Friday, April 25, 2008

Anterior Process Calcaneus Fracture

The calcaneus, or heel bone, is the largest tarsal bone. Most fractures of the calcaneus are typically easily seen on MRI, but if you are not careful, it is easy to miss a fracture of the anterior process of the calcaneus.

The fracture can be difficult to see on x-rays, especially the anteroposterior and lateral views. 16 year-old teenage girl with pain after trauma, with negative x-rays:


Sagittal STIR and T1 images reveal a subtle fracture (red arrows) of the anterior process of the calcaneus, with mild edema. Correlative CT scan confirms the fracture:



These fractures are typically treated with protected weight bearing. Displaced fractures involving more than 25% of the calcaneocuboid articular surface are usually treated operatively.

Note that an accessory ossicle (os calcaneus secundarius) can be difficult to distinguish from an anterior process fracture, especially if the suspected fracture is subacute or chronic in nature. History and correlation with the clinical examination will be needed in these cases.

Thus, it's a good idea to look specifically at anterior process of the calcaneus in any patient with a history of trauma, whether you are looking an x-ray, CT, or MRI. Many of these patients have the fracture missed initially, and present with chronic hindfoot pain.


17 comments:

Anonymous said...

This is exactly what I needed to read. For three weeks the break in my foot went undiagnosed. Upon returning to LSU Medical Center in Houma, Louisisan, also known as Chabert Medical Center, an MRI was done by the order of Dr. Jonathon Allen and that revealed a fracture of the anterior process of the left os calcis adjacent to the calcaneal cuboid joint. This is the closest thing that I have found on line. I was seen in the emergency room and was fitted with a cast that covered both sides of my calf and ankle and was wrapped with ace bandages. It got pretty wet and I removed it after several days. I am a 57 year old grandmother who can't be too immobile. There is no one to do my job. Because I was supposed to be scheduled with an appointment with an orthopedic doctor I didn't worry too much about getting back there to be refitted for a new cast. At first, my ankle was feeling really great and after a week or two of no cast, I am aware of the pain in my foot. Any suggestions, besides get back there for a new cast. Constance Rorers; webaddress/ mellebelle74@msn.com

Heather said...

I'll be dipped - this does look a lot like what I've got going on in my foot. That said, my podiatrist didn't remark on it, but that's where my pain and edema are.

(http://farm4.static.flickr.com/3590/3381544843_227937ed8a_o.jpg for the MRI if you'd like it.)

I'm going to crosslink to your blog, if that's okay. And get a second opinion.

Melissa said...

Sounds like me too. I injured my foot over a month ago and the doctors couldn't figure out if it was broke or not. I had incredible pain for several weeks, swelling, and circulation issues with no diagnosis. Two xrays and CT later I finally got the answer. I just got a call from doctors after reading CT scan results that it is indeed broke, a transverse fracture through the anterior process of the calcaneus. Go to see an orthopedic doctor tomorrow.

Anonymous said...

Sounds like the pain I am in now, they keep telling me it isn't broken.

Heather said...

On July 21st, I stepped down wrong (yeah, klutzy, i know) and the X-ray done in the ER didn't reveal anything ... a week later, I had a second x-ray because it still really hurt and motrin didn't do anything ... that x-ray didn't reveal anything either so they sent me for a CT scan ... it took another week to get the CT ... the CT revealed the break mentioned here and a navicular fracture ... it's going to take me another week to be seen by an orthopedic surgeon and I was told to stay off of my foot. I'm the mother of two small children (nearly 4 and 2.5) and classes start in a few weeks ... how am I supposed to stay off of my foot?

nop said...

I have an anterior Process Calcaneous which was diagnosed 2 weeks after the incident. They initially gave me treatment for a sprain.I am in an aircast now and wil see the surgeon in 2 weeks. There is also minor para tendonitis of the Achilles. What is worrying me is that my foot can not bend backwards (tows down). Tows up, I can do. Is there a reason for that? Am I going to reamin limping for the rest of my life or is this something that gradually will get better?

Anonymous said...

I was diagnosed with this fracture over 2 years after the fall, plus after 1 mri, 3 xrays, 4 months in a walking cast, 6 months of PT, and 3 months in a brace. The podiatrist missed it and the ortho specialist nailed it within a week.
I had surgery 5 weeks ago and get my cast off in another week. I'm a distance runner and hope to be able to complete my first 50 miler in a year. What kind of pain levels do people have post op?? I've read things saying some people have pain forever and some it completely goes away...I hope I'm the second type!
Good luck to everyone!

Anonymous said...

It sounds like these kinds of fractures are hard to diagnose. A bad injury on my left ankle left me with a chronic something that bothered when doing certain exercises (Running, tennis, any full motion move of the foot). A small fall caused lots of swelling and pain so I went to a foot and ankle specialist because the swelling was just not from the cut; after 3 X rays I was diagnosed with Tibiales Tendonitis and “possible early stages of arthritis” caused by my history of chronic injury. I was put on an air boot cast for a month, lots of swelling and pain during that time! Went back to the doctor, ohhh lets send you for some PT. I went to PT 3 times a week for 3 weeks and kept the boot cast during this time. I will cry and be in bad pain during therapy and daylong after. Went back to the doctor after 10 sessions of PT and 2 months of boot cast, a new X ray caught my Calcano Navicular Fracture. I am scheduled for a CT tomorrow and surgery Oct 16th I just want to be over with this!

Lisa said...

I injured my foot the end of January. My primary DR took an xray and of course didn't see anything and gave me an aircast. Went to an orthopedist in March, did an MRI. MRI revealed a bone bruise in anterior process of calcaneus with a possible stress fracture. I wore a boot for 5-6 weeks till the end of May. It was better but not 100%. By the end of July, the pain was there when I walked barefoot, ran, stood on toes, walked backward, walked on sand. So.. went to a podiatrist today that did a different type of x-ray that showed a fracture, not a stress fracture. He said MRI's sometimes miss fractures as they are image slices, and if the fracture is at the location of the edge of a slice, it might be missed. So.. I'm in a boot for 6 ish weeks and wondering what would have happened had I gone to a podiatrist initially instead of an orthopedist that didn't specialize in any certain body parts.

Jen said...

I did this to my foot while 37 weeks pregnant. I now have a bump on the outside of my foot that is much more pronounced than on the other foot. May have done more than just the fracture. Going for tests next month. Was on crutches for 5-6 weeks (baby came early at 38 weeks). Limped for at least 5 months. 20 months later and it is still not normal. I can walk fine, but don't think I can run. There is some "pain" around the bump when pressed. Sometimes aches/hurts across the top of the foot at the ankle. Other times is aches/hurts on the side by the bump. When I injured it, it didn't hurt at all; I was actually laughing because I was mortified to be that pregnant and having to go to the hospital in an ambulance. It was an inverse injury meaning that when I injured it, my foot rolled outward. I did hear a pop, and I couldn't stand after that. Now, I don't like to walk barefoot because the foot is still rolled a bit, and I tend to walk on the outer edge of the foot which hurts the ball of my little toe.

SaraKate said...

This is the exact break that I currently am recovering from. In December of 2009, I fell and sprained my left ankle. 7 months later, I still had pain and swelling after exercising, long walks, swimming etc. A visit to my podiatrist revealed a break in the anterior process of the calcaneus. The XRay showed the break a bit, but the CT revealed the true break which was 0.6 x 1 mm. The Radiologist actually missed it on the first read. I am 3 days post surgery for the removal of the small fragment. They had to bisect the muscle to remove it. I have a soft cast for 1 week and then get a hard cast for 2 weeks. After that I think I am in a boot. Anybody else have a similar experience? I am wondering about the recovery since they only did an extraction of the bone, not a fusion. I have no pain, with little meds, and elevation as much as possible. I have 2 kids at home (7,4) and it's gonna be a long haul.

cahancock81 said...

just what i needed to read too, my 7 year old daughter twisted her ankle and fell on it from about 2foot height, .... after an xray there was no break, .... 3 weeks and 5 days later, she still can't weight bear and it is still very swolen, mainly below the ankle and across front of foot, i took her back to a&e and demanded another x-ray , .... to which the nurse has said there is an area on the x-ray that looks rough that should be smooth on the bone below the ankle??? (not sure what meant by that) and that i am to go back with her in 3 days after she has had a consultant look at the x-ray, after coming on here and looking it seems this maybe the same fracture my daughter possibly has. Fingers crossed she will be on the mend very soon!!!

marli said...

Just got this injury 3days ago. Thank goodness my orthopedist was able to diagnose it from the patterns of pain and swelling and the x ray. I'm on crutches with a support sock and allowed to move the foot up and down a little but with no twisting or weight bearing. After a couple of more days I will start bearing a little weight with the boot and increase time in the boot gradually as tolerated (based on swelling and discomfort). Except for limited movement my Dr. wants the foot propped up (higher than the heart) to manage swelling and avoid blood clot) for the next 2 weeks until I see him for followup. Right at the beginning of summer!

marli said...

Just got this injury 3 days ago. My orthopedist was able to diagnose it based on the patterns of pain and swelling and an x ray, thank goodness. He has me bearing no weight (on crutches) for a couple of more days with my foot and calf in a support "stocking", propped up higher than my heart to manage swelling and blood clot risk. Then I can slowly start to use a boot for gradually increasing periods based on swelling and discomfort. He is allowing me to move the foot up and down little but no twisting. He said this often goes undisclosed for some time without a CT so I am very grateful to him for an early diagnosis especially after reading about these difficult situations. Still wish it hadn't happened at the beginning of summer but I'll start making my wish list for next summer's activities, I guess.

4simonboyz said...

I 'sprain' my ankle more than 4 weeks ago. After misdiagnosis of x-rays, Doppler x-rays and an MRI, I finally was referred to an Ankle and Foot Specialist. He took 2 little x-rays and right there, it was diagnosed. He even showed it to me on the x-ray! Why couldn't 2 radiologists, an ER doctor and an Internal Medicine see that in the MRI?? Anyway, he put me in a Walking Air-Cast. Thank you Dr.Oldani!

Danielle said...

I'm trying to decide what to do about surgery right now. I have had the fracture for 2 years now, it had gone undetected, I'm having hip and knee pain, and my pain is getting worse. Has anyone experienced anything similar

cassie quah said...

I walk with a limp after i learned that i had fractured the anterior calcaneus. it has been over 1 year now, and find it very shaky and unstable on my left foot and there is mild edema there in the left foot too. I wonder when ill ever stop limping? my podiatrist says give it a few months. really hope that is the case, i feel so silly limping around everywhere i go.