Pediatric Calcaneus Fractures and Associated Injuries

CATEGORY: Trauma; Hindfoot INTRODUCTION/PURPOSE: The objective of the study was to determine the injuries associated with calcaneus fractures in pediatric patients and to determine if the skeletally immature sustain different injury patterns than the skeletally mature. In the adult population, these concurrent injuries are well-defined and consistent with a large axial load; however in the pediatric population, we anticipate that the differences in the mechanism of injury and developmental anatomy will alter the types of injuries observed with calcaneus fractures. Additionally, given the plasticity of immature bone, the skeletally immature patients may sustain different fracture patterns than the skeletally mature. METHODS: A retrospective chart review was performed of pediatric patients presenting with a calcaneus fracture from 2008 to 2017. Patients under the age of 18 with an ICD code consistent with a calcaneus fracture were included. Patients who sustained penetrating trauma were excluded along with medical records with incomplete data. Demographics, injury information, associated injuries, skeletal maturity, fracture characteristics, and treatment were recorded. As defined by calcaneal apophyseal closure, the cohort was divided into the skeletally mature and immature for analysis. Student’s t-test and Fisher’s exact tests were used to determine significance. RESULTS: 199 records were reviewed resulting in a sample of 81 pediatric patients with 91 calcaneus fractures. 37(40.7%) patients were immature at the time of injury. The most common mechanism witnessed was a fall in 52(64.2%) patients, with an average age of 12.8 years-old (range 0-17). There were 50(54.9%) intra-articular fractures and 15(16.5%) who underwent reduction and fixation. In the immature, open reduction internal fixation was performed on 6(14.3%) fractures which demonstrated a significantly decreased average Bohler’s angle than the conservatively treated, 14 degrees(p= 0.048). Fractures of the spine were the most commonly associated injury in 10(12.3%) pediatric patients however tibia fractures were the most commonly observed injury in the skeletally immature cohort, 7(18.9%). There were no associated injuries significantly unique to the skeletally immature. CONCLUSION: The present study provides one of the largest published cohorts to date of pediatric calcaneus fractures. They were most commonly associated with fractures of the spine however in the skeletally immature group as defined by apophyseal staging, tibia fractures were most often observed. No injuries were found to be significantly associated with immature patients. The skeletally immature calcanei produce fracture patterns which may be difficult to observe on radiographs and often require advanced imaging to delineate. While the majority may be treated with conservative therapy, there are no current concrete operative indications for the closed skeletally immature calcaneus fracture.