Calcaneal Fracture- Tongue Type

History: 26 yo fall, ankle pain.

Real History: Jumped down 10 stair flight and heard a pop and felt immediate ankle pain. 

The mysteries begin early here. Wonder where that's coming from...

Not not helpful. But mostly not helpful....

Good golly.

Tongue Type Calcaneal Fracture.  

Gopal refers to this as the T-Rex Sign.  Seems like something my preschooler would find cute.  But you know what's not cute, Tongue Type Calcaneal Fractures.

In general, calcaneal fractures are categorized in 2 types: 

Which are associated with different point of maximal depression force through the calcaneus...

We'll talk about central depression at some point. 

Seems like a simple fracture in this case but the potential for poor outcome actually relates more to the adjacent soft tissues.  Appreciate the compression of the overlying subcutaneous plane at the superiorly deviated fracture fragment...

Which looks like this on physical exam.

Seems like most tissue in the body relies on continuous perfusion to persist.  Soft tissue complications occur in approximately 21% of these fractures. If the Sawbone doesn't get this reduced emergently, the likelihood of tissue necrosis goes up significantly.  Of course, proper and persistent reduction is also a challenge because the Achilles is attached to the fragment, hence the superior deviation of the fragment. 

And if the tissue over a bone is bad, the underlying bone won't last long. 

7 months out....

The irregular look of this fixation is not atypical for this type of fracture.  Those screws and the fracture line are under constant tension from the Achilles. 

Unfortunately, you can also appreciate continued abnormality along the overlying soft tissues, that now look like this on physical exam... 

CT is showing some ragged, heterogeneously sclerotic ununited bone that is probably a combination of incomplete reduction, osteonecrosis (also a potential complication), and possible chronic osteomyelitis.  The foci of gas along the bone should make us all nervous.

Another fracture to avoid.

Heres a nice recent RSNA reference for all things hindfoot.

https://pubs.rsna.org/doi/full/10.1148/rg.210167

Hope you didn't mind a traditional disastergram for a palate cleanser.  For the next case, we'll get back to subtle findings and search patterns.