dedicated for orthopods

1. Fractures of the calcaneus
Ahmad F. Ja’far
Orthopaedic resident
JUH

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.
• Although not all these fractures have bad results, the
results of treatment of calcaneus fractures over the
years have not been good.

3. Relevant Anatomy
• Largest tarsal bone.
• Dense cancellous bone
covered with a very thin
cortical bone.
• Articular surfaces-ant half
• Post half/ tuberosity
• Plantar fascia
Functions:
• Lever arm powered by
gastrocnemius
• Foundation for body wt.
• Supports/ maintains lat.
column of foot

4. • Articular surface for cuboid
• Ant./middle/post articular
facet for talus
• Post articular facet
– Is the calcaneal portion of
the subtalar joint
– Is the largest and is convex
in shape
– Is separated by the tarsal
sinus and the tarsal
ligament from the middle
and anterior facets
• Interosseous ligament
• Sinus tarsi
Post.
Middle
Ant.
Ant.
Post.
Middle
CC

5. Sustentaculum tali:
• Projects medially and supports
the neck of talus.
• FHL passes beneath it .
• Deltoid and talocalcaneal
ligament connect it to the talus
• Clinical significance :
contained in the
anteromedial
fragment, which remains
"constant" due to medial
talocalcaneal and
interosseous ligaments

6. Ant.
process
Tuberosity
Sinus tarsi
Lateral Aspect

7. Classification
• Intra-articular fractures 60-75%
• Extra-articular fractures 25-30% and include :
Anterior process fractures.
Beak or avulsion fractures of the tuberosity.
Medial process fractures.
Sustentaculum tali and body fractures.

8. Anterior process fracture
• Inversion “sprain”
• Frequently missed
• Most are small: treat like
sprain
• Large/displaced: ORIF

9. Tuberosity body fracture
• Fall/MVA
• Usually non-
operative
─ Swelling control
─ Early ROM
─ PWB

10. Tuberosity avulsion fractures
• Achilles avulsion
• Wound problems
• Surgical urgency
─ Lag screws or
tension band

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

12. “Intra-articular” fractures

13. Mechanism of injury
• High energy: Axial load
─ MVA, fall
 Lateral process of talus acts as
wedge
• Oblique shear
1ry # line  2 fragments:
-- Superomedial (constant)
fragment.
-- Superolateral fragment>(intra-
articular aspect through post
facet)
 2ry # line dectates whether
there is joint depression or tongue-
type fracture

14. z
Mechanism of injury

15. • Secondary fracture
line runs in one of
two planes
• beneath the facet
exiting posteriorly
in tongue-type
fracture
• behind the posterior
facet in joint
depression fractures
Mechanism of injury

16. IMAGING: plain films
Standard Views
1. Lateral
2. Broden’s
3. Axial
• Scan other
regions
- Lumbar spine?
- Contra lateral side?
- Knees?

17. Lateral view
• Bohler’s angle
• 20-40
• Gissane’s angle
• 95-105

19. Broden’s view
• Positioning
– 20° IR view (mortise)
– 10°-40° plantar flex
Demonstrating the
articular surface of the
posterior facet.

20. Axial Harris view
• Very difficult to obtain in
the acute setting
• 45° axial of heel
• 2nd toe in line w/ tibia
• Assess varus/valgus
-- Normal »10° valgus --
• Joint displacement
• Tuberosity angulation
• Heel width.

21. Imaging: CT
Coronal Axial Sagittal

22. Classifications (intra-articular)
• Several used- None are
ideal
• Most commonly used
─ Essex-Lopresti
─ Sanders

23. Classifications
• Essex-Lopresti
• Sanders:
• Based on CT findings
• Coronal plane
• # joint fragments
• 2 = type II
• 3 = type III
• 4 or more = type IV
• Predictive of results

24. Sander’s

25. Sander’s

26. Associated injuries
– Extension into the calcaneocuboid joint occurs in
63%
– Vertebral injuries in 10%
– Contralateral calcaneus in 10%
– Compartment syndrome 2-10%

27. Principles of treatment
1) No reduction, with elevation of the foot, compression
dressing, and early ROM.
2) Closed reduction, with elevation of the foot,
compression dressing, and early ROM.
3) Percutaneous reduction (Essex-Lopresti) .
4) ORIF as popularized by Palmer and McReynolds .
5) Primary arthrodesis.
• Medial approaches, lateral approaches, or dual
approaches

28. TREATMENT: historical
• <1850: bandages/elevation
• 1850: Clark: traction
• 1931: Bohler: closed red./cast
• 1952: Essex-Lopresti: perQ fixation
• 1993+: Benirschke/Letournel/Sanders:
– Extensile lateral approach & plating

29. Management of intra-articular
calcaneal fractures
• Conservative
• Operative.
 Formal ORIF
 Minimally invasive techniques
 Ex. Fixation.
 Fusion

30. Conservative
• Admit to hospital
• Ice packs applied with or without compression
• Elevation.
• Below knee lightweight cast / functional brace for a 4–6
week period
• Non-weight bearing for a further 2 w

31. 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

32. • Prospective, randomized, controlled multicenter trial(level II)
• 82 patients …Follow-up at 1year and 8-12 years
• Primary out come at one 1 year no difference
• 8-12 years  Better VAS score for pain and function (p = 0.07)
and the physical component of the SF-36 (p = 0.06) in the
operative group.
• The prevalence of radiographically evident posttraumatic
subtalar arthritis was lower in the operative group (risk
reduction, 41%).

33. Canadian Calcaneus Registry, R. Buckley et al., JBJS, 2002
• The following did better with surgery:
• Women
• Age <29 years
• Non-Work-Comp
• Bohler angle <10˚
• Comminuted fracture
• Large initial joint step off

34. Difficulties with ORIF
 Difficult exposure
 Complex 3D-shape of the bone
 Ever-changing fixation devices
 Open fractures
 Osteopenic bone disease.
 Increased incidence of wound complications in patients
with DM, HTN, or PVD, and tobacco chewers and
smokers

35. Indications for ORIF
• Displaced intra-articular fractures involving the
posterior facet.
• Anterior process of the calcaneus fractures with
more than 25% involvement of the calcaneocuboid
articulation.
• Displaced fractures of the calcaneal tuberosity.
• Fracture-dislocations of the calcaneus.
• Selected open fractures of the calcaneus

36. Rel. Contraindications
• Diabetes
• Vascular insufficiency
• Smoker
• Severe swelling
• Open fractures
• Elderly
• Neuropathic
• Non-compliant pt.
• In-experienced surgeon
• Lymphedema.
• Immune compromise

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

38. Operative treatment: contraindications
• 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
Heier KA, Infante AF, Walling AK, et al.
J Bone Joint Surg Am 2003, 85-A: 2276-82

39. Preparing Soft Tissues
• Elevation
• Compression stocking
• Cast boot
• Care of blisters
• ORIF @ 10-17 days
• + Wrinkle test

40. ORIF via Extensile Lateral Approach

42. Non touch technique

43. • Schanz pin to
manipulate tuberosity
• Clean out fracture
• Disimpact sustentacular
fragment
• Reduce tuberosity
(body) fragment to
sustentaculum

44. Tuberosity Reduction

45. Restore Joint Surface +/- graft

46. Lag screw below post facet
≥2 screws in each major fragment

47. Fixation Options

48. • Replace lateral wall
• Apply plate
• Recheck Xrays

49. Drain and deep closure

50. Post op care
• Elevate, splint
• Sutures out @ 3 wks.
• Fracture boot
• Early motion
• NWB for 8-12 weeks
• Improvement up to 2 yrs

51. Other Surgical Options
• Closed Reduction/ Int. Fixation
–Percutaneous
–Arthroscopic assisted
• Ilizarov
• Primary Fusion.

52. Surgery: percutaneous
• Fewer wound problems
• More difficult
reductions?
• Ex. Essex-Lopresti
maneuver (Tongue type)

53. Ilizarov
• Minimally invasive
• Indirect reduction
• Learning curve
• Immediate
weightbearing

54. Primary Fusion
• Sanders type IV or
severe cartilage injury
• ORIF calcaneus, debride
cartilage, and fuse ST
joint

55. • 69 patients(75 displaced intra-articular fractures)
• 36 fractures initial ORIF +fusion
• 39 fractures conservative –later fusion
• Follow-up 63 months
• First group : fewer postoperative wound complications and
had significantly higher Maryland Foot Scores (90.8
compared with 79.1; p < 0.0001) and American
Orthopaedic Foot and Ankle Society ankle-hindfoot scores
(87.1 compared with 73.8; p < 0.0001) than did Group B.

56. Complications
 Malunion
 Varus hindfoot
 Shortened foot = short
lever arm
 Peroneal
impingement/
dislocation
 Shoewear problems
 Valgus>varus with
surgical

57. Complications
• Stiffness
─ Prevention (early ROM)
• Subtalar arthritis
• 5-20% of calcaneal fractures may require
subtalar arthrodesis
─ NSAIDs
─ Subtalar fusion

58. Complications
• Peroneal tendon problems
─Tendonitis- NSAIDs, therapy
─Entrapped-release tendons,
exostectomy
─Dislocated-open reduction

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

60. Take home message
Thank you
• Complex injuries ,, patient education
• Don’t miss other injuries.
• Pay attention to soft tissue envelope.
• Functional impairment up to 5 years.
• Much controversies (classification, management, op
techniques…etc)
• ORIF is a good option for displaced intra-articular fractures
in selected group of pateints (on the long term)