmed that he was in no acute distress, had no open wounds, and had palpable pedal pulses with soft foot compartments. He had moderate edema and ecchymosis around his foot and no other lower extremity or back injuries. Lateral radiograph of the right ankle is shown (Fig. 5–66).
 |
Figure 5–66 Lateral radiograph of the ankle.
What is the appropriate next step in management?
-
X-rays of the contralateral ankle
-
Padded splint and crutches with referral to clinic
-
Urgent orthopaedic evaluation and surgical treatment
-
Delayed surgical intervention once soft tissue edema has resolved
Discussion
The correct answer is (C). Fractures of the posterior tuberosity may be intra-articular or extra-articular. Figure 5–66 shows a beak fracture of the calcaneus with
intra-articular extension. This fracture has a significant risk of damaging the thin layer of skin and soft tissue over the posterior calcaneus by pressure necrosis. Urgent evaluation of the soft tissues will frequently show puckering of the soft tissues in the fracture gap, and blanching of the skin overlying the prominent fracture fragment posteriorly. This injury should be evaluated urgently and treated with reduction before the pressure on the skin causes necrosis. Despite swelling and ecchymosis, this fracture is not appropriate to be referred to clinic for delayed fixation. The procedure can often be performed with a limited open approach and screw fixation to minimize further injury to the soft tissues (Figs. 5–67 and 5–68).
 |
Figure 5–67 A percutaneous guide pin is placed into the posterior calcaneal tuberosity to control the main fragment and lever it into an anatomically reduced position.
 |
Figure 5–68 The posterior tuberosity fragment is fixed with two large fragment screws after anatomic reduction, thereby preserving the posterior soft tissue envelope.
Objectives: Did you learn...?
Identify the importance of soft tissue injury associated with calcaneal beak fractures?
Discuss the standard treatment approach for a calcaneal beak fracture with posterior skin tenting?