3. Faculty of Medicine
ORTHOPEADIC SURGERY & TRAUMA Dept.
ANATOMICAL CALCANEAL PLATE IN
MANAGEMENT OF DISPLACED INTRA-ARTICULAR
CALCANEAL FRACTURES
Thesis submitted in partial fulfillment of
Requirement of M. Sc. degree in Orthopeadic& Trauma
By
Waleed Maher Ali
MB, B.CH, RESIDENT OF ORTHOPEADIC SURGERY & TRAUMA
FACULTY OF MEDICINE - MINIA UNIVERSITY

4. UNDER SUPERVISION OF
Prof. Hussein Abdel- Salam Nazim
PROFESSOR OF ORTHOPEADIC SURGERY & TRAUMA
FACULTY OF MEDECINE EL-MINIA UNIVERSITY
Dr. Ahmed Saleh Abdel-Fattah
ASSISTANT PROFESSOR OF ORTHOPEADIC SURGERY &
TRAUMA FACULTY OF MEDICINE MINIA UNIVERSITY
Dr. Mohamed Yehia Hassan
LECTURER OF ORTHOPEADIC SURGERY & TRAUMA
FACULTY OF MEDICINE MINIA UNIVERSITY

5. I would like to express my deep
gratitude to the spirit of ..
Prof. Hussein Abdel- Salam Nazim
who patiently followed up and
corrected the thesis, helping this
work to come to light in proper
form. Thanks for his continuous
guidance.

6. Also I would like to express my deep respect to
Dr. Ahmed Saleh Abdel-Fattah ,
who helped and guided me in very hard
times in this work.
I would like to express my special thanks to ..
Dr. Mohamed Yehia Hassan,
who helped me in choosing the subject of
this thesis and who kindly helped me with
his valuable advice and great effort.

7. I would like to thank ..
Dr. HATEM GALAL ZAKI
ASSISSTANT PROFESSOR OF
ORTHOPEADIC SURGERY & TRAUMA –
ASSUIT UNIVERSITY
For accepting to discus my thesis ,
giving us sharing time in his very
busy schedule and traveling to reach
our university

8. I WOULD LIKE TO THANK
Prof. Dr. Mohamed Elshafaei
The Head of the our Department
Orthopedic surgery and trauma
of
I would like to thank our staff members in
orthopedic surgery and trauma dept. who
helped me so much by their experience
and guidance.

10. 
The calcaneus is the most frequently fractured
tarsal bone, accounting for 60% of all tarsal
injuries, and represents 2% of all fractures and
75% of calcaneal fractures are intra_articular.

Are bilateral in 5-9% of patients .

11. 
Incidence of associated injuries such as
compression fractures of the lumbar
and/or dorsal spine is 10% .

These fractures are complicated by a
compartment syndrome in 10% of cases.

13.  Is
to evaluate the results and
efficacy of the anatomical calcaneal
plate in treating displaced intraarticular calcaneal fractures .

15. ANATOMY OF THE CALCANEUS
1-BONY ANATOMY:

The calcaneus is the largest of the tarsal
bones It is irregularly cuboidal in form, having
its long axis directed forward and lateralward

17. THE MEDIAL SURFACE

18. THE LATERAL SURFACE

19. 
On the superior aspect are three articular
surfaces: the posterior, middle, and anterior
facets. The posterior is the largest and is
convex. The middle one, which is slightly
concave, is situated on the sustentaculum tali.
The anterior facet, also slightly concave.

20. THE SUPERIOR SURFACE

21. 2-RADIOLOGICAL ANATOMY

22. BÖHLER'S ANGLE

formed by drawing two lines. The first is
drawn from the highest point on the anterior
process to the highest point on the posterior
facet. The second line is tangential to the
superior edge of the tuberosity. The normal
value of Böhler's angle is 25 to 40°.

23. THE CRITICAL ANGLE OF GISSANE

24. 
is the angle formed by the intersection of a
line drawn along the dorsal aspect of the
anterior process of the calcaneus and a line
drawn along the dorsal slope of the posterior
facet. The normal value of Gissane's angle is
120 to 145°.

26. 
Lateral radiograph of the normal calcaneus.
Lateral radiograph of the calcaneus shows
compression (light blue arrows) and traction
(yellow arrows) trabeculae,with the neutral
triangle (brown triangle) in between with
sparse trabeculae. The thickened cortical or
thalamic portion of the bone supporting the
articular facets is shown (T).

27. 3- Attachments & Relations :

29. 4- ARTICULATIONS:





TALOCALCANEAL
JOINT (SUBTALAR
JOINT) :
Lateral talocalcaneal
ligament.
Medial talocalcaneal
ligament.
Interosseous
talocalcaneal ligament.
Cervical ligament

30. 
TALOCALCANEONAVICULAR JOINT
It is regarded as two joints, i.e. the anterior part of the
'subtalar' joint and the talonavicular joint.

CALCANEOCUBOID JOINT
at the same level as the talonavicular joint and,
together, they represent the transverse tarsal joint.

31. 5- SURGICAL ANATOMY

The sural nerve runs about 3 cm above the
tip of the lateral malleolus.

The tendon of flexor hallucis longus running
under
the
calcaneus.
sustentaculum
tali
of
the

32. BIOMECHANICS

The calcaneus contributes to :

The posterior aspect of the longitudinal arch.

Supporting the talus.

Sharing in weight bearing.

Transmitting body weight to the ground and
creates a strong lever for the muscles of the
calf.

33. BIOMECHANICS OF SUBTALAR JOINT
Subtalar
Joint
Axis of
motion
Subtalar
Joint Motion

34. 
passes obliquely from
posterolateral aspect
of calcaneus through
the neck of the talus .

42° from transverse
plane

16° from sagittal plane

35. 
Pronation of the Subtalar
joint
calcaneal abduction, eversion
and dorsiflexion .

Supination of the Subtalar
joint
calcaneal adduction, inversion
and plantar flexion

36. MECHANISM OF INJURY


intra-articular
calcaneus
fractures
are usually the result
of a fall from a height
or an motor vehicle
accident.
High-energy axial load,
the talus is forced
downward into the
calcaneus

37. 
primary fracture line, or
separation
fracture,
marked 1, runs from
the critical angle of
Gissane to the medial
wall,
dividing
the
calcaneus
in
the
coronal
plane.
An
additional fracture line
is often seen extending
from
the
anterior
process
to
the
tuberosity

38. 
The shear fracture splits the calcaneus into
the anteromedial (or sustentacular) and
posterolateral (or tuberosity) fragments. The
compression fracture runs in the coronal
plane, with the anterior limb running through
the critical angle of Gissane and the
posterior limb extending either horizontally
toward the tuberosity as a tongue type
fracture (red line) or more vertically, just
posterior to the posterior facet, as a joint
depression type fracture (blue line).

40. CLASSIFICATION :

Essex-Lopresti (British
Journal of Surgery 1952):

1- joint depression type

41. 2 – tongue type

42. SANDER’S CLASSIFICATION

44. DIAGNOSIS:

Plain x-rays :

Lateral radiograph

Anteroposterior radiograph of the foot

Harris axial radiograph of the heel Patient supine,
foot maximally dorsiflexed, beam 45°cephalad

Oblique/Broden’s view

46. Brodén’s view
The articular surface of
the posterior facet

47. CT

Coronal View

Sagittal View

48. 
Sanders type II A

Sanders type III AC

49. 
Sanders type IV

50. COMPLICATIONS

Early complications:

Late complications:

Significant Swelling

chronic foot pain
can develop healing
problems .

difficulty with certain
types of footwear
Compartment
Syndrome

arthritis

51. TREATMENT






Calcaneus fractures are among the most difficult
fractures to operatively reduce and internally fix.
Methods:
Closed reduction, with elevation of the foot,
compression dressing, and early motion.
Percutaneous reduction techniques such as EssexLopresti .
Open reduction and internal fixation as popularized
by Palmer et tal .
Primary arthrodesis.

53. This prospective study was carried
out from December 2008 to July 2010 in
emergency section of our Department of
Orthopedic Surgery and Traumatology in
Minia University Hospital . We treated 30
patients with displaced intra articular
calcaneal fractures with anatomical plate

54. Age and sex:

The age of the patients ranged between 22 and
40 years with the mean age 31 year , there were
18 cases below 31 years (60%) and 12 cases
above 31 years (40%) . There were 22 males
(73%) and 8 females (27%) .
Affected Side:

The left side was affected in 10 patients (33%),
while the right was affected in 14 patients (47%)
and it was bilateral in 5 patients (20%)

55. Mechanisms of Injury

25 cases were due to fall from hieght (83%)
and 5 cases were due to motor vechile
accident (17%)
Classification systems:

According to Essex-Lopresti there were 20
cases with joint depression type and 10 cases
with tongue type .

According to Sander’s 18 (60%)
type-II
fracture 8 cases (26%) were type III fractures
and 4 (14%) cases were type IV fracture .

56. INCLUSION CRITERIA

Sanders types II or III .

Age 20 to 45.

Closed inra articular calcaneal fractures.

Available for folloaw up for at least 2 years
after surgeury.

57. EXCLUSION CRITERIA

Sanders types I or IV .

Medical
contraindications
Previous
calcaneal
to
pathology
tumor ) .

Open calcaneal fractures.

Injury greater than 3 weeks old .

Extra- articular fractures .
surgery,
(infection,

58. ANATOMICAL CALCANEAL PLATE

59. ADVANTAGES

Low-profile,
1.2
mm
thickness
may
reduce
the potential for peroneal tendon irritation and
facilitates soft-tissue closure .

Reduced profile helps to simplifiy intraoperative
contouring

Calcaneal Plate’s Y-arm provides structural support
for joint depression fractures

60. 
K-wire holes allow for provisional stabilization and
verification of reduction

Central hole permits increased screw angulation to
allow for precise fixation of sustentacular Tali

All plates are available in 50mm, 60mm and 70 mm
lengths .

61. SURGICAL TECHNIQUE

Preoperative Planning :

Clinical examination of the affected and
contra-lateral limb .

Vascular examination .

Examination of the spine .

67. RESULTS

68. Functional
Results
Grade
Criteria
 no or mild pain, unlimited activities of daily
Excellent
living and work, no difficulty with walking on
various surfaces, no use of walking aids and
normal range of motion of STJ.
moderate pain, slight limited activities of daily
living and work, slight difficulty with walking on
Good
various surfaces, no use of walking aids and
slight decrease range of motion of STJ.
Fair
Severe pain, limitation of walk, work ability and
decrease STJ motion
usage of aids
Poor
Severe pain, Complete stiff STJ .

69. FUNCTIONAL RESULTS

72. RADIOLOGICAL RESULTS

73. According To Bohler And Gissan’s Angle

74. CASE PRESENTATION
Case one
Age: 25
Sex: Female
Classification: Type IIC , Joint Depression.
The affected side: RT
Mechanism of trauma: FFH

76. POST OPERATIVE

77. 6 MONTHS POST OPERATIVE

78. CASE PRESENTATION
Case two
Age: 28
Sex: male
Classification: Type IIIAB, tongue-type .
The affected side: Lt
Mechanism of trauma: FFH

79. Preoperative

80. POST OPERATIVE

81. 6 MONTHS POST OPERATIVE

82. CASE PRESENTATION
Case Three
Age: 35
Sex: Male
Classification: Type IIIBC, Joint Depression
type .
The affected side: Lt
Mechanism of trauma: FFH

83. PRE OPERATIVE

87. 
As regard pre operative assessment of our
patients we agree with Leung et al.that
standard lateral, axial, and internal oblique
radiographs
are
not
adequate
for
the
assessment of the subtalar joint and CT is
needed for almost all fractures to detect the
extent and type of the fracture .

88. 
As regard the surgical approach used in our
study is the extended lateral approach in all
cases
popularized
by
Benirschke
and
Sangeorzan . The merits of this approach
involve the inclusion of the peroneal tendon
and sural nerve with the flap, which helps to
minimize the risk of injury to these structures.

89. The clinical outcome for 10 (33%) of the 30
feet was excellent and 15 (50%) was good .
3 feet (10%) had a fair result, and 2 were
considered to have had poor ; of these one
feet, needed a subtalar arthrodesis

90. 
The
radiological
anatomical
resuls
reduction,
13
are
80%
had
%
had
near
anatomical reduction and 7 % had failure of
treatment. And thus we consider 93% of
cases are satisfactory results and only 7% of
cases are unsatisfactory

91. Benirschke and Sangeorzan 2004
(25 cases)
The bony results were five excellent (17.8%),
nine good (50.0%), two fair (11.1%), and two
poor (11.1%). .
The functional results were excellent in
(21.9%) patients, good in
(43.7%), fair in
(12.5%), and poor in (21.9%).

92. 
(Zhongguo Xiu Fu 2008 reported on ( 50
cases)
The results were excellent and good in (8
%) , fair in (5%) and poor in (7%).

93. 
The results of Christoph are better than our
results this is due to the fact that some of
our patients were not compliant during the
follow up period either by missing their follow
up appointments frequently or by starting
weight bearing too early before we advise
them to do so.

94. DISCUSSION OF COMPLICATIONS
Study
Our Study
Subtalar
56%
osteoarthritis
Buckley et al Geel,
2002
Christoph
2005
65%
73%
Compartment 6%
syndrome
28%
33%
Wound
infections
12%
21%
25%
Pain
75%
84%
63%

95. 
As regard post operative complications in our
study, Injury of
the sural nerve has been
reported in 3 cases (10%) , Infections ,
wound breakdown and late deep infections
occur
in
30%
of
cases
and
Subtalar
osteoarthritis occurred in 6 cases (20%).

97. 
The focus of current treatment is on operative methods,
with the goal of restoring not only articular congruency
but also the shape and alignment of the calcaneus and
this can be easily achieved by using the anatomical plate.

A lateral approach with use of an extensile incision
appears to be associated with the fewest soft-tissue
complications .

98. 
Intra
operative
fluoroscopy
to
obtain
Brodén’s, lateral, and axial radiographs is
strongly
recommended
anatomical reduction.
to
ensure
an

99. Thank
you