The Journal of Foot & Ankle Surgery 54 (2015) 458–463
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Superior Peroneal Retinacular Injuries in Calcaneal Fractures Kwasi Yiadom Kwaadu, DPM, AACFAS 1, Justin James Fleming, DPM, FACFAS 2, 3, Derek Florek, DPM, AACFAS 4 1
Assistant Professor, Temple University School of Podiatric Medicine, Philadelphia, PA Fellowship Director, Philadelphia Foot and Ankle Fellowship, Aria 3B Orthopaedic Institute Northeast, Muscle, Bone, and Joint Center, Philadelphia, PA 3 Podiatric Residency Director, Aria Health Systems, Philadelphia, PA 4 Postgraduate Year 3 Resident, Aria Health Systems, Philadelphia, PA 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Calcaneal fractures are injuries that occur generally as the result of high-energy mechanisms, and, as such, the presence of concurrent injuries should be suspected. The presence of peroneal tendon and superior retinacular injuries has been underreported. We sought to report the incidence of peroneal tendon pathologic features in our population of patients with calcaneal fractures, with emphasis on the method of identification. Furthermore, we sought to identify whether specific fracture patterns were more commonly associated with this pathologic finding. Of the 97 cases, 13 (13.4%) required repair of the superior peroneal retinaculum, 11 of which demonstrated the Sanders A fracture line. Our findings have demonstrated an incidence of pathologic features, in particular, with the presence of the Sanders A fracture line, that warrants attention to potentially help improve the outcome of these devastating injuries. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: calcaneus fibula intra-articular fracture lateral malleolus peroneal retinaculum peroneal tendon subluxation
Calcaneal fractures are devastating injuries with poor outcomes historically. Accounting for approximately 2% of all fractures, it is the most commonly fractured tarsal bone (1). This injury, resulting in an axial force applied to the foot that drives the talus into the calcaneus, has most commonly been seen in males in the industrial sector and in motor vehicle accidents (2). When this occurs, it can result in injury of the superior peroneal retinaculum, with subsequent displacement of the peroneal tendons (3). Acute dislocation of the peroneal tendons is a relatively rare injury, with a reported incidence of approximate 0.5% (4). The mechanism of these retinacular injuries and dislocations has been elucidated but not in the setting of these fractures (5). In addition to the blowout that occurs with the fracture, the reduction in height generates slack in the tendons that could exacerbate subluxation, especially in the presence of a flat or convex peroneal groove (2). We sought to report the incidence of these retinacular injuries and tendinous subluxation and/or dislocations and demonstrate whether any association was present with specific fracture patterns. We also
Financial Disclosure: Dr. Fleming is a consultant for Stryker. Conflict of Interest: None reported. Address correspondence to: Kwasi Yiadom Kwaadu, DPM, AACFAS, Temple University School of Podiatric Medicine, 148 North 8th Street, Philadelphia, PA 19107. E-mail address: [email protected] (K.Y. Kwaadu). Video online only at http://www.jfas.org
sought to emphasize the dynamic nature of this pathologic entity and the clinical technique of diagnosis. Patients and Methods After approval by the institutional board review, the patients were identified by reviewing all the operative procedures performed by the primary author (J.J.F.) from January 2006 to December 2012 from the medical records. One of us (K.Y.K.) performed an additional search using the Current Procedural Terminology (American Medical Association, Chicago, IL) code 28415, representing open treatment of calcaneal fracture. We initially identified 130 consecutive calcaneal fractures that had been repaired by the primary author (J.J.F.). Two of us (K.Y.K., D.F.) then reviewed all the operative notes to determine the presence or absence of peroneal injury. To reduce the likelihood of missing any potential repairs, one of us (K.Y.K.) performed the following additional Current Procedural Terminology searches for code 27675 (repair of dislocating peroneal tendons without fibular osteotomy) and code 27676 (repair of dislocating peroneal tendons with fibular osteotomy) and cross-referenced these searches with the Current Procedural Terminology 28415 code. Our inclusion criteria were an acutely sustained intra-articular calcaneal fracture, the availability of preoperative computed tomography (CT) images, and treatment with open reduction and internal fixation. The exclusion criteria included calcaneal fractures that required primary fusion, calcaneal fractures treated definitively with external fixation, patient age
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Superior Peroneal Retinacular Injuries in Calcaneal Fractures Kwasi Yiadom Kwaadu, DPM, AACFAS 1, Justin James Fleming, DPM, FACFAS 2, 3, Derek Florek, DPM, AACFAS 4 1
Assistant Professor, Temple University School of Podiatric Medicine, Philadelphia, PA Fellowship Director, Philadelphia Foot and Ankle Fellowship, Aria 3B Orthopaedic Institute Northeast, Muscle, Bone, and Joint Center, Philadelphia, PA 3 Podiatric Residency Director, Aria Health Systems, Philadelphia, PA 4 Postgraduate Year 3 Resident, Aria Health Systems, Philadelphia, PA 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Calcaneal fractures are injuries that occur generally as the result of high-energy mechanisms, and, as such, the presence of concurrent injuries should be suspected. The presence of peroneal tendon and superior retinacular injuries has been underreported. We sought to report the incidence of peroneal tendon pathologic features in our population of patients with calcaneal fractures, with emphasis on the method of identification. Furthermore, we sought to identify whether specific fracture patterns were more commonly associated with this pathologic finding. Of the 97 cases, 13 (13.4%) required repair of the superior peroneal retinaculum, 11 of which demonstrated the Sanders A fracture line. Our findings have demonstrated an incidence of pathologic features, in particular, with the presence of the Sanders A fracture line, that warrants attention to potentially help improve the outcome of these devastating injuries. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: calcaneus fibula intra-articular fracture lateral malleolus peroneal retinaculum peroneal tendon subluxation
Calcaneal fractures are devastating injuries with poor outcomes historically. Accounting for approximately 2% of all fractures, it is the most commonly fractured tarsal bone (1). This injury, resulting in an axial force applied to the foot that drives the talus into the calcaneus, has most commonly been seen in males in the industrial sector and in motor vehicle accidents (2). When this occurs, it can result in injury of the superior peroneal retinaculum, with subsequent displacement of the peroneal tendons (3). Acute dislocation of the peroneal tendons is a relatively rare injury, with a reported incidence of approximate 0.5% (4). The mechanism of these retinacular injuries and dislocations has been elucidated but not in the setting of these fractures (5). In addition to the blowout that occurs with the fracture, the reduction in height generates slack in the tendons that could exacerbate subluxation, especially in the presence of a flat or convex peroneal groove (2). We sought to report the incidence of these retinacular injuries and tendinous subluxation and/or dislocations and demonstrate whether any association was present with specific fracture patterns. We also
Financial Disclosure: Dr. Fleming is a consultant for Stryker. Conflict of Interest: None reported. Address correspondence to: Kwasi Yiadom Kwaadu, DPM, AACFAS, Temple University School of Podiatric Medicine, 148 North 8th Street, Philadelphia, PA 19107. E-mail address: [email protected] (K.Y. Kwaadu). Video online only at http://www.jfas.org
sought to emphasize the dynamic nature of this pathologic entity and the clinical technique of diagnosis. Patients and Methods After approval by the institutional board review, the patients were identified by reviewing all the operative procedures performed by the primary author (J.J.F.) from January 2006 to December 2012 from the medical records. One of us (K.Y.K.) performed an additional search using the Current Procedural Terminology (American Medical Association, Chicago, IL) code 28415, representing open treatment of calcaneal fracture. We initially identified 130 consecutive calcaneal fractures that had been repaired by the primary author (J.J.F.). Two of us (K.Y.K., D.F.) then reviewed all the operative notes to determine the presence or absence of peroneal injury. To reduce the likelihood of missing any potential repairs, one of us (K.Y.K.) performed the following additional Current Procedural Terminology searches for code 27675 (repair of dislocating peroneal tendons without fibular osteotomy) and code 27676 (repair of dislocating peroneal tendons with fibular osteotomy) and cross-referenced these searches with the Current Procedural Terminology 28415 code. Our inclusion criteria were an acutely sustained intra-articular calcaneal fracture, the availability of preoperative computed tomography (CT) images, and treatment with open reduction and internal fixation. The exclusion criteria included calcaneal fractures that required primary fusion, calcaneal fractures treated definitively with external fixation, patient age
