Fractures of the calcaneus can cause long-term disability if not treated properly. While the best treatment method is controversial, operative treatment via open reduction internal fixation may provide better outcomes than non-operative treatment by restoring anatomy and preventing malunion. However, operative treatment also carries risks of wound complications. Treatment must be individualized based on the injury pattern, patient characteristics, and surgeon experience to weigh the risks and benefits of operative versus non-operative management.

1. Fractures of
the Calcaneus
Cory Collinge, MD
Keith Heier, MD

2. Introduction
“…the man who breaks his heel bone is
done.”
- Cotton and Henderson, 1916
“…results of crush fractures of the os calcis
are rotten.”
- Bankhart, 1942

3. Introduction
• High potential for disability
─ Pain
─ Gait disturbance
─ Unable to work
• “Best” treatment method controversial

4. Anatomy
• Subtalar joint
─ Facets: anterior, middle, posterior
• Calcaneocuboid joint
• Sustentaculum
• Tuberosity
• Anterior process

5. Anatomy:
Bony
SustentaculumSustentaculum
Medial
Lateral
Ant.Ant.
processprocess
TuberosityTuberosity
Sinus tarsiSinus tarsi

6. Anatomy: Joints
Subtalar
Subtalar CalcaneoCalcaneo
-cuboid-cuboid

7. Anatomy:
Facets of
ST Joint
Ant.Ant.
MiddleMiddle
Post.Post.
Tub.Tub.
IOIO
lig.lig.

8. Anatomy:
Soft
Tissues
FHL
Peroneal
Tendons
Achilles
Tendon
ThinThin
skin/skin/
little SQlittle SQ

9. Hindfoot Function
Calcaneus
• Lever arm powered by
gastrocnemius
• Foundation for body wt.
• Supports/ maintains lat.
column of foot

10. Hindfoot Function
Subtalar Joint
• Inversion/ eversion of
hindfoot
• Hindfoot position
locks/ unlocks
midfoot joint

11. “Extra-articular” Fractures
• Anterior process fracture
• Tuberosity (body) fracture
• Tuberosity avulsion
• Sustentacular fracture

12. Anterior Process Fracture
• Inversion “sprain”
• Frequently missed
• Most are small: treat like
sprain
• Large/displaced: ORIF

13. • Fall/MVA
• Usually non-operative
─ Swelling control
─ Early ROM
─ PWB
Tuberosity Fracture

14. Tuberosity Avulsion
• Achilles avulsion
• Wound problems
• Surgical urgency
─ Lag screws or
tension band

15. Sustentacular Fracture
• May alter ST jt. mechanics
• Most small/ nondisplaced:
─ Non-operative
• Large/ displaced
─ ORIF (med. approach)
─ Buttress plate

16. “Intra-articular” Fractures

17. Mechanism of Injury
• High energy:
─ MVA, fall
• Lateral process of talus
acts as wedge
• Impaction fracture

18. Pathoanatomy
• Primary
fracture
line
• Constant
fragment

19. Pathoanatomy
• Secondary
fracture line
• Extends
posteriorly
through
tuberosity
• Creates 3 parts
1
2
3

20. Pathoanatomy
• Articular incongruity
• Hindfoot varus
• Shape of foot
─ Wide
─ Loss of height
─ Short
• Peroneal impingement
• Heel pad crush

21. Pathoanatomy
Compartment syndrome (up to 10%)
↑ pressure, limited space
↓ tissue perfusion
– Tense foot or marked
pain, check pressure
– Fasciotomy

22. Clinical Problems
• Stiffness
• Loss of normal gait
• Shoewear problems
• Arthritic pain
• Peroneal pain
• Heel pad pain

23. Imaging: Plain Films
Standard Views
• 1. Lateral
• 2. Broden’s
• 3. Axial (HLA)
1.1.
3.3.2.2.

24. Lateral View
Bohler’sBohler’s
AngleAngle Gissane’sGissane’s
AngleAngle

25. Broden’s View
• Posterior facet
• Positioning
A. 20° IR view
(mortise)
B. 10°-40° plantar flex.

26. Broden’s
View
• Posterior facet

27. Axial View
• Assesses varus/valgus
• 45° axial of heel
• 2nd
toe in line w/ tibia
• Normal ≈ 10° valgus

28. Imaging: CT
Foot flat on table
• Coronal
• Transverse
• Sagittal Reconstruction
CORONALCORONAL

29. Imaging: CT Scan
• ST joint
• Heel width/ shortening
• Lateral wall
• Peroneal impingement
CORONALCORONAL

30. Imaging: CT Scan
•
CalcaneocuboidCalcaneocuboid
jt.jt.
• Similar to lateralSimilar to lateral
radiographradiograph
TRANSVERSETRANSVERSE SAGITTALSAGITTALSAGITTALSAGITTAL
• Similar toSimilar to
lateral Xraylateral Xray

31. Classifications
• Several used- None are ideal
• Most commonly used
─ Essex-Lopresti
─ Sanders

32. ESSEX-LOPRESTI
Classification
• Historical
• Basic
1. Joint depression type
2. Tongue type
1.
2.

33. ESSEX-LOPRESTI
Joint Depression Type Tongue Type

34. Sanders
Classification
• Based on CT findings
• # joint fragments
• 2 = type II
• 3 = type III
• 4 or more = type IV
• Subtype: L → M fx position
• Predictive of results

35. Sanders
Example:Type IIA

36. Treatment: Historical
• <1850: bandages/elevation
• 1850: Clark: traction
• 1931: Bohler: cl. red./cast
• 1952: Essex-Lopresti: perc. fixation
• 1993: Benirschke/Letournel/Sanders: “modern”
plating

37. Non-op Treatment: Natural History
Nade and Monahan, Injury, 1973
• 57% long term symptoms (pain, swelling,
stiffness)
• 95% symptoms on uneven ground
• 76% broad heel
As a standard treatment …..”[results] are not
good enough and deserve further studies”

38. Non-op Treatment:
Complications
Malunion
• Varus hindfoot
─ Locks midfoot
─ Medializes “foundation” for stance
• Shortened foot = short lever arm
• Peroneal impingement/ dislocation
• Shoewear problems

39. Non-op Treatment:
Injury

40. Non-op Treatment:
Malunion

41. Non-op Treatment:
Complications
• Malunion treatment
Orthosis/ custom shoe
Lateral wall exostectomy
Peroneal tenodesis
Subtalar fusion +/- bone block
Sliding wedge osteotomy

42. Non-op Treatment:
Complications
• Stiffness
─ Prevention (early ROM)
─ Therapy
• Subtalar arthritis
─ NSAIDs
─ Subtalar fusion

43. Non-op Treatment:
Complications
• Peroneal tendon problems
─ Tendonitis- NSAIDs, therapy
─ Entrapped-release tendons, exostectomy
─ Dislocated-open reduction

44. • Sural nerve pain
─ Medications
─ Orthosis
─ Neurectomy
• Heel pad pain
─ Orthosis
Non-op Treatment:
Complications

45. Operative Treatment:
Natural History
• Early studies recommending non-op treatment:
─ Old ORIF techniques
─ No CT classification
─ No assessment of fracture reduction

46. Operative Treatment:
Natural History
• Initial results were poor (wound problems)
• Newer ORIF techniques improved results
─ Anatomic reduction for good result
─ Fracture severity correlates with results
─ Learning curve

47. Operative Treatment:
Rationale
• Restore anatomy
─ Shape and alignment of hindfoot
─ Articular congruency
• Return to function & prevent arthritis
• Typically, restoring articular anatomy gives
improved results if complications are avoided

48. Operative vs. Non-op Treatment
• Orthopedic literature is lacking
• No prospective, randomized studies with
longterm follow-up

49. Operative vs. Non-op Treatment
Thodarson and Krueger, F&A, 1996
• Matched set of op and non-op treatment
• Modern operative technique
• AOFAS scores: Operative= 86.7
Non-op= 55
“Operative treatment successful and preferable unless
contrainications present”

50. Operative Treatment:
Contraindications
• Diabetes
• Vascular insufficiency
• Smoker
• Severe swelling
• Open fractures
• Sanders type IV
(very comminuted)
• Elderly
• Neuropathic
• Non-compliant pt.
• In-experienced
surgeon

51. Operative Treatment:
Contraindications
Folk et al., JOT, 1999
• Diabetes
• Vascular insufficiency
• Smoker
Wound problems: these factors have additive effects.
If all 3, >90%.

52. Operative Treatment:
Contraindications
Heier, et al., OTA, 1999/AAOS, 2000
• Open Fractures
– Mostly medial wounds, varied severity
– All treated with I&D/ IV abx
– Grade II-III: 48% infections
– Grade IIIB: 77% infections & 46% BKAs

53. Operative Treatment:
Contraindications
Open Fracture Recommendations
• ORIF?: Medial grade I open fx
• Closed treatment for all lateral wounds and
grade III medial open fx
• Percutaneous methods?

54. Treatment:
A Rational Approach?
• Many treatment methods attempted
• “Best” method remains controversial
• Assess each case individually
– Injury/ patient/ surgeon
– Risks vs. benefits

55. ORIF via Extensile Lateral
Approach
Benirschke/Sangeorzan, Clin Orthop, 292: 128-134, 1993
Letournel, Clin Orthop, 290: 60-67, 1993
Sanders et al., Clin Orthop, 290, 87-95, 1993

56. ORIF: Pre-op
• Elevation
• Compression stocking
• Cast boot
• ORIF @ 10-14 days
• + Wrinkle test

57. ORIF: Lateral Approach
• Lateral decubitusLateral decubitus • ““L” incisionL” incision

58. ORIF: Lateral Approach
• ““No touch”No touch”
techniquetechnique
• Lateral wallLateral wall
removedremoved

59. ORIF: Lateral Approach
• Schanz pin to
manipulate tuberosity
• Clean out fracture
• Disimpact
sustentacular fragment

60. ORIF: Lateral Approach
• Reduce post. facet
fragments if comm.
• K-wires/ absorbable
pins
• Reduce post. facet to
sustentaculum- ant.
process

61. ORIF: Lateral Approach
• Reduce tuberosity fragment
to sustentacular complex
1. Restore height
2. Restore valgus
3. Medial translation

62. ORIF: Lateral Approach
•Pin reducedPin reduced
tuberositytuberosity
•AssessAssess
radiographicallyradiographically

63. ORIF: Lateral Approach
• Bone graft?
• Replace lateral wall
• Apply plate
• Recheck radiographs

64. ORIF: Lateral Approach
• Check peroneal tendons
• Drain
• Layered closure
1. Periosteum/SQ
2. Skin
• Atraumatic technique
• Advance flap toward apex
• Splint

65. Postoperative Care
• Elevate, splint
• Sutures out at 3 wks.
• Fracture boot
• Early motion
• NWB for 9-12 weeks
• Improvement up to 2 yrs.

66. Operative Treatment:
Complications
• All those of non-operative care….
─ Malunion
─ Stiffness
─ Subtalar arthritis
─ Peroneal tendons
─ Sural nerve pain
─ Heel pad problems, plus…

67. Operative Treatment:
Complications
Wound problems
• Apical wound necrosis
– Stop ROM
– Leave sutures in
• Infection
– Antibiotics
– I&D
– Soft tissue coverage?

68. Operative Treatment:
Other Surgical Options
• Closed Reduction/ Int. Fixation
─ Percutaneous
─ Arthroscopic assisted
• Ilizarov
• Primary Fusion
• Others?

69. Surgery: Percutaneous
• Fewer wound
problems
• More difficult
reductions?
• Ex. Essex-Lopresti
maneuver

70. Surgery: Percutaneous I
• Essex-Lopresti
maneuver
• Tongue type
fractures
Essex-Lopresti, Clin Orthop, 290: 3-16, 1993

71. Surgery: Percutaneous I
Essex-Lopresti, Clin Orthop, 290: 3-16, 1993

72. GIII open fractureGIII open fracture
Surgery: Percutaneous II

73. Surgery: Percutaneous II
• Joint elevated through openJoint elevated through open
woundwound
• Percutaneous fixationPercutaneous fixation

74. Surgery: Ilizarov
• Minimally invasive
• Indirect reduction
• Learning curve
• Immediate
weightbearing
Paley and Fischgrund, Clin Orthop, 290: 125-131, 1993

75. Surgery: Ilizarov
GIII open fractureGIII open fracture

76. Surgery: Ilizarov

77. Surgery:
Primary Fusion
• Sanders type IV
• Severe cartilage
injury
• ORIF calcaneus,
debride cartilage,
and fuse

78. Summary
• High energy injuries
• Risk for long term morbidity
• ORIF can give good, reproducible results if
complications are avoided
• Individualize treatment
• Longterm outcomes studies are needed
comparing treatment alternatives
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