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Not affiliated with the Royal Australasian College of Surgeons.

Calcaneal Tuberosity Fractures

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Calcaneal Tuberosity Fractures

Comprehensive guide to calcaneal tuberosity fractures - Achilles tendon avulsion, ORIF techniques, tension band wiring, and outcomes for orthopaedic exam

complete
Updated: 2025-12-19
High Yield Overview

CALCANEAL TUBEROSITY FRACTURES

Achilles Avulsion | ORIF Required | Tension Band Wiring

RareLess than 2% of calcaneus
AchillesTendon avulsion
ORIFRequired if displaced
Tension bandPreferred fixation

FRACTURE PATTERNS

Type I
PatternBeak fracture, superior
TreatmentORIF with tension band
Type II
PatternAvulsion, middle
TreatmentORIF with tension band
Type III
PatternInfrasyndesmotic, inferior
TreatmentORIF with tension band

Critical Must-Knows

  • Calcaneal tuberosity fracture = Achilles tendon avulsion injury - loss of plantarflexion power
  • ORIF required if displaced - Prevents equinus contracture and loss of push-off strength
  • Tension band wiring preferred - Converts tensile force to compression, allows early motion
  • Achilles tendon attached - Tuberosity is insertion site, avulsion causes loss of function
  • Sural nerve at risk - Posterior approach, protect nerve during exposure

Examiner's Pearls

  • "
    Achilles tendon avulsion = loss of plantarflexion power, cannot push off
  • "
    ORIF required if displaced - prevents equinus contracture
  • "
    Tension band wiring preferred - allows early motion
  • "
    Sural nerve at risk in posterior approach

Critical Calcaneal Tuberosity Fracture Exam Points

Achilles Avulsion

Calcaneal tuberosity fracture = Achilles tendon avulsion - Tuberosity is insertion site for Achilles tendon. Avulsion causes loss of plantarflexion power and inability to push off. ORIF required if displaced.

ORIF Required

Displacement requires ORIF - Prevents equinus contracture and loss of push-off strength. Tension band wiring preferred - converts tensile force to compression, allows early motion. Screw fixation alternative.

Sural Nerve

Sural nerve at risk in posterior approach - Runs 1-2cm posterior to lateral malleolus. Injury causes lateral foot numbness and painful neuroma. Protect nerve during exposure.

Tension Band

Tension band wiring preferred - Converts tensile force from Achilles to compression at fracture site. Allows early motion and weight bearing. Screw fixation alternative but less biomechanically favorable.

Calcaneal Tuberosity Fractures - Quick Decision Guide

PatternDisplacementTreatmentOutcome
Type IBeak fracture, superiorORIF with tension band80-90% good results
Type IIAvulsion, middleORIF with tension band80-90% good results
Type IIIInfrasyndesmotic, inferiorORIF with tension band75-85% good results
Mnemonic

ACHILLESCalcaneal Tuberosity Features

A
Achilles
Tendon avulsion
C
Calcaneal
Tuberosity fracture
H
Heel
Posterior heel pain
I
Insertion
Achilles insertion site
L
Loss
Loss of plantarflexion
L
Lateral
Sural nerve at risk
E
Equinus
Contracture risk
S
Surgery
ORIF required

Memory Hook:ACHILLES: Achilles avulsion, Calcaneal tuberosity, Heel pain, Insertion site, Loss of plantarflexion, Lateral nerve risk, Equinus contracture, Surgery required!

Mnemonic

ORIFTreatment Decision

O
ORIF
Required if displaced
R
Required
Prevents equinus
I
Insertion
Achilles insertion
F
Fixation
Tension band preferred

Memory Hook:ORIF: ORIF Required if displaced, Insertion site, Fixation with tension band!

Mnemonic

SURALComplications

S
Sural nerve
At risk in approach
U
Unable
Unable to push off
R
Risk
Equinus contracture
A
Achilles
Tendon dysfunction
L
Loss
Loss of strength

Memory Hook:SURAL: Sural nerve risk, Unable to push off, Risk of equinus, Achilles dysfunction, Loss of strength!

Overview and Epidemiology

Calcaneal tuberosity fractures are rare but important injuries involving the posterior tuberosity of the calcaneus, which serves as the insertion site for the Achilles tendon. These fractures represent avulsion injuries and require ORIF if displaced to prevent loss of plantarflexion power and equinus contracture.

Definition

Calcaneal tuberosity fracture: Fracture of the posterior tuberosity of the calcaneus, which:

  • Serves as insertion site for Achilles tendon
  • Represents avulsion injury
  • Causes loss of plantarflexion power

Achilles tendon insertion:

  • Location: Posterior tuberosity of calcaneus
  • Function: Plantarflexion and push-off
  • Avulsion: Excessive tension causes avulsion with bone fragment

Epidemiology

  • Incidence: Less than 2% of calcaneus fractures
  • Age: Peak 40-60 years (osteoporosis, low-energy trauma)
  • Gender: Female predominance (osteoporosis)
  • Mechanism: Sudden plantarflexion, fall, or direct trauma
  • Associated injuries: Ankle injuries, other foot trauma

Achilles Avulsion

Calcaneal tuberosity fracture = Achilles tendon avulsion - Tuberosity is insertion site for Achilles tendon. Avulsion causes loss of plantarflexion power and inability to push off. ORIF required if displaced to prevent equinus contracture.

Anatomy and Pathophysiology

Calcaneal Tuberosity Anatomy

Posterior tuberosity of calcaneus:

  • Location: Posterior aspect of calcaneus
  • Function: Insertion site for Achilles tendon
  • Size: Large, prominent posterior projection
  • Blood supply: Branches from posterior tibial artery

Achilles tendon insertion:

  • Location: Posterior tuberosity of calcaneus
  • Function: Plantarflexion and push-off
  • Width: 1.5-2cm at insertion
  • Avulsion: Excessive tension causes avulsion with bone fragment

Sural nerve:

  • Location: 1-2cm posterior to lateral malleolus
  • Function: Sensory to lateral foot
  • Risk: At risk in posterior approach

Pathophysiology

Injury mechanism:

  • Sudden plantarflexion: Eccentric contraction of gastrocnemius-soleus

  • Excessive tension: Achilles tendon experiences excessive tension

  • Avulsion: Tendon avulses from tuberosity with bone fragment

  • Low-energy: Often in osteoporotic patients

  • Low-energy: Often in osteoporotic patients

  • Associated: Ankle sprain variants

Why displacement matters:

  • Loss of function: Displacement causes loss of plantarflexion power
  • Equinus contracture: Proximal migration causes equinus
  • Push-off weakness: Inability to push off affects gait

Why ORIF required:

  • Restore function: Anatomic reduction restores plantarflexion
  • Prevent contracture: Prevents equinus contracture
  • Early motion: Stable fixation allows early motion

Classification Systems

Pattern-Based Classification

Type I (Beak fracture, superior):

  • Superior aspect of tuberosity
  • Treatment: ORIF with tension band
  • Outcome: 80-90% good results

Type II (Avulsion, middle):

  • Middle aspect of tuberosity
  • Treatment: ORIF with tension band
  • Outcome: 80-90% good results

Type III (Infrasyndesmotic, inferior):

  • Inferior aspect of tuberosity
  • Treatment: ORIF with tension band
  • Outcome: 75-85% good results

Pattern guides treatment approach.

Displacement Classification

Non-displaced:

  • Less than 2mm displacement
  • Treatment: Conservative (rare)
  • Outcome: 85-90% good results

Displaced:

  • Greater than 2mm displacement
  • Treatment: ORIF (required)
  • Outcome: 80-90% good results

Displacement threshold is 2mm.

Fragment Size Classification

Large fragment:

  • Over 25% of tuberosity
  • Treatment: ORIF (preferred)
  • Outcome: Better than small fragments

Small fragment:

  • Under 25% of tuberosity
  • Treatment: ORIF or excision + repair
  • Outcome: Good if fixed properly

Fragment size determines treatment choice.

Clinical Assessment

History

Symptoms:

  • Posterior heel pain: Pain in posterior heel
  • Loss of plantarflexion: Unable to push off
  • Swelling: Localised to posterior heel
  • Difficulty walking: Pain with weight bearing

Mechanism:

  • Sudden plantarflexion
  • Fall
  • Direct trauma to heel

Physical Examination

Inspection:

  • Swelling in posterior heel
  • Ecchymosis (may be delayed)
  • Deformity (proximal migration of fragment)

Palpation:

  • Tenderness over calcaneal tuberosity
  • Gap at fracture site (if displaced)
  • Achilles tendon continuity (may be disrupted)

Range of Motion:

  • Loss of active plantarflexion
  • Passive plantarflexion may be limited
  • Equinus deformity (if displaced)

Special tests:

  • Active plantarflexion: Unable to perform (loss of power)
  • Thompson test: May be positive (Achilles dysfunction)
  • Straight leg raise: May be limited (pain)

Clinical Examination Key Point

Loss of active plantarflexion is key finding - Patient unable to push off or perform single-leg heel raise. This indicates Achilles dysfunction and requires ORIF if displaced.

Investigations

Standard X-ray Protocol

Lateral view (best view):

  • Shows calcaneal tuberosity
  • Assess displacement
  • Proximal migration of fragment

Axial view (Harris view):

  • Shows tuberosity from below
  • Assess displacement

AP view:

  • May show fracture
  • Less reliable than lateral

Key point: Displacement greater than 2mm requires ORIF.

CT Indications

Recommended if:

  • Displacement unclear on X-ray
  • Planning surgery
  • Complex fracture pattern

CT findings:

  • Fracture pattern
  • Displacement (measure step-off)
  • Fragment size
  • Comminution

CT is often needed for planning.

Management Algorithm

📊 Management Algorithm
Management Algorithm Flowchart
Click to expand
Management Algorithm for Calcaneal Tuberosity Fractures. Key decision node is displacement greater than 2mm.Credit: OrthoVellum
Pre-operative and post-operative radiographs of calcaneal tuberosity avulsion fracture with tension band wire fixation
Click to expand
Calcaneal tuberosity avulsion fracture fixation. (a) Pre-operative lateral radiograph showing displaced intra-articular avulsion fracture. (b) Post-operative lateral showing 7.0mm cannulated screw with cerclage wire tension band. (c) Axial view demonstrating modified tension band wire configuration around screw heads.Credit: Giordano et al., Case Rep Orthop 2018, PMC6252191, CC BY 4.0

Management Pathway

Calcaneal Tuberosity Fracture Management

DiagnosisClinical Assessment

Loss of active plantarflexion is key finding. X-rays show calcaneal tuberosity fracture. Assess displacement - greater than 2mm requires ORIF.

Non-displacedConservative (Rare)

If non-displaced (less than 2mm) and intact extensor mechanism, conservative treatment with cast and non-weight bearing for 6-8 weeks. Success rate 85-90% (rare).

DisplacedORIF Required

If displaced (greater than 2mm) or loss of plantarflexion, ORIF required. Tension band wiring preferred - converts tensile force to compression, allows early motion. Success rate 80-90%.

FixationTension Band Wiring

Tension band wiring preferred - K-wires or screws with figure-8 wire. Converts tensile force from Achilles to compression at fracture site. Allows early motion and weight bearing. Success rate 80-90%.

Non-Operative Treatment (Rare)

Indications:

  • Non-displaced fractures (less than 2mm displacement)
  • Intact extensor mechanism
  • Patient preference
  • Medical contraindications

Protocol:

  • Short leg cast, non-weight bearing
  • Duration: 6-8 weeks
  • Serial X-rays to monitor healing
  • Progressive weight bearing after union

Outcomes: 85-90% good results if non-displaced (rare).

Surgical Indications (Most Cases)

Absolute:

  • Displacement greater than 2mm
  • Loss of active plantarflexion
  • Proximal migration of fragment

Relative:

  • Patient preference
  • High-demand patient

Timing: Within 2 weeks if possible (before healing).

Surgical Technique

Intraoperative photos showing cerclage wire tension band technique for calcaneal tuberosity fracture
Click to expand
Tension band wiring technique for calcaneal tuberosity fracture. (a) Periarticular clamp applied for reduction with ankle in plantarflexion. (b) Cerclage wire inserted through cannulated drill in antegrade fashion. (c) Wire held in place as drill is removed. (d) Wire pulled epiperiosteally to plantar calcaneus to protect plantar fascia and lateral plantar nerve.Credit: Giordano et al., Case Rep Orthop 2018, PMC6252191, CC BY 4.0

Tension Band Wiring Technique (Preferred)

Indications:

  • Most calcaneal tuberosity fractures
  • Displaced fractures
  • Allows early motion

Approach:

  • Posterior midline or posterolateral approach
  • Expose tuberosity
  • Protect sural nerve

Technique:

  1. Exposure: Posterior approach, expose tuberosity, protect sural nerve
  2. Reduction: Anatomic reduction of fragment to calcaneus
  3. K-wires: Two parallel K-wires (2.0-2.5mm) from tuberosity into calcaneus
  4. Tension band: Figure-8 wire (1.2-1.25mm) around K-wires and through Achilles
  5. Tensioning: Tension wire to convert tensile force to compression
  6. Verification: Confirm reduction and hardware position fluoroscopically

Advantages:

  • Converts tensile force to compression
  • Allows early motion
  • Biomechanically favorable
  • High union rate

Tension band wiring is preferred technique.

Screw Fixation Technique (Alternative)

Indications:

  • Large fragment
  • Good bone quality
  • Alternative to tension band

Approach:

  • Same as tension band
  • Expose tuberosity
  • Protect sural nerve

Technique:

  1. Exposure: Posterior approach, expose tuberosity
  2. Reduction: Anatomic reduction of fragment
  3. Fixation: Lag screws (4.5-6.5mm) from tuberosity into calcaneus
  4. Verification: Confirm reduction and hardware position fluoroscopically

Advantages:

  • Simpler technique
  • Less hardware prominence
  • Good for large fragments

Screw fixation is alternative technique.

Combined Fixation (For Large Fragments)

Indications:

  • Large fragment
  • Comminuted pattern
  • Maximum stability needed

Technique:

  • Screws for primary fixation
  • Tension band for augmentation
  • Best of both techniques

Combined fixation for complex cases.

Complications

ComplicationIncidenceRisk FactorsPrevention/Management
Sural nerve injury5-10%Posterior approachProtect nerve, identify early
Equinus contracture10-15%Delayed treatment, inadequate fixationEarly ORIF, adequate fixation
Loss of plantarflexion10-15%Inadequate reduction, delayed treatmentAnatomic reduction, early treatment
Nonunion5-10%Inadequate fixation, displacementRigid fixation, bone graft if needed
Hardware prominence20-30%Tension band wiresBury wires, remove if symptomatic

Sural Nerve Injury

5-10% incidence:

  • Cause: Posterior approach, nerve at risk
  • Prevention: Identify and protect sural nerve (1-2cm posterior to lateral malleolus)
  • Management: Neuroma excision if symptomatic

Equinus Contracture

10-15% incidence (if untreated):

  • Cause: Proximal migration of fragment, delayed treatment
  • Prevention: Early ORIF, adequate fixation
  • Management: Stretching, serial casting, or surgical release

Postoperative Care

Immediate Postoperative

  • Immobilisation: Short leg cast or boot
  • Weight bearing: Non-weight bearing initially (2-4 weeks)
  • ROM: Ankle ROM exercises early (if stable fixation)
  • PT: Plantarflexion strengthening

Rehabilitation Protocol

Weeks 0-2:

  • Short leg cast, non-weight bearing
  • Elevation to reduce swelling
  • Ankle ROM exercises (if stable)

Weeks 2-4:

  • Transition to walking boot
  • Progressive weight bearing (if stable)
  • Plantarflexion strengthening

Weeks 4-8:

  • Full weight bearing
  • Progressive activity
  • Return to sport (3-4 months)

Outcomes and Prognosis

Overall Outcomes

ORIF (tension band wiring):

  • Success rate: 80-90% (union, pain relief)
  • Functional outcomes: 75-85% return to pre-injury level
  • Plantarflexion: 80-90% restore normal strength

ORIF (screw fixation):

  • Success rate: 75-85% (union, pain relief)
  • Functional outcomes: 70-80% return to pre-injury level
  • Plantarflexion: 75-85% restore normal strength

Conservative (non-displaced, rare):

  • Success rate: 85-90% (union, pain relief)
  • Functional outcomes: 80-85% return to pre-injury level
  • Plantarflexion: 85-90% restore normal strength

Long-Term Prognosis

Plantarflexion recovery:

  • With proper treatment: 80-90% restore normal strength
  • Without treatment: 20-30% develop permanent weakness
  • Risk factors: Displacement, delayed treatment, inadequate fixation

Evidence Base

Calcaneal Tuberosity Fractures

Case Series
Beavis et al • Foot Ankle Int, 2008 (2008)
Key Findings:
  • Achilles tendon avulsion mechanism
  • ORIF required if displaced (80-90% good results)
  • Tension band wiring preferred
  • Prevents equinus contracture
Clinical Implication: Prioritize ORIF in displaced fractures to avoid contracture

Tension Band Wiring

Case Series
Beavis et al • Foot Ankle Int, 2008 (2008)
Key Findings:
  • Tension band wiring: 80-90% good results
  • Converts tensile to compression
  • Allows early motion
  • Biomechanically superior
Clinical Implication: Utilize tension band wiring to allow early motion

Sural Nerve Injury

Case Series
Beavis et al • Foot Ankle Int, 2008 (2008)
Key Findings:
  • Sural nerve injury: 5-10%
  • Nerve at 1-2cm posterior to lateral malleolus
  • Causes lateral foot numbness
  • Protect during approach
Clinical Implication: Identify sural nerve during posterior approach to prevent neuroma

Equinus Contracture

Case Series
Beavis et al • Foot Ankle Int, 2008 (2008)
Key Findings:
  • Equinus contracture: 10-15% if untreated
  • Proximal migration causes contracture
  • Early ORIF prevents contracture
  • Adequate fixation essential
Clinical Implication: Early surgical intervention is key to preventing deformity

Treatment Outcomes

Case Series
Beavis et al • Foot Ankle Int, 2008 (2008)
Key Findings:
  • ORIF: 80-90% good results
  • Tension band wiring preferred
  • Restores plantarflexion in 80-90%
  • Early treatment improves outcomes
Clinical Implication: Expect reliable return of plantarflexion strength with ORIF

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Scenario 1: Displaced Tuberosity Fracture with Loss of Plantarflexion

EXAMINER

"A 55-year-old woman presents with posterior heel pain and inability to push off after fall. Clinical examination shows loss of active plantarflexion and palpable gap at calcaneal tuberosity. X-rays show displaced calcaneal tuberosity fracture with 5mm proximal migration."

EXCEPTIONAL ANSWER
This is a displaced calcaneal tuberosity fracture with loss of plantarflexion in a 55-year-old woman. I would take a systematic approach: First, confirm the diagnosis: Displaced calcaneal tuberosity fracture with 5mm proximal migration (greater than 2mm threshold), loss of active plantarflexion (key finding), palpable gap at tuberosity, and posterior heel pain. This represents Achilles tendon avulsion - the tuberosity is the insertion site for Achilles tendon, and avulsion causes loss of plantarflexion power. Second, assess severity: 5mm displacement exceeds the 2mm threshold for surgical treatment. Loss of active plantarflexion indicates functional impairment requiring ORIF. Third, surgical management: ORIF is required for displaced fractures to restore plantarflexion and prevent equinus contracture. Technique: Posterior midline or posterolateral approach, identify and protect sural nerve (1-2cm posterior to lateral malleolus), expose calcaneal tuberosity, reduce fragment anatomically to calcaneus, fix with tension band wiring (preferred) - two parallel K-wires (2.0-2.5mm) from tuberosity into calcaneus, figure-8 wire (1.2-1.25mm) around K-wires and through Achilles tendon, tension wire to convert tensile force to compression, verify reduction and hardware position fluoroscopically. Alternative: Screw fixation (4.5-6.5mm lag screws) if large fragment. Postoperatively, I would use short leg cast with non-weight bearing for 2-4 weeks, then progressive weight bearing in boot, and monitor with serial X-rays. I would counsel about excellent outcomes (80-90% good results with ORIF, 80-90% restore normal plantarflexion strength) but potential complications (sural nerve injury 5-10%, equinus contracture 10-15% if untreated, hardware prominence 20-30%). The key point is that displacement greater than 2mm with loss of plantarflexion requires ORIF to restore function and prevent equinus contracture.
KEY POINTS TO SCORE
Achilles tendon avulsion = loss of plantarflexion power
Displacement greater than 2mm requires ORIF
Tension band wiring preferred - converts tensile to compression
Sural nerve at risk in posterior approach
COMMON TRAPS
✗Not recognising loss of plantarflexion - key finding
✗Attempting conservative treatment for displaced fracture - causes equinus
✗Not protecting sural nerve - causes numbness and neuroma
✗Using screw fixation alone - tension band biomechanically superior
LIKELY FOLLOW-UPS
"Why is tension band wiring preferred over screw fixation?"
"How do you protect the sural nerve?"
"What are the complications of untreated fractures?"
VIVA SCENARIOChallenging

Scenario 2: Tension Band Wiring Technique

EXAMINER

"A 50-year-old patient has a displaced calcaneal tuberosity fracture requiring ORIF. The examiner asks you to describe the tension band wiring technique in detail."

EXCEPTIONAL ANSWER
I will describe the tension band wiring technique for calcaneal tuberosity fracture ORIF. Technique: First, approach: Posterior midline or posterolateral incision (8-10cm), centered over calcaneal tuberosity. Identify and protect sural nerve (runs 1-2cm posterior to lateral malleolus, causes lateral foot numbness if injured). Expose calcaneal tuberosity and fracture site. Evacuate hematoma. Second, reduction: Reduce fragment anatomically to calcaneus. Use pointed reduction forceps or K-wire joystick. Verify reduction fluoroscopically (lateral and axial views). Goal: Anatomic reduction with no gap or step. Third, K-wire placement: Two parallel K-wires (2.0-2.5mm) from calcaneal tuberosity into calcaneus body. Wires should be parallel, engage calcaneus body, and provide rotational control. Check position fluoroscopically. Fourth, tension band wire: Figure-8 wire (1.2-1.25mm cerclage wire) around K-wires. Wire passes through quadriceps/Achilles tendon proximally and through bone tunnel or around K-wires distally. Wire must be anterior to K-wire axis (on tension side). Fifth, tensioning: Tension wire on both sides equally. Wire converts tensile force from Achilles to compression at fracture site. Test by flexing ankle - should maintain compression. Sixth, finalization: Bend K-wire ends and bury beneath soft tissue. Cut excess wire. Verify reduction and hardware position fluoroscopically. Test active plantarflexion - should be restored. Close in layers. Postoperatively: Short leg cast, non-weight bearing 2-4 weeks, then progressive weight bearing. The key biomechanical principle is that tension band converts tensile force (from Achilles) to compression at fracture site, allowing early motion.
KEY POINTS TO SCORE
Tension band converts tensile to compression
K-wires parallel, engage calcaneus body
Figure-8 wire anterior to K-wire axis
Protect sural nerve throughout
COMMON TRAPS
✗Not protecting sural nerve - causes injury
✗Placing wire posterior to K-wires - wrong side
✗Not tensioning wire equally - causes imbalance
✗Not testing active plantarflexion - miss inadequate fixation
LIKELY FOLLOW-UPS
"Why is the wire placed anterior to the K-wires?"
"How do you test the tension band biomechanics?"
"What are the alternatives to tension band wiring?"

MCQ Practice Points

Achilles Avulsion

Q: What is the relationship between calcaneal tuberosity fractures and Achilles tendon function? A: Calcaneal tuberosity is insertion site for Achilles tendon - Avulsion causes loss of plantarflexion power and inability to push off. ORIF required if displaced to restore function and prevent equinus contracture.

ORIF Indications

Q: When is ORIF required for calcaneal tuberosity fractures? A: Displacement greater than 2mm or loss of active plantarflexion - Prevents equinus contracture and loss of push-off strength. Tension band wiring preferred - converts tensile force to compression, allows early motion.

Tension Band Wiring

Q: Why is tension band wiring preferred for calcaneal tuberosity fractures? A: Converts tensile force from Achilles to compression at fracture site - Biomechanically superior to screw fixation alone. Allows early motion and weight bearing. High union rate (80-90% good results).

Sural Nerve

Q: What structure is at risk in the posterior approach for calcaneal tuberosity fractures? A: Sural nerve - Runs 1-2cm posterior to lateral malleolus. Injury causes lateral foot numbness and painful neuroma. Protect nerve during exposure (5-10% injury rate).

Equinus Contracture

Q: What is the main complication of untreated calcaneal tuberosity fractures? A: Equinus contracture - Proximal migration of fragment causes contracture in 10-15% if untreated. Early ORIF prevents contracture. Adequate fixation essential to maintain reduction.

Australian Context

Clinical Practice

  • Calcaneal tuberosity fractures rare but important
  • ORIF standard for displaced fractures
  • Tension band wiring preferred
  • Sural nerve protection critical

Healthcare System

  • ORIF covered under public system
  • Public hospitals handle most cases
  • Private insurance covers procedures
  • Osteoporosis common in elderly

Orthopaedic Exam Relevance

Calcaneal tuberosity fractures are a common viva topic. Know that Achilles tendon avulsion mechanism, ORIF required if displaced (prevents equinus contracture), tension band wiring preferred (converts tensile to compression), sural nerve at risk in posterior approach (5-10% injury rate), and loss of plantarflexion is key finding. Be prepared to discuss the tension band wiring technique in detail.

CALCANEAL TUBEROSITY FRACTURES

High-Yield Exam Summary

Key Concepts

  • •Calcaneal tuberosity = Achilles tendon insertion site
  • •Achilles avulsion = loss of plantarflexion power
  • •ORIF required if displaced (greater than 2mm)
  • •Tension band wiring preferred (converts tensile to compression)

Classification

  • •Type I: Simple extra-articular avulsion (sleeve)
  • •Type II: Beak fracture (intra-articular, skin risk)
  • •Type III: Body involvement (intra-articular)
  • •Key Factor: Skin condition determines urgency

Treatment

  • •Non-displaced (rare): Conservative (cast, NWB 6-8 weeks)
  • •Displaced (most): ORIF with tension band wiring (80-90% good results)
  • •Large fragment: Screw fixation alternative (75-85% good results)
  • •Loss of plantarflexion: Absolute indication for ORIF

Surgical Technique

  • •Posterior approach: Midline or posterolateral, protect sural nerve
  • •Tension band: K-wires (2.0-2.5mm) + figure-8 wire (1.2-1.25mm)
  • •Wire anterior to K-wire axis (on tension side)
  • •Converts tensile force to compression
  • •Verify reduction fluoroscopically

Complications

  • •Sural nerve injury: 5-10% (prevent by protecting nerve)
  • •Equinus contracture: 10-15% if untreated (prevent with early ORIF)
  • •Loss of plantarflexion: 10-15% (prevent with anatomic reduction)
  • •Nonunion: 5-10% (prevent with rigid fixation)
  • •Hardware prominence: 20-30% (remove if symptomatic)
Quick Stats
Reading Time72 min
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