The Heel of Achilles: Calcaneal Avulsion Fracture from a Gunshot Wound

Abstract

Greek mythology relates that the legendary warrior Achilles was made invincible by his mother Thetis, who dipped him in the River Styx while holding him by his heel. Because his heel was never immersed, it remained his one area of vulnerability. After the fall of Troy, Achilles met his demise when he was shot in the heel by Paris, whose arrow was guided by the Greek god Apollo. This is the derivation of the term “Achilles tendon.”

Avulsion fractures of the tuberosity of the calcaneus are rare injuries. ^1,2,3,6,7,12 Schonbauer ¹⁴ reviewed a series of 870,000 accident cases treated at the Vienna Trauma Hospital and found only four such cases in addition to 151 cases of subcutaneous Achilles tendon rupture. In Bohler's ⁴ series of 182 calcaneal fractures, avulsion of the calcaneal tuberosity accounted for less than 1% of these injuries. Rowe ¹³ reported four Achilles avulsion fractures in his series of 154 calcaneal fractures. Three basic mechanisms of injury have been described: (1) dorsiflexion violence against the maximally plantarflexed foot, typically occurring in a fall from a height; (2) powerful contraction of the triceps surae muscle with simultaneous extension of the knee such as when a person is about to sprint in a race; (3) a direct blunt blow to the hindfoot. ^1,2,8

We are describing a case of avulsion of the calcaneal tuberosity due to direct penetrating trauma from a gunshot wound, a mechanism not previously reported.