This document discusses fractures of the calcaneus bone, also known as the heel bone. It begins with an introduction stating that calcaneus fractures make up approximately 2% of all fractures and are most common in males aged 21-45. The document then covers the anatomy and mechanisms of injury, describing how these fractures usually occur from high-energy impacts like falls from heights. It classifies fractures as either extra-articular or intra-articular and discusses the clinical features, imaging, treatment, and complications associated with calcaneus fractures.

1. FRACTURES OF THE
CALCANEUM
Murtadha Nadhom
Mohammed Mawash

2. INTRODUCTION
• Approximately 2% of all fractures.
• Most frequent tarsal bone fracture
• Challenging fracture for orthopedists
• 90% occur in males between 21-45 years of age.
• More than 20% show associated injuries of the spine, pelvis or hip.
• Although not all these fractures have bad results, the results of treatment of
calcaneus fractures over the years have not been good.
‘the man who breaks his heel-bone is finished’

3. ANATOMY

4. MECHANISM OF INJURY
In most cases the patient undergoes high energy axial load:
• Falls from a height, often from a ladder, onto one or both heels.
• Motor Vehicle Accidents
The calcaneum is driven up against the talus and is split or crushed.

5. PATHOLOGICAL ANATOMY
Palmer and Essex Lopresti classified calcaneal fractures
into
•Extra-articular fractures: those involving the various
calcaneal processes or the body posterior to the
talocalcaneal joint
•Intra-articular fractures: those that split the
talocalcaneal articular facet

6. EXTRA-ARTICULAR FRACTURES
• These account for 25% of calcaneal injuries.
• are usually easy to manage and have a good prognosis.

7. EXTRA-ARTICULAR FRACTURES
Fractures may occur through
the anterior process the body the tuberosity

8. EXTRA-ARTICULAR FRACTURES
Fractures may occur through
the sustentaculum tali (5) the medial tubercle

9. INTRA-ARTICULAR FRACTURES
•These injuries are much more complex and unpredictable in
their outcome.

10. INTRA-ARTICULAR FRACTURES
They are best understood by imagining
the impact of the talus cleaving the bone
from above to produce a primary fracture
line that runs obliquely across the
posterior articular facet and the body
from posteromedial to anterolateral

11. INTRA-ARTICULAR FRACTURES
•The articular facet is split apart and may be displaced
into the body of the calcaneum; there may be severe
comminution.

12. CLINICAL FEATURES
There is usually a history of a fall from a
height or a road traffic accident; in
elderly osteoporotic people even a
comparatively minor injury may
fracture the calcaneum.

13. CLINICAL FEATURES
•The foot is painful and swollen and a large
bruise appears on the lateral aspect of the
heel.
•The heel may look broad and squat.

14. CLINICAL FEATURES
•The surrounding tissues are thick and
tender, and the normal concavity below
the lateral malleolus is lacking.
•The subtalar joint cannot be moved but
ankle movement is possible.

15. CLINICAL FEATURES
Always check for signs of a
compartment syndrome of the foot
•intense pain
•very extensive bruising and swelling
•diminished sensation
•pain on passive toe movement

16. IMAGING
•Plain X-rays should include AP, Axial,
lateral views, but once a fracture has
been identified then cross-sectional
imaging (CT scan) is the standard of
care.
•Broden’s View is also Helpful to check
posterior facet for intraarticular
displacement
•3D reconstruction views are even
better.

17. IMAGING
With severe injuries – and especially
with bilateral fractures or in the
unconscious patient – it is essential to
assess the knees, spine and pelvis as
well.

18. IMAGING
Bohler’s Angle
•Normally 20-40°.
•If < 20° represents a calcaneal
fracture (or more specifically a
collapse of the posterior facet)

19. IMAGING
•Line 1: Drawn between the most
cephalic part of the posterior process
of the calcaneus bone (point a) and
the most cephalic point of the
posterior facet of the calcaneus bone
(point b)
•Line 2: Drawn between the most
cephalic point of the posterior facet
of the calcaneus bone (point b) and
the highest point of the calcaneus
bone articulating with the cuboid
bone (point c)

20. TREATMENT
Initially:
•For all except the most minor
injuries, the patient is admitted to
hospital
•Neurovascular exam
• the leg and foot should be elevated
and treated with ice –packs and
compression until swelling subsides.
• This also gives time to obtain the
necessary CT scans.

21. TREATMENT
Undisplaced fractures
• can be treated closed
• Exercises are encouraged from the
outset.
•When the swelling subsides, a firm
bandage is applied and the patient is
allowed up
•non-weightbearing on crutches for 6
weeks.

22. TREATMENT
Displaced intra-articular fractures
•are best treated by open
reduction and internal fixation
with plates and screws.
•This is difficult surgery, which calls
for complete familiarity with the
local anatomy.
•Postoperatively, the foot is lightly
splinted and elevated.

23. TREATMENT
Displaced intra-articular fractures
•Exercises are begun as soon as pain
subsides and, after 2–3 weeks
•the patient can be allowed up, non-
weightbearing on crutches.
• Partial weightbearing is permitted
only when the fracture has healed
(seldom before 8 weeks) and full
weightbearing about 4 weeks after
that.

24. COMPLICATIONS
EARLY
•Swelling and blistering: The limb
should be elevated with the
minimum of delay.
• Compartment syndrome: In about
10% of patients. This can be
minimized by starting treatment
early.

25. COMPLICATIONS
LATE
•Malunion: Closed treatment of
displaced fractures, or injudicious
weight-bearing after open reduction,
may result in malunion.
• Talocalcaneal stiffness and
osteoarthritis: Displaced intra-
articular fractures may lead to joint
stiffness and, eventually,
osteoarthritis.

26. Thank you