Abstract
Open calcaneal fractures rarely present with extrusion of posterior facet fragments. We report an unusual case of a 21-year-old male with an intra-articular calcaneal fracture and medial extrusion of a superolateral fragment of calcaneus posterior facet—an injury pattern scarcely described in the literature. The patient underwent delayed reconstruction on day 19 using an extensile lateral approach. The extruded fragment was retrieved laterally through blunt dissection, reduced anatomically into the defect, and fixed with a cannulated screw along with lateral wall plating. Despite early postoperative neuritic symptoms and later pain due to anterior process non-anatomical reduction, symptoms improved after implant removal and medical management. At 3-year follow-up, the patient had mild heel varus but maintained functional recovery and returned to work without analgesics. This case highlights the rarity of posterior facet fragment extrusion and demonstrates that anatomical reconstruction, even when delayed, can yield satisfactory outcomes.
Introduction
Open fractures of the calcaneus are relatively uncommon injuries. The majority of open fractures present with a medial wound, with reported incidences of up to 90 % in various series. ,,,
Lawrence described three mechanisms for medial-side open wounds in calcaneal fractures:
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1.
Axial loading drives the calcaneus into valgus, and in severe deformity the medial skin can rupture, producing an open fracture.
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2.
Axial compression creates a superomedial fragment with a sharp posteroinferior edge that can pierce the medial soft tissues from inside, causing the wound.
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3.
A penetrating object (e.g., projectile, blade) can directly injure the medial hindfoot and create an open wound.
In most intra-articular fractures, the sustentacular fragment—often termed the constant fragment—remains attached to the talus through strong medial ligamentous structures, including the interosseous and deltoid components. This fragment usually preserves its position even in high-energy axial loading injuries.
Mehta et al. described an unusual pattern in which the posterior facet was extruded through a medial wound. More recently, Bertha et al. also reported traumatic extrusion of posterior facet in 2024.
We report very unusual pattern of extrusion where the lateral part of posterior facet was extruded on the medial side along with medial wound.
CASE report
A 21-year-old male sustained a road-traffic injury while riding a motorcycle, resulting in trauma to the left foot with a wound over the medial aspect of the heel and severe swelling. He was taken immediately to a nearby hospital where the wound was irrigated, a back-slab was applied, and intravenous antibiotics and tetanus prophylaxis were administered. The limb was elevated. Radiographs and CT scans of the foot were obtained, and he was admitted for observation. After 2 weeks, the patient was referred to our center.
At presentation, there was a 4 cm × 1 cm wound over the medial aspect of the heel. The wound was partially healed with healthy granulation tissue and no discharge. Swelling was present around the hindfoot, extending to the midfoot. The wrinkle sign was present. Neurovascular examination revealed no deficit.
Radiographs and CT images were reviewed. They showed an intra-articular fracture of the calcaneus, with fracture extension into the anterior process and blowout of the lateral wall. A bony fragment was seen lying postero-medially. A clear void was visible in the posterior facet on coronal and sagittal CT sections. Three dimensional reconstructions demonstrated the location of the fragment and the defect in the posterior facet [ Fig. 1 ] .
A. Coronal section at the level of posterior facet from anterior to posterior. Void in the posterior facet noted and fragment seen lying medially. B. Reconstructed 3D CT Scan shows position of extruded facet. C. Lateral view left ankle and foot. Extruded fragment seen posteriorly with void in posterior subtalar joint, fracture extension in anterior process.
Surgery was planned for the 19th day after injury. Under spinal anesthesia, the patient was positioned laterally. An extensile lateral approach was used, raising the flap subperiosteally. The flap was retracted using three 1.8 mm K-wires. The lateral wall was removed and kept on the back table. Hematoma was evacuated and the field was thoroughly irrigated. A 4 mm Steinmann pin was inserted from lateral to medial and used to invert the heel to improve visualization. The posterior facet was not visible.
An artery forceps was inserted anterior to the Achilles tendon, allowing palpation of the fragment on the medial side. Blunt dissection was performed along the medial side using the artery forceps from the lateral approach. After releasing adhesions, the extruded posterior facet fragment was retrieved through the lateral incision [ Fig. 2 ]. The medial wound was left untouched as it was partially healed.
Extensile lateral approach, extruded fragment retieved from same approach.
Heel varus and length were corrected using the Steinmann pin placed in the tuberosity, and the medial calcaneal silhouette was restored and confirmed under imaging, then provisionally fixed with K-wires. A tongue-type posterior tuberosity fragment was elevated to restore height and provisionally fixed with K-wires. The extruded fragment was cleaned and placed into the defect, then secured with a K-wire passed into the sustentaculum tali. A 4 mm partially threaded cannulated screw was used to further fix the fragment to the sustentaculum tali. The previously removed lateral wall was replaced and fixed with a calcaneal plate [ Fig. 3 A-C)]. The wound was closed in layers over a negative-suction drain. A bulky dressing and posterior back-slab were applied.
A-C: Immediate Post operative X- ray. A- Anteroposterior view of foot. B- Lateral view of foot. C- Axial view of Heel. D-F: Follow up X-ray at 3 months. D-Lateral view of foot. Note non anatomical reduction of anterior process. E-Axial view of Heel. F- Broden’s view. Note lysis around screw tips.
The drain was removed on postoperative day 2, and the dressing was changed. On day 7, the wound remained healthy, with no signs of infection or flap necrosis. Sutures were removed on postoperative day 21 and a short-leg cast was applied for 3 weeks. The patient was mobilized with crutches and kept non-weight-bearing.
At 6 weeks, the cast was removed and ankle and subtalar mobilization exercises were initiated. Non-weight-bearing continued for one more month. At 2.5 months, partial weight-bearing was started after radiographs confirmed healing [Fig. D-F], and crutches were discontinued after 3 additional weeks.
During follow-up, the patient complained of paresthesia along the medial heel. Tinel’s sign was positive over the scar, but plantar sensation was preserved. He was prescribed pregabalin 75 mg twice daily for 3 months, after which symptoms improved. The dose was tapered to 50 mg once daily for another 3 months.
Later, the patient reported pain over the subtalar joint and sinus tarsi. Radiographs showed some collapse of the tuberosity fragment and possible impingement of anterior screws on the talar neck and sinus tarsi. We identified missed fixation of the anterior process fracture, which had migrated anteriorly, and inadequate restoration of calcaneal length [ Fig. 3 D-F]. Implant was removed at 6 months. The patient was encouraged to resume work with well-padded footwear. Pain gradually subsided and pregabalin was discontinued. He continued working and performing daily activities without analgesics.
At final follow-up, about 3 years post-operation, we called him for review. He had a mild heel varus and slight varus motion; eversion was absent. His contralateral right foot showed an asymptomatic Cavo varus deformity [ Fig. 4 ]. There was mild varus of the great toe, which was a cosmetic concern. Flexor tendons were functioning normally without signs of scarring. Radiographic evaluation showed healthy subtalar joint with acceptable alignment of calcaneum [ Fig. 5 ]. The patient had been doing his previous job and was satisfied with the overall outcome.
