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Spontaneous calcaneal fracture after deep heel burns with diabetes
Burns 24 (1998) 683±686
Spontaneous calcaneal fracture after deep heel burns with diabetes Hajime Matsumura a, b, *, Yoshio Jimbo b, Takeo Kato b, Susumu Imai b a
Department of Plastic Surgery, Burn Unit, Tokyo Medical College Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160, Japan b Division of Plastic Surgery, Kosei General Hospital, Tokyo, Japan Accepted 23 June 1998
Abstract Two patients with diabetes mellitus sustained spontaneous calcaneus fracture after deep heel burns. Both cases had avulsion type fracture of the os calcis. The authors discuss the incidence and possible etiology with literature review. # 1998 Elsevier Science Ltd for ISBI. All rights reserved. Keywords: Calcaneus; Diabetes mellitus; Burns; Spontaneous fracture
1. Introduction Spontaneous fracture of the calcaneus is uncommon [1] but does occur in some cases of diabetic osteopathy, usually associated with severe diabetic neuropathy [2]. Recently we encountered two cases of spontaneous fracture of the calcaneus after deep heel burns extending to the surface of the calcaneus in patients with diabetes mellitus. The aim of this paper is to document these two cases and discuss the etiology. 2. Case reports 2.1. Case 1 A 66-year-old male sustained deep burns of his left heel from prolonged exposure to a fan heater on 12/19/1995. The patient was treated by local physicians for one month and then referred to a regional hospital on 1/19/1996. The patient was known to have had diabetes mellitus with neuropathy for ten years and 34 units of biphasic isophane insulin had been subcutaneously injected daily. HbA1c level on admission was 7.8%. * Corresponding author. Tel.: +81-3-3342-6111 ext. 5796, 3320; Fax: +81-3-5322-8253; E-mail: [email protected].
On physical examination, the burn wound extended to the calcaneus bone (Fig. 1). Although dorsalis pedis and posterior tibial arteries were palpable, a loss of sharp±dull sensation of the foot was noted. Wound swab culture grew Pseudomonas aeruginosa and methicillin resistant Staphylococcus aureus. On 2/8/96, the wound was surgically debrided and covered with a free latissimus dorsi musculocutaneous ¯ap using the posterior tibial artery for the vascular pedicle. Flap survival was total and the wound was closed (Fig. 2). One month later on 3/5/96, while the patient was ambulating, the wound suddenly hemorrhaged and broke down. An X-ray showed an avulsion type calcaneus fracture (Rowe's type II, Fig. 3). On 3/14/96, open reduction and pinning of the left os calcis was performed. The patient was later discharged walking without assistance. 2.2. Case 2 A 52-year-old male who was diagnosed with schizophrenia at the age of 18 and diabetes mellitus with neuropathy at the age of 40, sustained deep burns to his left heel from long contact with a hot plate in 5/96 (Fig. 4). Daily doses of eighteen units of isophane insulin had been injected subcutaneously and HbA1c level at injury was 7.2%.
0305-4179/98/$19.00 # 1998 Elsevier Science Ltd for ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 9 8 ) 0 0 1 0 4 - 1
684
H. Matsumura et al. / Burns 24 (1998) 683±686
The patient refused surgical treatment of his burns and, therefore, was treated as an outpatient at a regional hospital. His wound did develop granulation tissue but remained open. Wound swab culture grew b-streptococcus. On 10/3/97 he was walking in his home and there was a sudden bleeding from the wound. The X-ray showed an avulsion type spontaneous calcaneus fracture (Rowe's type II, Fig. 5) similar to case 1. Because of his severely deranged mental status, he did not undergo surgical repair. 3. Discussion
Fig. 1. Case 1: before treatment.
Pathological fractures of the os calcis after heel burns are quite rare and we could ®nd no case reports in the literature. Calcaneal fractures were categorized into ®ve types by Rowe [3]. Both of the fractures we described were type II, the avulsion type fracture. This avulsion type fracture is thought to result from strong traction by the Achilles tendon. Rowe et al. reported that the occurrence of this type of fracture is only 3% [3]. A pathological fracture is usually seen in general systemic diseases, such as diabetes mellitus. Diabetics are also prone to lower extremity injury because of the associated neuropathy [4]. In our cases, osteoporotic changes were not observed in the unburned feet. This implies that diabetes may not be the sole cause, but that the burn
Fig. 2. Case 1: the wound was covered with a free latissimus dorsi musculocutaneous ¯ap.
H. Matsumura et al. / Burns 24 (1998) 683±686
Fig. 3. Case 1: X-rays after fracture showing avulsion type fracture.
Fig. 4. Case 2: before treatment.
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H. Matsumura et al. / Burns 24 (1998) 683±686
Fig. 5. Case 2: X-rays after fracture showing avulsion type fracture similar to case 1.
wound may also contribute to the development of the pathological fractures. Loss of skin and subcutaneous tissue or wound infection might decrease the bone vascularity. Ligamental and periosteal damage could lead to instability of the calcaneus. All of these factors may have contributed to the fractures. In conclusion, we have reported two rare cases of pathological fracture of the os calcis after deep heel burns in diabetic patients. Acknowledgements The authors thank Professor Loren H. Engrav, University of Washington Burn Center, Division of
Plastic Surgery and Department of Surgery, University of Washington, for reviewing this manuscript.
References [1] Chagares W, Stepanczuk P, Pandit JK, Lasker A. Bilateral, spontaneous calcaneal fractures in a diabetic. Journal of Foot Surgery 1981;20:38±40. [2] El-Khoury GY, Kathol MH. Neuropathic fractures in patients with diabetes mellitus. Radiology 1980;134:313±6. [3] Rowe CR, Sakellarides HT, AFreeman P, Sorbie C. Fracture of the Os Calcis, a long-term follow-up study of 146 patients. JAMA 1963;184:920±3. [4] Helfand AE. Common foot complications in the elderly diabetic. JAPA 1977;67:406±7.
Spontaneous calcaneal fracture after deep heel burns with diabetes Hajime Matsumura a, b, *, Yoshio Jimbo b, Takeo Kato b, Susumu Imai b a
Department of Plastic Surgery, Burn Unit, Tokyo Medical College Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160, Japan b Division of Plastic Surgery, Kosei General Hospital, Tokyo, Japan Accepted 23 June 1998
Abstract Two patients with diabetes mellitus sustained spontaneous calcaneus fracture after deep heel burns. Both cases had avulsion type fracture of the os calcis. The authors discuss the incidence and possible etiology with literature review. # 1998 Elsevier Science Ltd for ISBI. All rights reserved. Keywords: Calcaneus; Diabetes mellitus; Burns; Spontaneous fracture
1. Introduction Spontaneous fracture of the calcaneus is uncommon [1] but does occur in some cases of diabetic osteopathy, usually associated with severe diabetic neuropathy [2]. Recently we encountered two cases of spontaneous fracture of the calcaneus after deep heel burns extending to the surface of the calcaneus in patients with diabetes mellitus. The aim of this paper is to document these two cases and discuss the etiology. 2. Case reports 2.1. Case 1 A 66-year-old male sustained deep burns of his left heel from prolonged exposure to a fan heater on 12/19/1995. The patient was treated by local physicians for one month and then referred to a regional hospital on 1/19/1996. The patient was known to have had diabetes mellitus with neuropathy for ten years and 34 units of biphasic isophane insulin had been subcutaneously injected daily. HbA1c level on admission was 7.8%. * Corresponding author. Tel.: +81-3-3342-6111 ext. 5796, 3320; Fax: +81-3-5322-8253; E-mail: [email protected].
On physical examination, the burn wound extended to the calcaneus bone (Fig. 1). Although dorsalis pedis and posterior tibial arteries were palpable, a loss of sharp±dull sensation of the foot was noted. Wound swab culture grew Pseudomonas aeruginosa and methicillin resistant Staphylococcus aureus. On 2/8/96, the wound was surgically debrided and covered with a free latissimus dorsi musculocutaneous ¯ap using the posterior tibial artery for the vascular pedicle. Flap survival was total and the wound was closed (Fig. 2). One month later on 3/5/96, while the patient was ambulating, the wound suddenly hemorrhaged and broke down. An X-ray showed an avulsion type calcaneus fracture (Rowe's type II, Fig. 3). On 3/14/96, open reduction and pinning of the left os calcis was performed. The patient was later discharged walking without assistance. 2.2. Case 2 A 52-year-old male who was diagnosed with schizophrenia at the age of 18 and diabetes mellitus with neuropathy at the age of 40, sustained deep burns to his left heel from long contact with a hot plate in 5/96 (Fig. 4). Daily doses of eighteen units of isophane insulin had been injected subcutaneously and HbA1c level at injury was 7.2%.
0305-4179/98/$19.00 # 1998 Elsevier Science Ltd for ISBI. All rights reserved. PII: S 0 3 0 5 - 4 1 7 9 ( 9 8 ) 0 0 1 0 4 - 1
684
H. Matsumura et al. / Burns 24 (1998) 683±686
The patient refused surgical treatment of his burns and, therefore, was treated as an outpatient at a regional hospital. His wound did develop granulation tissue but remained open. Wound swab culture grew b-streptococcus. On 10/3/97 he was walking in his home and there was a sudden bleeding from the wound. The X-ray showed an avulsion type spontaneous calcaneus fracture (Rowe's type II, Fig. 5) similar to case 1. Because of his severely deranged mental status, he did not undergo surgical repair. 3. Discussion
Fig. 1. Case 1: before treatment.
Pathological fractures of the os calcis after heel burns are quite rare and we could ®nd no case reports in the literature. Calcaneal fractures were categorized into ®ve types by Rowe [3]. Both of the fractures we described were type II, the avulsion type fracture. This avulsion type fracture is thought to result from strong traction by the Achilles tendon. Rowe et al. reported that the occurrence of this type of fracture is only 3% [3]. A pathological fracture is usually seen in general systemic diseases, such as diabetes mellitus. Diabetics are also prone to lower extremity injury because of the associated neuropathy [4]. In our cases, osteoporotic changes were not observed in the unburned feet. This implies that diabetes may not be the sole cause, but that the burn
Fig. 2. Case 1: the wound was covered with a free latissimus dorsi musculocutaneous ¯ap.
H. Matsumura et al. / Burns 24 (1998) 683±686
Fig. 3. Case 1: X-rays after fracture showing avulsion type fracture.
Fig. 4. Case 2: before treatment.
685
686
H. Matsumura et al. / Burns 24 (1998) 683±686
Fig. 5. Case 2: X-rays after fracture showing avulsion type fracture similar to case 1.
wound may also contribute to the development of the pathological fractures. Loss of skin and subcutaneous tissue or wound infection might decrease the bone vascularity. Ligamental and periosteal damage could lead to instability of the calcaneus. All of these factors may have contributed to the fractures. In conclusion, we have reported two rare cases of pathological fracture of the os calcis after deep heel burns in diabetic patients. Acknowledgements The authors thank Professor Loren H. Engrav, University of Washington Burn Center, Division of
Plastic Surgery and Department of Surgery, University of Washington, for reviewing this manuscript.
References [1] Chagares W, Stepanczuk P, Pandit JK, Lasker A. Bilateral, spontaneous calcaneal fractures in a diabetic. Journal of Foot Surgery 1981;20:38±40. [2] El-Khoury GY, Kathol MH. Neuropathic fractures in patients with diabetes mellitus. Radiology 1980;134:313±6. [3] Rowe CR, Sakellarides HT, AFreeman P, Sorbie C. Fracture of the Os Calcis, a long-term follow-up study of 146 patients. JAMA 1963;184:920±3. [4] Helfand AE. Common foot complications in the elderly diabetic. JAPA 1977;67:406±7.