Presentation
Diabetic patient with history of foot trauma.
Patient Data
Linear dense structure is seen superior to the calcaneal tuberosity. There is mild thickening of the achilles tendon shadow and opacification of the Kager's fat pad. Vascular calcification is seen.
There is osseous avulsion fracture of the posterior calcaneus associated with thickening and proximal retraction of the Achilles tendon. Heterogeneous echogenicity of the distal achilles tendon and tendinosis / partial tearing of the distal achilles tendon are seen near the calcaneal attachment. Small fluid in the retrocalcaneal region and diffuse subcutaneous edema are seen.
Complete avulsion fracture of the calcaneal tuberosity with very thin osseous fragment resulting in proximal retraction of the achilles tendon from calcaneal attachment. Thickening and increased signal intensity are seen indicating underlying tendinosis. Bone marrow edema is seen in the posterior calcaneal tuberosity. Fluid in the retrocalcaneal and retroachilleal bursae are noted suggestive of traumatic bursitis.
Short segment split tear of peroneus brevis tendon is seen at the level of the lateral malleolus with reconstitution of the tendon distally. Mild increased signal intensity and thickening of medial and central band of the plantar fascia in keeping with plantar fasciitis. Subcutaneous soft tissue edema and fatty replacement of the plantar foot muscles are noted.
Tibiotalar Joint: Subchondral marrow edema like signal along the medial talar dome with tiny subchondral cystic changes along the tibial plafond indicating degenerative changes. The joint space is preserved.
Subtalar Joint(s): Intact. Small fluid is seen.
Talonavicular Joint: Mild degenerative changes.
Case Discussion
Diabetic patients are at risk of developing insufficiency avulsion fractures of the calcaneal tuberosity with minor trauma or even without a significant history of trauma. In this case, the fracture line runs along the apophyseal scar, which is compatible with type 1 avulsion fracture. In this type, the bony fragment can be variable in size. Therefore, when reading ankle radiographs, care must be taken not to mistake a thin avulsed fragment with vascular calcifications, which are commonly observed in diabetic patients.
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