JC on CALCANEUM FRACTURE

1. Calcaneal fractures
Presenter -Dr. Shubhanshu Ranjan
Singh
Guide – Dr. John Mukhopadhaya

2. Introduction
• M/C tarsal bone to be fracture (60%)
• Axial load
• 1-2% of all fracture

3. Anatomy
• Thin cortex
• Neutral triangle
• 4 articulating surfaces :- 3 superior one
anterior
– Posterior facet
– Middle calcaneal facet
– Anterior calcaneal facet
– Triangular articular surface

4. • Lateral surface
• Medial surface

5. Mechanism of fracture
• Primary fracture line
• Extends obliquely from posteromedial to anterolateral calcaneum
• Produces posterolateral segment consist of
– Tuberosity
– Lateral wall
– Variable portion of posterior
articular surface
• Anteromedial segment consist of
– Anterior process
– Medial sustentaculum
– Remaining medial aspect of
posterior articular surface

6. Secondary fracture lines
• Extend into calcaneocuboid joint
– Separating anterior process into anterior
process into anteromedial and anterolateral fragments
• Extend medially
– Separating sustentacular fragment from anteromedial fragment.
• Constant fragment
– Lateral fragment of posterior articular surface joint depression
patterns and is produced by extension of secondary fracture line
to cranial portion of tuberosity
– Because of strong ligamentous attachment between the talus
and sustentacular fragment is constant
– Location and density of this fragment bone are critical for
reduction and fixation

7. Vascular supply of lateral skin
• Lateral calcaneal artery
• Lateral hindfoot artery
• Lateral tarsal artery

8. Clinical Evaluation
• A/w spine(dorsolumbar injury), head injury,
others injury
• Evaluation of soft tissue injury
– Haematoma
– Fracture blisters (clear/Hemorrhagic)
– Oedema
– Skin necrosis
• Compartment syndrome
• Open fractures

9. Radiological - Xrays
• Lateral hind foot
– Confirms diagnosis
– Crucial angle of gissane (95-105)
– Tuber angle of boehler (20-40)
– Intraarticular fracture
• Loss of height of posterior facet
• Reduced Bohler angle
• Increased Gissane angle
• AP Foot
– Calcaneocuboid joint involvement
– Anterior process fracture
• Harris heel view
– Visualization of joint surface
– Loss of height
– Increased width
– Angulation of tuberosity fragment
– Difficult to obtain due to pain

10. • Brodens view
– Leg rotated internal 20 degree
– Foot neutral
– Beam directed 10/20/30/40 degree towards head
– Centered over lateral malleolus
– Demonstrater articular surface of posterior facet
• Ankle AP, Lateral, Mortise
• Thoracolumbar spine AP, Lateral

12. CT scan
• Coronal image
– Articular surface of post facet
– Sustentaculum
– Shape of heel
– Position of peroneal FHL tendons
– Articular of posterior facet with talus
maintain medially and more angulated laterally
• Saggital image
– Depression of tuberosity fragment
• Transverse (axial) images
– Calcaneocuboid joint
– Anteroinferior aspect of posterior facet
– Sustentaculum

13. Classification
• Intra-articular
– Essex Lopresti
classification
• Joint depression type
• Tongue type
– Sanders classification
• Extra-articular
classification
– Doest not involve post
facet
– Anterior process
fracture (Degan)
– Mid calcaneal fracture
• Body
• Sustantaculum tali
• Peroneal tubercle
• Lateral process
– Posterior calcaneal
fracture
• Tuberosity
• Medial calcaneal
tubercle

14. Sanders Classification

16. Extra-articular Classification

17. Anterior process fracture
• Forced inversion or forced
abduction and dorsiflexion
• Best in oblique view
• Degan Classification
• Treated with protective
weight bearing
• > 25% calcaneocuboid
articular surface treated
with ORIF

18. • For Anterior process
– Anterior process reduction necessary to re-
establish the lateral column of foot
• Increasing anterior process comminution
associated with worse functional outcome
Musculoskeletal Functional Assessment (MFA)
• Follow up 4.3 year

19. Fracture Dislocations of Calcaneus
• Swollen hindfoot
• Talar tilt
• Flake fracture of lateral malleolus

20. Treatment History
1908, Cotton and Wilson
ORIF of calcaneal fracture contraindicated
1920s
Abandoned treated of acute fractures altogether and
turned instead to treatment of healed malunions
1931, Bohler
Open reduction advocated
Problem with operative treatment
Infection, malunion, nonunion, need of amputation
1935, Conn
Delayed primary arthrodesis

21. 1943, Gallie
Subtalar arthrodesis is definitive treatment but only for
healed
1948, Palmer
Described operative treatment of acute displaced intra
articular calcaneal fractures
Standard lateral kocher approach to reduce joint
1952, Essex – Lopresti
Tongue or joint depression fracgment
Tongue type fracture with percutaneous fixation
Joint depression with ORIF
Treatment remains challenging

22. Non- Operative Indications
• Non-displaced or minimal displaced extra-
articular fractures
• Non-displaced intra-articular fractures
• Anterior process fracture with < 25% involvement
of calcaneocuboid articulation
• Fracture in patient with severe PVD, insulin
dependent diabetes, other comorbidities
prohibiting surgery, heavy smokers(>2packs)
• Blisters, Massive swelling, open wound, life-
threatening injuries

23. Non Operative treatment
• Supportive splint f/b prefabricated fracture
boot with ankle locked in neutral flexion to
prevent equinus contracture
• Early range of motion
• Non weight bearing for 10-12 weeks till
radiological union confirmed

24. Non Operative treatment
• Reserved for non displaced intraarticular
fracture
• Displaced intraarticular fracture
– Malunion
– Reduction of articular surface not achieved
– Heel shorten widened
– Talus in dorsiflexion, lateral wall impingement and
peroneal tendons

25. Operative Indications
• Displaced intraarticular fracture involving posterior facets
• Anterior process >25% involvement of calcaneocuboid
articulation
• Displaced tuberosity
• Fracture dislocations
• Selected open fracture
– Open type I Delayed ORIF
– Open wound type II with medial wound Delayed ORIF
– Open wound type II with
non-medial wound ExFix/Percutaneous Fixation
– Open Type III A ExFix/Percutaneous Fixation

26. Operative Treatment
• External Fixation
• Closed reduction internal fixation
– Especially for tongue type fracture
• Percutaneous screws (7.2/6.5)
– Simple fracture
– Low energy Tongue type (very hard to maintain)
– Extra-artricular tongue
– Skin at risk, heavy smokers, medically unfit, diabetic patient
• Arthroscopic assisted
• ORIF
• Primary Fusion
– Sanders type IV highly comminuted intraarticular fracture

27. Timing of surgery
• Timing of surgery is important
• Early surgery (3 days from injury) runs the risk
of wound breakdown and necrosis.

28. • Operative vs non operative- very scant
differences, predicting patients characteristics
worse outcomes & late ST fusion
• Male worse outcome because of activities
• Bohlers angle <15 good unusal ST fusion to be
• With ST fusion good result in outcomes (10%)
• Bad foot shaped more towards operative as
they will lead to difficult fusion lately

29. • Non operative even bohlers angle >15
– Poor surgical candidates
– Older, bad medical condition
– Heavy smokers
• No difference between ORIF or ORIF + PSTA in
type 4 sanders. So patient and surgeon choice
• Primary fusion prevent two operation, heels
more quickly, start weight bearing quickly within
6 weeks with little stiffness as compared to
operative where it takes 10-12 weeks

30. Approach
• The sinus tarsi approach access to the subtalar and
calcaneocuboid joint. (Two point fixation)
– One study demonstrated that there were fewer wound
complications and better preservation of lateral skin flap
blood supply in Sanders II and III fractures
– Poor anatomical reduction
– Superficial infection rates of up to 14%
– Fusion rate increases
• A combined medial and lateral approach for displaced
intra-articular fractures which has wound
complications

31. • One hundred eight fractures in 93 patients were
follow-up avg 15years
• 80 joint depression
• 28 tongue-type
• 70 Sanders type II
• 38 Sanders type III
• Posterior facet reduction anatomic in 103
fractures (95%)
• 1 missed peroneal tendon dislocation.
• 7 patients had sural neuritis.

32. • 12 fractures (11%) required local wound care for apical
necrosis.
• 1 patient had a dehiscence resulting in osteomyelitis,
requiring a ST fusion.
• 32 fractures (29 patients) developed ST arthritis, requiring
an arthrodesis (30 ST, 1 triple) for pain
• Long-term failure rate of 29%.
• ST fusion - 47% of type III fractures (18/38) & 19% of type II
(13/70) fractures
• The remaining 66 patients (77 fractures) who did not
require a fusion were evaluated for long-term functional
outcome.
• Mild pain, minimal alterations in activities of daily living or
work, and essentially normal shoe wear can be expected
from a properly performed open reduction and internal
fixation

33. Sanders type IV
fractures
• wound problems
• sural nerve injury
• peroneal tendon
injury
• Infection
• Didn’t mention about
number of patients,
open injury had
complicated,
Sanders Type (148) Anatomical
reduction
Type 2 86 %
Type 3 60%
Type 4 none

34. • Buckley conducted a multicentre trial including
424 patients comparing non-operative treatment
of Sanders types II and III intra-articular calcaneal
fractures with operative.
• He demonstrated that non-operative treatment
– Need for late subtalar arthrodesis
– No difference in the clinical outcomes
– Anatomic reduction better long-term outcomes
• 73% of the fractures were operated on by one
surgeon
• Operator bias

35. Case
• 32 year old married female having h/o trauma
18 days back fall from 10 feet on heel
• Xray suggestive of left side depressed
comminuted intra-articular calcaneum
fracture for which below knee slab applied
elsewhere for 4 days then because of swelling
and blisters in left foot slab removed.
• No other comorbidities

36. Sanders Type III AC

37. • Fragment mobilization by Hoke osteotome/
periosteal elevator
• Articular reduction – Height, rotation, varus-
valgus alignment / window visualization
• Definitive Fixation
• Locking plate
• Assessment of peroneal tendon
• Repair of superior peroneal retinaculum
• Wound closure
• Post op care

38. • Anterosuperior most hole fill first f/b postero
superior and postero inferior screws holes
over posterior tubercle
• As tuberosity screw are placed a lateral to
medial force is applied to plate by thumb
whereas valgus force is applied to tuberosity
by long and ring finger pulling upward on the
tuberosity

39. ORIF

41. Post Op

42. Complications
• Compartment syndrome
• Wound dehiscence
• Calcaneal osteomyelitis
• Peroneal tendon problems
– Tendonitis
– Stenosis
– Dislocation
– Tenosynovitis
• Neurological complication
– Nerve entrapment
– Cutaneous nerve injury
– Reflex sympathetic
dystrophy
• Malposition of tuberosity/
superolateral fragment
• Calcaneal malunion/nonunion
• Arthritis
(subtalar/calcaneocuboid)
• Chronic ankle pain
• Heel exostoses
• Heel pad pain

43. Take Home Message
• Anterior Process of calcaneum is key in
restoring calcaneal length during ORIF
• Type III fracture having 4 fold greater need for
subtalar fusion than Type II
• Skin condition is major component for further
prognosis and management of fracture
• Calcaneum fracture management still point of
discussion

44. Thankyou