Calcaneal fractures

1. Calcaneal Fractures
Presenter: Dr. Bhanubhakta Chalise
Moderator: Dr. Bidur Gyawali

2. Epidemiology
• Calcaneus fractures account for approximately 1% to 2% of all fractures.
• The calcaneus, or os calcis, is the most frequently fractured tarsal bone.
• Represents 60% of all tarsal fractures in adults
• Male-to-female ratio of 2.4:1
• Peak incidence in males aged 20 to 29 years
• Displaced intra-articular fractures constitute 60% to 75% of calcaneus
fractures.
• Approximately 10% of calcaneus fractures are open injuries
• Approximately 70% of calcaneal fractures resulted from falls

3. Anatomy
• The articular surface contains three
facets that articulate with the talus.
• The posterior facet is the largest and
constitutes the major weight-
bearing surface.
• The middle facet is located
anteromedially on the sustentaculum
tali. The anterior facet is often
confluent with the middle facet.
• Between the middle and posterior
facets lies the interosseous sulcus
(calcaneal groove), which, with the
talar sulcus, forms the sinus tarsi.

4. • The sustentaculum tali supports
the neck of the talus medially;
it is attached to the talus by the
interosseous talocalcaneal and
deltoid ligaments and contains
the middle articular facet on its
superior aspect.
• The flexor hallucis longus
tendon passes beneath the
sustentaculum tali medially

5. • The peroneal tendons pass laterally between the calcaneus and the
lateral malleolus.
• The Achilles tendon attaches to the posterior tuberosity

11. Mechanism of Injury
Axial loading:
• Falls from a height are responsible for most intra-
articular fractures;
• They occur as the talus(lateral process of talus
acts as a wedge) is driven down into the calcaneus
(primary fracture line)
• In motor vehicle accidents, calcaneus fractures
may occur when the accelerator or brake pedal
impacts the plantar aspect of the foot.
Twisting forces
• May be associated with extra-articular calcaneus
fractures, in particular fractures of the anterior
and medial processes or the sustentaculum.
In diabetic and porotic patients, there is an
increased incidence of tuberosity fractures due to
avulsion by the Achilles tendon.

12. Clinical Evaluation
• Moderate-to-severe heel pain, tenderness, swelling, heel
widening, and shortening.
• Ecchymosis around the heel extending to the arch or
forefoot is highly suggestive of calcaneus fracture.
• Blistering may be present and results from massive
swelling usually within the first 36 hours after injury.
• Open fractures are rare, but when present, they occur
medially.
• Careful evaluation of soft tissues and neurovascular status
is essential. Compartment syndrome of the foot must be
ruled out because it occurs in up to 10% of calcaneus
fractures and may result in clawing of the lesser toes.

13. ASSOCIATED INJURIES
• Up to 50% of patients with
calcaneus fractures may have other
associated injuries, including
lumbar spine fractures (10%) or
other fractures of the lower
extremities (25%); intuitively, these
injuries are more common in higher
energy injuries.
• Bilateral calcaneus fractures are
present in 5% to 10% of cases.

14. Radiographic Evaluation
• Lateral view of the hindfoot, an anteroposterior (AP)
view of the foot, a Harris axial view, and an ankle series.
Lateral radiograph
• The Böhler (tuber) angle is composed of a line drawn
from the highest point of the anterior process of the
calcaneus to the highest point of the posterior facet and
a line drawn tangential from the posterior facet to the
superior edge of the tuberosity.
• The angle is normally between 20 and 40 degrees; a
decrease in this angle indicates that the weightbearing
posterior facet of the calcaneus has collapsed, thereby
shifting body weight anteriorly

15. • The Gissane (crucial) angle is formed by
two strong cortical struts extending
laterally, one along the lateral margin of
the posterior facet and the other
extending anterior to the beak of the
calcaneus.
• These cortical struts form an obtuse
angle usually between 105 and 135
degrees and are visualized directly
beneath the lateral process of the talus;
an increase in this angle indicates
collapse of the posterior facet

16. AP/oblique radiograph of the foot:
• This may show extension of the fracture
line into the calcaneocuboid joint.
Harris axial view
• This is taken with the foot in dorsiflexion
and the beam angled at 45 degrees
cephalad.
• It allows visualization of the joint surface
as well as loss of height, increase in
width, and angulation of the tuberosity
fragment, usually in varus

17. Broden views
• Have been replaced by computed
tomography (CT) scanning.
• They are used intraoperatively to assess
reduction.
• These are obtained with the patient supine
and the x-ray cassette under the leg and the
ankle.
• The foot is in neutral flexion, and the leg is
internally rotated 15 to 20 degrees (mortise
view).
• The x-ray beam then is centered over the
lateral malleolus, and four radiographs are
made with the tube angled 40, 30, 20, and
10 degrees toward the head of the patient.
• These radiographs show the posterior facet
as it moves from posterior to anterior;
• The 10-degree view shows the posterior
portion of the facet, and the 40-degree
view shows the anterior portion.

18. CT
• CT images are obtained in the axial, 30-
degree semicoronal, and sagittal planes.
• Three- to 5-mm slices are necessary for
adequate analysis.
• The coronal views provide information
about the articular surface of the
posterior facet, the sustentaculum, the
overall shape of the heel, and the
position of the peroneal and flexor
hallucis tendons

19. The axial views reveal
information about the
calcaneocuboid joint, the
anteroinferior aspect of the
posterior facet, and the
sustentaculum.
Sagittal reconstruction views
provide additional
information on the posterior
facet, the calcaneal
tuberosity, and the anterior
process.

20. Classification

21. Extraarticular fractures
• These do not involve the posterior facet.
• They make up 25% to 30% of calcaneus
fractures.
Body fractures not involving the subtalar
articulation:
• These are caused by axial loading.
• Significant comminution, widening, and loss of
height may occur along with a reduction in the
Böhler angle without posterior facet
involvement
Anterior process fractures:
• Result from strong plantar flexion and inversion,
which tighten the bifurcate and interosseous
ligaments leading to avulsion fracture
• Often confused with lateral ankle sprain and are
seen on lateral or lateral oblique views.

22. Sustentacular fractures:
• These occur with heel loading accompanied
by severe foot inversion. They are often
confused with medial ankle sprain and are
seen on axial radiographs.
Tuberosity fractures of the posterior
calcaneus:
• These may result from eccentric loading of
the Achilles tendon, especially in diabetic
patients or osteoporotic women, or, rarely,
by direct trauma; they are seen on lateral
radiographs.
Medial process fractures:
• These vertical shear fractures are due to
loading of heel in valgus; they are seen on
axial radiographs.

23. Intraarticular fractures
Essex-Lopresti Fractures
Primary Fracture Line
• The posterolateral edge of the talus splits the
calcaneus obliquely through the posterior facet.
• The fracture line exits anterolaterally at the crucial
angle or as far distally as the calcaneocuboid joint.
• Produces two main fragments: the sustentacular
(anteromedial) and tuberosity (posterolateral)
fragments.
• The anteromedial fragment is rarely comminuted
and remains attached to the talus by the deltoid and
interosseous talocalcaneal ligaments.
• The posterolateral fragment usually displaces
superolaterally with variable comminution resulting
in incongruity of the posterior facet as well as heel
shortening and widening

24. Secondary Fracture Line
• With continued compressive forces, there is
additional comminution, creating a free lateral
piece of posterior facet separate from the
tuberosity fragment.
Tongue-type fracture:
• A secondary fracture line appears beneath the
facet and exits posteriorly through the
tuberosity.
Joint depression fracture:
• A secondary fracture line exits just behind the
posterior facet.

25. • Continued axial force causes the sustentacular fragment to
slide medially, causing heel shortening and widening.
• As this occurs, the tuberosity fragment will rotate into
varus.
• The posterolateral aspect of the talus will force the free
lateral piece of the posterior facet down into the tuberosity
fragment, rotating it as much as 90 degrees.
• This causes lateral wall blowout, which may extend as far
anteriorly as the calcaneocuboid joint.
• As the lateral edge of the talus collapses further, there will
be additional comminution of the articular surface.

26. Sanders Classification
• This is based on the coronal CT image.
• This classification is based on the number and
location of articular fragments; it is, which
shows the widest surface of the posterior facet
of the talus.
• The posterior facet of the calcaneus is divided
into three fracture lines (A, B, and C,
corresponding to lateral, middle, and medial
fracture lines on the coronal image).
• Thus, there can be a total of four potential
pieces: lateral, central, medial, sustentaculum
tali.

27. Type I:
All nondisplaced fractures regardless
of the number of fracture lines
Type II:
Two-part fractures of the posterior
facet; subtypes IIA, IIB, IIC, based on
the location of the primary fracture line

28. Type III:
Three-part fractures with a
centrally depressed fragment;
subtypes IIIAB, IIIAC, IIIBC
Type IV:
Four-part articular fractures;
highly comminuted

29. Treatment
• Despite adequate reduction and treatment, fractures of the
calcaneum may be severely disabling injuries, with variable prognoses
and degrees of functional debilitation with chronic pain issues.
• Treatment remains controversial. Recent evidence has elucidated
several factors associated with improved outcomes.

30. Non-operative
Indications
• Nondisplaced or minimally displaced extra-articular fractures
• Nondisplaced intra-articular fractures (Sanders I)
• Anterior process fractures with less than 25% involvement of the calcaneal–
cuboid articulation
• Fractures in patients with severe peripheral vascular disease or insulin-dependent
diabetes
• Fractures in patients with other medical comorbidities prohibiting surgery
• Fractures associated with blistering and massive prolonged edema, large open
wounds, or life-threatening injuries
Initial treatment is placement of a bulky Jones dressing.

31. • Nonoperative treatment consists of a
supportive posterior splint to allow
dissipation of the initial fracture
hematoma
• Early subtalar and ankle joint range-of-
motion exercises are initiated
• Non–weightbearing restrictions are
maintained for approximately 10 to 12
weeks, until radiographic union.

32. Operative
Indications
• Displaced intra-articular fractures involving the posterior
facet
• Anterior process of the calcaneus fractures with >25%
involvement of the calcaneal– cuboid articulation
• Displaced fractures of the calcaneal tuberosity, with or
without skin compromise
• Fracture-dislocations of the calcaneus
• Open fractures of the calcaneus

33. • Surgery should be
performed within the initial
3 weeks of injury, before
early fracture consolidation.
• Surgery should not be
attempted until swelling in
the foot and ankle has
adequately dissipated, as
indicated by the
reappearance of skin
wrinkles.

34. Approach
Lateral extensile “L” incision
• Based on the blood supply of the
lateral calcaneal artery
• The vascular supply to the planned
flap is a “watershed” area; the corner
of the soft tissue flap
at the juncture of the longitudinal and
vertical posterior incisions must be
treated with
infinite care
• Sural nerve injury can occur in the
proximal and distal aspects of the L-
shaped incision

35. The sinus tarsi approach
• A limited lateral approach which
allows access to the subtalar and
calcaneocuboid joint
• 3- to 4-cm incision from the tip of
the fibula toward the base of the
fourth metatarsal and protects the
sural nerve and tendons inferiorly.
• It allows for adequate visualization
of the posterior facet joint surface,
lower wound complication rates,
and equivalent functional
outcomes to the extended L
incision in limited comparative
studies.

36. Medial Approach
• A long medial longitudinal
incision is made from the tip
of the medial malleolus
to the naviculocuneiform
joint
• Interval is created between
neurovascular bundle and
the flexor hallusis longus
tendon to access the
sustentaculum tali

37. Extraarticular fractures
Anterior process fractures
• Surgical management of anterior
process fractures is performed
for fractures involving >25% of
the calcaneal–cuboid articulation
on CT scan evaluation.
• Definitive fixation involves small
or mini-fragment screws.
• The patient may ambulate in a
hard-soled shoe, but regular
shoes are discouraged for 10 to
12 weeks postoperatively.

38. Tuberosity (avulsion) fractures
• These result from a violent pull of the gastrocnemius–soleus complex, such as
with forced dorsiflexion secondary to a low-energy stumble and fall, producing
an avulsed fragment of variable size.
Indications for surgery
• Posterior skin is at risk from pressure from the displaced tuberosity.
• The posterior portion of the bone is extremely prominent and will affect shoe wear.
• Gastrocnemius–soleus complex is incompetent.
• Avulsion fragment involves the articular surface of the joint.
Surgical treatment involves lag screw fixation with or without cerclage wire.

39. Calcaneus body fractures
• True extra-articular fractures of the
calcaneus, not involving the subtalar
joint, probably account for 20% of all
calcaneal fractures.
• Minimally displaced fractures (<1 cm)
are treated with early motion and non–
weight bearing for 10 to 12 weeks.
• Those with significant displacement
resulting in varus/valgus deformity,
lateral impingement, loss of heel
height, or translation of the posterior
tuberosity require open reduction and
internal fixation.

40. Medial process fractures
• Rare and usually nondisplaced
• The fracture is best seen on the axial
radiographic view or on coronal CT
scans.
• Nondisplaced fractures can be treated
with a short leg weight-bearing cast
until the fracture heals at 8 to 10
weeks.
• When fractures are displaced, closed
manipulation may be considered

41. Intraarticular factures
• The Canadian Orthopaedic Trauma Society trial comparing operative
to nonoperative treatment of displaced intra-articular calcaneal
fractures found the following:
• Better outcomes
Women
Younger adults
Patients with a lighter workload
Patients not receiving workers’ compensation
Patients with a higher initial Böhler angle (less severe initial injury)
Those with an anatomic reduction on postoperative CT evaluation
Those having nonoperative treatment of their fracture were 5.5 times
more likely to require a subtalar arthrodesis for posttraumatic arthritis
than those undergoing operation.

42. Operative goals
• Restoration of congruity of the subtalar articulation
• Restoration of the Böhler angle
• Restoration of the normal width and height of the
calcaneus
• Maintenance of the normal calcaneocuboid
articulation
• Neutralization of the varus deformity of the fracture

43. • The posterior facet is reduced and
stabilized with lag screws into the
sustentaculum tali.
• The calcaneocuboid joint and the lateral
wall are reduced. The length of the heel
is regained with neutralization of varus.
• A thin plate is placed laterally and is
used as a buttress. Bone void filling of
the defect is not required but may be
associated with earlier weight bearing.
• A one-third tubular plate can be used
for displaced simple fracture patterns.
• In a calcaneal fracture that is
comminuted and has poor bone stock, a
locking plate may be more appropriate
•

46. • Essex-Lopresti technique
as modified by Tornetta.
• Once guide pins are
correctly positioned,
they are exchanged for 6.5-
to 8.0-mm cannulated
cancellous lag screws.
• Good results have been
reported for tongue-type
fractures using
percutaneous reduction
(Essex-Lopresti maneuver)
and lag screw fixation

47. • Primary subtalar or triple
arthrodesis has had good reported
results for select high-energy
injuries (type 4).

48. Postoperative management
• Early supervised subtalar range-of-motion exercises
• Non–weight bearing for 8 to 12 weeks
• Full weight bearing by 3 months

49. Complications
Wound dehiscence/necrosis:
• Most common at the angle of incision. Avoidance requires meticulous soft tissue
technique and minimization of skin trauma during closure. It may be treated with
wet to dry dressing changes, skin grafting, or muscle flap if necessary.
Calcaneal osteomyelitis:
• Associated with more complex injuries, diabetes
Posttraumatic arthritis (subtalar or calcaneocuboid):
• This reflects articular damage in addition to fracture displacement and
comminution; thus, it may occur even in the presence of an anatomic reduction; it
may be treated with injections or orthoses, or it may ultimately require subtalar or
triple arthrodesis.
Heel widening:
• May result in lateral impingement on the peroneal tendons or the fibula. It is
aggravated by increased residual lateral width and may be treated by wall resection
or hardware removal.

50. Loss of subtalar motion:
• This is common with both operative and nonoperative treatment of intra-
articular fractures.
Peroneal tendonitis:
• This is generally seen following nonoperative treatment and results from
lateral impingement.
Sural nerve injury:
• This may occur in up to 15% of operative cases using a lateral approach.
Chronic pain:
• Despite nonoperative or operative treatment of calcaneal fractures, many
patients have chronic heel pain that may be debilitating; many individuals
are unable to return to gainful employment.
Complex regional pain syndrome:
• This may occur with operative or nonoperative management

51. References
• Campbell operative orthopaedics 13th edition
• Apley and Solomon’s System of Orthopaedics and Trauma: 10th
edition
• Rockwood and Green Fractures in Adults -8th, 9th edition
• Handbook of fractures 6th edition
• Grey’s Anatomy-The Anatomical Basis of Clinical Practice 41ST edition
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5862705/

52. Thank you