SLR - May 2014 - Matthew German
Reference: Toussaint RJ, Lin D, Ehrlichman LK, Ellington JK, Strasser N, Kwon JY. Peroneal Tendon Displacement Accompanying Intra-Articular Calcaneal Fractures. Bone and Joint Journal. 2014; 96: 310-315.
Scientific Literature Review
Reviewed By: Matthew German, DPM
Residency Program: University Hospital, Newark NJ
Podiatric Relevance: The calcaneus is the most common fracture of the rearfoot with near 75 percent articular involvement. The most common etiologies of intra-articular calcaneal fractures are high energy falls or motor vehicle accidents. Concomitant injuries are common and include bilateral involvement, lumbar spine injury, or upper extremity injury. This article evaluates the rate of concomitant peroneal tendon subluxation or dislocation with high energy, intra-articular calcaneal fractures.
Methods: The authors performed a retrospective radiographic review of all intra-articular calcaneal fractures that presented to their institution from June 2006 through June 2011. Those that did not have CT scan, extra-articular fractures, skeletally immature patients, and gunshot wounds were excluded. All fractures were classified via Essex-Lopresti and Sanders classifications. CT scans were evaluated for displacement of peroneal tendons on soft tissue windows as well as maximum heel width. Plain radiographs were also evaluated for “fleck sign” of avulsion of fibular cortex at attachment of superficial peroneal retinaculum. Statistical analysis was performed with bivariate associations to evaluate between predictor values and presence of peroneal displacement. A p-value of < 0.05 was considered significant.
Results: Four-hundred and twenty one (421) intra-articular calcaneal fractures were evaluated. Peroneal tendon displacement was evident on 118 (28 percent), of all cases. This was only correctly identified in radiology reports in 12 cases. Fleck sign was present in 44 (10.5 percent) of all cases. Utility of fleck sign on plain radiographs had high specificity of 0.98, but low sensitivity of 0.31. Mean heel width was significantly wider for those with peroneal displacement (45 ± 7.4mm) than those without peroneal displacement (41.6 ± 7.3mm). Increasing fracture severity on the Sanders classification was also associated with increased rate of peroneal displacement (p < 0.002) with Sanders IV type fractures having a rate of 58 percent displacement.
Conclusion: This paper suggests that due to the high energy trauma associated with calcaneal fractures, peroneal displacement is a common concomitant injury. Due to the disability of peroneal subluxation, this may be a frequently overlooked injury that may cause significant morbidity to patients suffering high energy calcaneal fractures. They also mention that it may be possible that the peroneal tendons may reduce following anatomic reduction in the operating room. They also suggest being cognizant of the “fleck sign” on plain radiographs and its association to peroneal displacement. They conclude that this is a frequently missed diagnosis that may, or may not, play a significant role in disability associated with high energy intra-articular calcaneal fractures.