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Bone bruise of the calcaneus
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ABSTRACT
deformity. The intramedullary nail was inserted through the heel, and the interlocking screws `drilled and filled'. The authors report fusion after an average time of 19 weeks (range 12±65 weeks). One of their criteria for union was no movement, although they do not consider the fact that movement is in any case impossible immediately after insertion of this very stable fixation device. Only 38 of the 56 ankles healed without complications, which included non-union and infection. There was one bilateral case, and 48 of the 55 patients were satisfied with the procedure. Function is, of course, far from normal after this procedure, and the average AOFAS (American Orthopaedic Foot and Ankle Surgery) ankle/hindfoot score was 66 out of a normal score of 100. The authors conclude that this is a useful salvage procedure, although the patients must be warned that they will not have a normal joint and will continue to have limitations. T. Smith
Dienst M and Blauth M. Bone bruise of the calcaneus. Clin Orthop 2000; 378: 202±205. The increasing use of magnetic resonance imaging (MRI) has shown that bone bruising is commonly associated with ligamentous injury in the knee. It is seen less commonly in the foot and ankle but is useful in explaining persistent pain when no fracture has been demonstrated by radiography. Different methods of MRI scanning show different abnormalities in patients with bone bruising. On the T1 weighted image there is a decreased signal, and on the T2
weighted image an increased signal is characteristic of bone bruising. It is assumed that bone bruising represents bleeding after microtrabecular fractures. Dienst and Blauth suggest that bone bruising should be defined as `a traumatically involved, geographical and non-linear area of signal loss involving the subcortical bone'. The fractures are expected to heal without displacement, but damage to perforating transcortical blood vessels may be followed by chondrolysis. Little is known about the natural history of bone bruising in the foot. How long does it take to develop? How long does it take to resolve? Does immobilisation or any other treatment speed up its resolution? In this paper, the authors reported that the MRI scan in bone bruising returned to normal after 6 months. However, the clinical course must be variable and depends upon the level of initial trauma. They report a single case of a patient who had painful heels after falling from a height. Radiographs were normal but, in view of persistent pain, an isotope bone scan was advised. This showed increased uptake in the calcaneus on both sides. The typical changes of bone bruising were found on an MRI scan. On the right side, the changes were less severe and the patient was able to weight bear fully on this side after 1 week. On the left side, with more marked change on the MRI scan, full weight bearing took 12 weeks, and the pain persisted for 16 weeks. Many questions remain. It seems likely that bone bruising is more common in the foot than previously suspected. Most cases seem to resolve without treatment, although there is no evidence that any treatment will change the prognosis. Serial MRI scans would allow healing to be monitored but are too expensive for routine use. T. Smith
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 125±126
ABSTRACT
deformity. The intramedullary nail was inserted through the heel, and the interlocking screws `drilled and filled'. The authors report fusion after an average time of 19 weeks (range 12±65 weeks). One of their criteria for union was no movement, although they do not consider the fact that movement is in any case impossible immediately after insertion of this very stable fixation device. Only 38 of the 56 ankles healed without complications, which included non-union and infection. There was one bilateral case, and 48 of the 55 patients were satisfied with the procedure. Function is, of course, far from normal after this procedure, and the average AOFAS (American Orthopaedic Foot and Ankle Surgery) ankle/hindfoot score was 66 out of a normal score of 100. The authors conclude that this is a useful salvage procedure, although the patients must be warned that they will not have a normal joint and will continue to have limitations. T. Smith
Dienst M and Blauth M. Bone bruise of the calcaneus. Clin Orthop 2000; 378: 202±205. The increasing use of magnetic resonance imaging (MRI) has shown that bone bruising is commonly associated with ligamentous injury in the knee. It is seen less commonly in the foot and ankle but is useful in explaining persistent pain when no fracture has been demonstrated by radiography. Different methods of MRI scanning show different abnormalities in patients with bone bruising. On the T1 weighted image there is a decreased signal, and on the T2
weighted image an increased signal is characteristic of bone bruising. It is assumed that bone bruising represents bleeding after microtrabecular fractures. Dienst and Blauth suggest that bone bruising should be defined as `a traumatically involved, geographical and non-linear area of signal loss involving the subcortical bone'. The fractures are expected to heal without displacement, but damage to perforating transcortical blood vessels may be followed by chondrolysis. Little is known about the natural history of bone bruising in the foot. How long does it take to develop? How long does it take to resolve? Does immobilisation or any other treatment speed up its resolution? In this paper, the authors reported that the MRI scan in bone bruising returned to normal after 6 months. However, the clinical course must be variable and depends upon the level of initial trauma. They report a single case of a patient who had painful heels after falling from a height. Radiographs were normal but, in view of persistent pain, an isotope bone scan was advised. This showed increased uptake in the calcaneus on both sides. The typical changes of bone bruising were found on an MRI scan. On the right side, the changes were less severe and the patient was able to weight bear fully on this side after 1 week. On the left side, with more marked change on the MRI scan, full weight bearing took 12 weeks, and the pain persisted for 16 weeks. Many questions remain. It seems likely that bone bruising is more common in the foot than previously suspected. Most cases seem to resolve without treatment, although there is no evidence that any treatment will change the prognosis. Serial MRI scans would allow healing to be monitored but are too expensive for routine use. T. Smith
Ó 2001 Blackwell Science Ltd, Foot and Ankle Surgery 2001, 7, 125±126