Isolated “Nutcracker” Fracture of the Anterior Calcaneal Process: do we need a more Comprehensive Classification for this Inury Spectrum? A Case Report

Fractures of the anterior calcaneal process are relatively rare accounting for 3-15% of all calcaneal fractures and can occur due to high or low energy trauma. Avulsion fractures are generally due to forced inversion and plantar flexion of the foot and are associated with ligament tears. More are impaction fractures, i.e. nutcracker fractures, are commonly described as due to a forced eversion and abduction of the foot with compression forcing the anterior process of the calcaneus against the cuboid. Clinical features are subtle and X-ray examination for the diagnosis of anterior calcaneal process fracture is challenging. A CT examination can reveal the fracture and should be performed whenever a doubt exists for correct diagnosis. Here we present the unique clinical case of a 44ys old female patient who suffered an isolated compression fracture of the anterior calcaneal process due to a fall from a stair with forced foot eversion and low energy trauma mechanism. The patient healed uneventfully with a conservative treatment. A more comprehensive classification of this spectrum injury is sought as many different fracture or combined bone-ligamentous lesions exist requiring different surgical or non surgical management. Actually, no clear guidelines exist in literature assisting the treating physician in the management of such challenging lesions.