What is the recommended treatment for a tiny avulsion fracture at the dorsal lateral aspect of the anterior calcaneum (calcaneus) near the calcaneocuboid joint?

Treatment of Tiny Avulsion Fracture at Dorsal Lateral Aspect of Anterior Calcaneum

Conservative management with immobilization is the recommended treatment for a tiny avulsion fracture at the dorsal lateral aspect of the anterior calcaneum near the calcaneocuboid joint.

Assessment and Diagnosis

• The diagnosis of calcaneal avulsion fractures is typically confirmed through radiographs, with CT or MRI sometimes needed to evaluate the extent of the fracture and associated soft tissue injuries 1, 2
• Avulsion fractures on the dorsolateral aspect of the calcaneus are relatively common, occurring in approximately 10% of emergency room patients with clinically suspected ankle fractures 3
• These fractures are often confused with the os peroneum or fractures of the anterior process of the calcaneus 3

Treatment Algorithm

First-Line Treatment: Conservative Management

• Simple immobilization is appropriate when fracture fragments are small, non-articular, or minimally displaced 1
• Treatment options include:
  • Protective immobilization with a walking boot or cast 1
  • Activity modification to reduce weight-bearing stress 1
  • NSAIDs for pain management 1

Duration of Immobilization

• Immobilization should typically be maintained until clinical and radiographic evidence of healing 1
• For small avulsion fractures, this is generally 4-6 weeks, depending on symptom resolution and evidence of healing 4

Rehabilitation Phase

• After immobilization period, gradual return to weight-bearing activities with supportive footwear 1
• Physical therapy may be beneficial to restore range of motion and strength 1

Special Considerations

• If the fracture is at the calcaneocuboid joint, monitor for persistent symptoms as some patients may develop refractory complaints 5
• For patients with persistent pain after adequate conservative management (6-8 weeks), further evaluation with advanced imaging may be warranted 1, 2

When to Consider Surgical Management

• Surgery is typically not indicated for tiny avulsion fractures of the calcaneum unless:
  • The fragment is significantly displaced (>2-3 mm) 6
  • There is involvement of a weight-bearing surface 1
  • Conservative management has failed after an appropriate trial period 5

Prognosis

• Most small avulsion fractures of the calcaneum heal uneventfully with conservative management 3, 5
• In cases where conservative measures fail and complaints are refractory, surgical excision of the avulsed fragment may be considered 5
• The overall prognosis for tiny avulsion fractures is excellent with appropriate management 3

Common Pitfalls to Avoid

• Misdiagnosis as an ankle sprain, leading to inadequate immobilization 3
• Failure to recognize associated soft tissue injuries that may require additional treatment 2
• Premature return to high-impact activities before adequate healing 1
• Overlooking these fractures on standard radiographs; careful examination of dorsolateral aspect of the calcaneum is important 3