The document discusses calcaneal fractures, covering aspects such as anatomy, mechanisms of injury, classification, diagnosis, treatment, and complications. It highlights the different types of calcaneal fractures, their causes, clinical features, radiological evaluation, and treatment approaches, both operative and non-operative, tailored for various patient demographics including pediatric cases. Additionally, it details complications that can arise from these fractures and their management strategies.

1. CALCANEAL FRACTURES
by
-Dr.Nisarg shah

2. index
● ANATOMY
● MECHANISM
● CLASSIFICATION
● RADIOLOGY
● TREATMENT
● OUTCOMES
● COMPLICATIONS
● PEDIATRIC
PECULIARITY

3. introduction
● Largest tarsal bone
● Most frequent tarsal
bone to be #ed
● Majort wt bearing bone
● 2% of all #s
● Bone- irregularly
cuboid, axis direted
forwards upwards &
laterally
● Dense cancellous bone
with thin cortical cover.

4. ● Inferior aspect – triangular,
apex anteriorly
● Medial process wt bearing
● Attaches abd hallucis , flexor
retinacula, plantar aponeurosis,
flexor digitorum brevis
● Lateral process attaches
abductor digiti minimi
● Anterior tubercle attaches short
plantar ligament
● Long plantar ligament central
rough area
● Flexor digitorum accesorius
also has attachments on inferior
surface

5. ● Superior surface- articular
● Anterior middle and posterior
articular facets
● Posterior facet- subtalar joint
-largest & convex
● Sinus tarsi – sulcus calcanei
-interrosseous lig. Cervical lig.
And bifurcate ligaments
● Attachment of extensor digitorum
brevis

6. Medial surface – concave
sustentaculum tali
slip from Tibialis posterio
flexor Digitorum brevis
posterior tibial Art, Vn, Nr
tendon of flexor Hallucis
longus
plantaris
flexor retinaculum
spring lig.
Medial talocalcaneal lig.
Deltoid lig.

7. ● Lateral surface
● Flat , subcutaneous
● Peroneal tubercle
● Peroneus brevis
● Peroneus longus
● Calcaneofibular lig.

8. ● Functions
● Lever arm for propulsion by
tendoachillies
● Body wt foundation
● Lateral column support
● Inversion at subtalar jnt locks
transverse tarsal joint – stability for toe
off. Axes NOT parellel.
● Eversion at subtalar jnt unlocks
transverse tarsal jnt – supple foot for
ground accomodation at heel strike.
Axes parellel.
● Windlass mechanism – plantar fascia.
During propulsion toes dorsiflex
causing shortening of foot and elevation
of longitudinal arch

9. Blood supply
Lateral calcaneal art -> peroneal art -> popliteal
art. ~ sural nerve
Perfusion of lateral flap
Medial calcaneal art -> lateral plantar art ->
PostTibialArt~PostTibial nerve

10. ● Mechanism of injury
● 60%-75% are i/a
● 30%-25% are e/a
● 50% have other associated injuries
● 10% with ls spine. 25% L/L
● 63% involve calcaneo-cuboid joint
● Eccentric Axial loading
● Depends on ht—bone—surface-position
of foot and ankle
● Contact point of calcaneum is lateral to
the wt bearing axis of L/L
● Centre of tuberosity lateral to talus
● Causes talus to exert shear force
obliquely across body
● The wedge like lateral talus process splits
the angle of gissane at lateral wall anterio
to the posterior facet
● The initial # line in vertical plane along
lateral cortex anterior to the post.facet

11. ● The primary # line runs from
portereomedial to anterolateral
calcaneus results into two thalamic
fragments
● The anteromedial/superomedial
/sustentacular/constant fragment
● Attached to deltoid lig. Will move
inferiorly medially and posteriorly
● Posterolateral/superolateral/
semilunar/comet fragment
● Will move superiorly laterally and
anteriorly
● Foot in pronation - #line
posterolateral to post.facet [2A]
● Foot Neutral – # line roughly
through middle of post.facet [2B]
● Foot Supination – # line
anteromedial to post.facet [2C]

12. ● Secondary # line
● Exists proximal to tendo
achillies insertion then it is
joint depression type
● Exits distal to tendoachillies
insertion then it is tongue type
● Anteriorly the secondary # line
may extend to calcaneo-cuboid
joint [I/A] or
[E/A] plantar surface , lateral
wall , medial wall

13. ● Clinical feature
● Pain / tenderness
● Soft tissue injuries
● Skin blisters
● Open # are 7%-17%
● Compartment syndrome
● Skin necrosis at posterior edge
● Thompson test – loss of plantar
flexion with manual calf compression
[tuberosity #]
● Hoffa's sign – laxity of achillies
tendon and weakness of plantar
flexion [I/A #]
● Evaluate comorbidyties to guide Rx
and outcomes --- pvd / dm / smoking /
bmi / age / gender / occupation /
?ambulatory

14. classification

15. classification● x-ray based - Essex lopresti ● Ct based – sander's
● View the widest articular surface
of subtalar joint in semi-coronal
● Lateral A - to - medial C

19. Anterior process #
● Sprain # due to misdiagnosis
● Forced plantar flexion and
inversion injury = avulsion #
● Forced Abduction & eversion =
impaction #
● Oblique foot xray
● Usual Rx non-ot
● >25% articular then orif

20. Sustentaculi #
● <2%
● Axial loading +
forced inversion
● Watch for FHL
injury
● Pain on inversion of
foot and passive
dorsiflexion of toes
● May Alter ST joint
mechanics
● Non union is
common
● Undisplaced – non
op
● Displaced – cc screw
or buttress plate
● Medial approach

21. Tuberosity
● 3%
● Body # due to direct trauma
or axial load – cc screw
● Beak # or tendoachillies
avulsion
● Wound problem = surgical
urgency
● lag screw or TBW
● Usually Non op – swelling
control
early ROM, PWB

22. Radiology

23. Xrays – 5 views
● Ap – calcaneocuboid joint
● Obliq – anterior facet and anterior process.
● Lateral- traction & compression trabecula. Neutral triangle . Thalamic portion is
condensed cortical bone inferior to post. Facet.
● Bohler [tuber angle ] normal 20-40 deg. Decreased in ht loss. Corelates with outcome.
● Crucial angle of gissane –Nr is 100 – 120 deg. Relation between 3 facets

24. ● Harris axial view
● Hind foot widening
● Loss of ht
● Varus-valgus deformity
● St joint information
● Maximum dorsiflexion of foot
and plantar tangential beam

25. ● Broden's view
● Foot neutral rotation and leg internally rotated
45 deg
● Beam focused on lat.malleolus and four views
moving cephalad 40,30,20,10 degrees projection
● Shows intra-articulat subtalar joint details
● Congruency through full range
● Intraop value

26. ● Axial cuts
● Calcaneo-cuboid joint
● Sustentaculum tali
● Anteroinferior portion
of post.facet
● 30deg semiCoronal cuts
● Shape of heel
● Peroneal and flexor tendons
● Post.facet articular surface
● Sander's classification
● Saggital cuts
● Tuberosity
● Anterior process
● Calcaneocuboid
and subtalar joints

27. ● G talar angle of declination indicates
dorsiflexion range. 20Deg is Nr
● A talocalcaneal ht. Nr is 85mm
● E talocalcaneal angle . Nr 35deg
● Each of these measurements along with
longitudinal arch are decreased in post
traumatic subtalar arthritis.

28. TREATMENT● Goals
● Congruency of ST and CC joints
● Restoration of ht [Bohler's angle]
● Reduction of width
● Decompression of subfibular
space for peroneal tendons
● Valgus realignment tuberosity
● Stable fixation
● Timing & important factors
● Age & other injuries
● General health & comorbidity
● Soft tissue envelope – tense
fascia - # blebs
● Open wounds & coverage
● Wrinkle test
● Operative
● Displaced I/A of post.facet
● >25% CC joint involved
● Displaced tuberosity #
● # dislocations
● Open #
● Non-operative
● Mini.displaced E/A
● Undisplaced I/A
● <25% CC joint involved
● Severe pvd
● Household ambulators
● Insulin dependent dm
● Medical comorbidity

29. ● Nonoperative
● Immobilization
● Splint – cast - boot
● Elevation and ice
● Bleb-care
● NWB 10-12 wks
● Early ROM for ankle and ST jnts
● Truly Nondisplaced good results
● Altered gait and atleast some
Persistent functional impairment

30. OPERATIVE
METHODS
● Essex Lopresti CRIF
● Benirsche Sangorzan
EXTENSILE
LATERAL
● Mcreynolds'
MEDIAL
APPROACH
● Stephenson
COMBINED
● U [Cincinnatti]
APPROACH
● ANTERIOR
PROCESS
APPROACH
● Bg Weber TBW
● Carr PRIMARY
ARTHRODESIS

31. ● CRIF – PERCUTANEOUS
● Essex-Lopresti
● Sanders 2C #
● displaced tuberosity or beak
#
● Emergent reduction and
temporary stabilization
● Relative contraindication
for ORIF
● Prone or lateral position
● 6.5-8mm cc screw
● 2 parellel cc screw posterio
to anterio preferablly
perpendicular to # line
● 1 lag screw from lateral to
medial beneath the
post.facet into the
sustentaculum tali

32. ● Benirsche Sangorzan
EXTENSILE LATERAL
● Lateral position
● Within tourniqet time
● L shaped incision
● Subperiosteal full thickness flap
● No touch retract
● No subcutaneous dissection
● Sural nerve and peroneal tendons
at risk
● Corner is water shed area
● Bulid from medial-lateral,
anterior-posterion, dorsal-plantar
● Void filling with autologus graft
or cement
● Lateral plate conturing –
physiological valgus
● Layered closure over drainfrom
periphery to apex. Allgower
donnati

33. ● Mcreynolds MEDIAL APPROACH
● 1cm anterior to navicular prominence
moving posteriorly crossing the
sustentaculum
● Simpler smaller non extensile
● Exposure limited
● Sustentacular & tuberosity fragments with #
line postereolateral to facet
● Posterior tibial neurovascular bundle at risk
● Stephenson COMBINED
APPROACH – campbell clinic
● Medial & lateral incisions
● Accurate reduction
● Exposure of both joints and both
surfaces
● Fixation medially with screw and
laterally with plate

34. ● SINUS TARSI APPROACH ● ANTERIOR PROCESS APPROACH
Minimal invasive procedures

35. ● U approach
● Cincinnati incision
● More wound problems

36. ● Carr [gallie's] primary arthrodesis
● Subtalar or triple arthrodesis
● For sanders 4, severe open sander 3.
● Correct any deformities
● Restore calcaneal ht and orientation
● Maintain talar declination angle and
valgus
● Autologus graft placement
● Denude lateral aspect of talus
● 2 large 6.5-8mm cc screwplaced into
corner of heel, perpendicular to
subtalar joint, entering the talus dome.
● Bg Weber tension band wiring
● For tendo achillies avulsions
● Prone position
● May need tendo achillies
lengthening or gastroc resection
● Splint in plantarflexion

37. Complications - early
● Wound complications.
● Dehiscence, necrosis, infection.
● Most common ~ 25%. upto
4wks. 4% closed. 20% open.
● Dm, smoking, high BMI, open
#, Sx technique.
● Late osteomyelitis.
● Mx as per infection guidelines
with strict immobilization.
● Compartment synd
● Within 30mm hg of
diasolic
● Severe relentless
burning pain in entire
foot
● Clawing of toes
● Decreased 2-point
discrimination and
light touch
● Decreased vibratory
perception @ 256Hz
● Urgent fasciotomy
● Loss of reduction
● If early wt bearing
● Minimum 8wks NWB
● Malreduction-Varus
malrotation
● Intra op harris view-
Achieve valgus
● Sural nerve injury
● Sensory deficit
● Peroneal tendon acute injury –
intraop repair
● Tenosynovitis and stenosis
common with non op Rx
● Hardware removal and tenolysis
● Tendon Dislocation with joint
depression & #dislocation types.
● More lateral the # line more
chances of SPR injury
● Operative SPR repair

38. Complications late● Subtalar arthritis
● Inadequae
reduction, hardware,
cartilage damage
● Severe pain,
disability
● Shoe modify,
NSAIDs, implant
removal or
arthrodesis
● Ankle pain
● By subtalar joint stiffness
● Lateral akle pain
● Conservative or
adhesionolysis
● Heel exostosis
● Painful plantar bony
prominences
● Surgical excision
● Heel pad pain
● Damage septate
architecture
● Not improved by
operatives
● Rx is Heel cusion
● Calcaneocuboid
arthritis
● Malreduction of
anterolateral
fragment
● Conservative,
exostectomy or
arthrodesis

39. Calcaneal malunion● ST and CC arthritis
● Subfibular impingement
● Heel widening and peroneal
tendon symptoms
● Loss of calcaneal ht – anterior
impingement of talus and loss
of ankle dorsiflesion
● Hindfoot malalignment –
altered gait
● Post.tibial and sural neuritis
● Stephens and sanders
classification
● Braly bishop & tullos procedure
● For lateral decompression
● Sural nerve decompression
● Peroneal tenolysis
● Lateral calcaneal osteotomy
● Z-lengthening of peroneals
●

40. Pediatric peculiarity
● Pry os. Cntr at 3mnth IUL
● Sec os. Cntr at 6-8 yrs. Cresentic
posterior.
Fuse with body at 14-16yr.
● Resembles adult calcaneum after
10yrs age
● Rare #. largely cartilaginous,
absorbs shock. Less
comminution
● More L/L # associated
● <14yr mostly E/A. >14yr ~
adults
● D/d sever disease, osteomylitis,
stress #
● Schmidt-weiner classification.
Type -6 is with bone loss +
achillies tendon detachment +
soft tissue injury
● Type1,2,3 = E/A. & 4,5 are I/A
● Rx consideration – remodelling, remaining growth,
ossification potential, morphologic difference opposite.
● Non-op Rx for E/A, undisplaced I/A, <10yr displaced I/A.
With 6wks immobilization & NWB.
● If posterior gap in tongue type <1cm & if achillies tendon is
not significantly shortened then non-op.
● Decreased wound dehiscence. Increased CRPS specially in
girls. RSD responds better to physitheray, requires less drugs
and operatives, increased recurrence rate which again
responds better to Rx reinstatement

41. THANK YOU ALL.........
.......Faculty and Colleagues.......
● References
● Rockwood & Greens
● Rockwood & Wilkins
● Campbell's Operative
● Davangiree Notes
● B.D.Chaurasia
● A.O.Surgical References
● Orthobullets
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● Google !