Calcaneal osteomyelitis
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1527 (Published 12 March 2013) Cite this as: BMJ 2013;346:f1527
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I agree with Dr Wellings. Unusual calcaneal fracture of this type is recognised to occur in diabetes. Although uncommon, it is so typical as to indicate diabetes even when that clinical information is not provided.
Competing interests: No competing interests
I believe that in addition to the described abnormalities in this case the authors have failed to identify the the pathological fracture of the calcaneum which is the cause of the crescentic lucency. With the dorsal calcaneum rotated by the traction of the achilles tendon.
They are correct in attributing this to osteomyelitis but the fracure is indicative of significant involvement of the calcaneum and would impact on function if the foot is saved from the sepsis.
Competing interests: Consultant Radiologist
Re: Calcaneal osteomyelitis
This is a typical 'pac-man' fracture of the calcaneus which is pathognomonic of neuropathic diabetes. It could be considered a variant of Brodsky type 3b Charcot arthropathy. The fracture usually enters the posterior facet of the subtalar joint or the floor of the sinus tarsi, and displaces gradually as a result of the pull of the achilles tendon. Ulceration and infection are probably secondary features, as a result of bony pressure on the heel skin. I have successfully treated a number of these fractures with prolonged offloading in a total contact cast or equivalent orthosis. Perhaps an achilles tenotomy might prevent ulceration occurring, if the diagnosis were to be made very early?
Competing interests: No competing interests