Pediatric Calcaneal Tuberosity Avulsion Fracture
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A 9-year-old female presented, with a right heel injury. She was at an indoor gymnastic facility, when she jumped into a foam pit, landing at the bottom of the pit. She immediately noticed right heel pain and swelling. She was initially seen at an urgent care; where she was evaluated with an X-ray and then was referred to our institution for definitive management. The patient had a medical history of acute lymphoblastic leukemia diagnosed at age 4 years, she was treated with vincristine, intrathecal methotrexate injection, and oral dexamethasone until she achieved remission, she was then kept on maintenance therapy until early 2015.

In the emergency room, her evaluation did show right heel swelling and skin blanching of the posterior aspect of the heel, an indication of impending skin compromise. The X-rays were positive for a Schmidt and Weiner type 2b displaced calcaneal tuberosity fracture. She was splinted in plantar flexion to decrease the pressure on the heel skin and was taken to the operating room emergently.

Operative technique
In the operating room, the heel skin was still blanched, without skin necrosis. Under general anesthesia, the patient was positioned prone and a tourniquet was placed on the right thigh. The approach was through an incision parallel to the lateral aspect of the Achilles tendon. The short saphenous vein and the sural nerve were protected. A small incision was made on the plantar aspect of the heel, to apply one limb of a pointed reduction clamp, the other limb of the pointed reduction clamp was applied through the surgical wound. The reduction was confirmed using the image intensifier on the lateral and axial views. Two guide wires for the 5.0 cannulated screws were inserted; then, the two screws were inserted with washers in lag fashion, making sure to engage the plantar cortex of the calcaneus. Wound closure was done in a standard fashion.

Rehabilitation protocol
Postoperatively, a short leg cast was applied with the ankle in plantar flexion. At 4 weeks, the cast was replaced by another short leg cast in neutral ankle flexion for 2 more weeks. The patient was non-weight-bearing for 6 weeks. At her 6 weeks follow-up visit, the cast was replaced with a cam boot, and the patient was instructed to ambulate weight-bearing as tolerated with the boot for 2 more weeks, and a home exercise program was initiated at that point. At 8 weeks, the cam boot was discontinued, and the patient was instructed to continue the home exercise program and to resume all activities except for contact sports. At her 12 weeks follow-up, she was pain-free and regained full motion and strength, and was able to return to sports activities. The child was followed for 2 years; she fully healed the fracture and resumed all daily life and sports activities. Because of her medical history, she was evaluated with a bone density scan postoperatively, which showed normal bone density.