Treating A Calcaneal Avulsion Fracture In A Patient With Poor Bone Quality

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Nicholas J. Bevilacqua, DPM, FACFAS

In Conclusion

Calcaneal tuberosity fractures represent the end product of an avulsion force as opposed to being the end product of a pure compression force, which occurs in standard calcaneal fractures.4 Therefore, one must neutralize the force of the Achilles tendon when fixating the fracture in order to prevent loss of reduction. Traditional operative treatment of calcaneal avulsion fractures entails ORIF. Other techniques include Steinmann pins, cerclage wire, suture anchors and external fixation.5 Khazen and co-workers proposed augmenting screw fixation with suture anchors to neutralize the pulling force of the Achilles tendon.4

   The case study demonstrates the deforming force of the Achilles tendon on the fixated fracture fragment in a beak type calcaneal avulsion fracture. This case also highlights the poor bone quality that one often encounters when dealing with fractures. I excised the fracture fragment and reattached the Achilles to the calcaneus using a transcalcaneal suture technique. I employed this technique to reattach the Achilles tendon and establish near normal tension of the Achilles tendon in a patient with very poor bone quality.

   Dr. Bevilacqua is a foot and ankle surgeon at North Jersey Orthopaedic Specialists in Teaneck, N.J. He is board certified in both Foot and Reconstructive Rearfoot and Ankle Surgery by the American Board of Podiatric Surgery. He is a Fellow of the American College of Foot and Ankle Surgeons and a member of the American Podiatric Medical Association.


1. Beavis RC, Rourke K, Court-Brown C. Avulsion fracture of the calcaneal tuberosity: a case report and literature review. Foot Ankle Int. 2008; 29(8):863-866.

2. Greenhagen RM, Highlander PD, Burns PR. Double row anchor fixation: a novel technique for a diabetic calanceal insufficiency avulsion fracture. J Foot Ankle Surg. 2012; 51(1):123-127.

3. Bibbo C, Anderson RB, Davis WH, Agnone M. Repair of the Achilles tendon sleeve avulsion: quantitative and functional evaluation of a transcalcaneal suture technique. Foot Ankle Int. 2003; 24(7):539-544.

4. Khazen GE, Wilson AN, Ashfaq S, Parks BG, Schon LC. Fixation of calcaneal avulsion fractures using screws with and without suture anchors: a biomechanical investigation. Foot Ankle Int. 2007; 28(11):1183-1186.

5. Ramanujam CL, Capobianco CM, Zgonis T. Ilizarov external fixation technique for repair of a calcaneal avulsion fracture and Achilles tendon rupture. Foot Ankle Spec. 2009; 2(6):306-308.

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