Calcaneus Fractures

Anthony J Longo M.D.

University of Texas Medical Branch

Slide 1
 Introduction

„ Most frequently fractured tarsal bone

„ Sixty % of all tarsal fractures and 1-2%
of all fractures
„ Seventy-five% are intra-articular
„ 10% are Bilateral
„ Seventy % occur in the work place
„ Majority occur in men age 25-45

Slide 2
 Introduction

„ Treatment is controversial, with mixed

outcomes for both surgical and
nonsurgical management.
„ Very severe injury, this was recognized
early
„ Initially all were treated nonsurgically.
„ Initial surgical treatment was a primary
subtalar fusion

Slide 3
 „ Second surgical method was closed
reduction and pins with plaster
„ Continue to have problems with
morning stiffness, subtalar motion and
long term running

Slide 4
 Anatomy

„ Largest tarsal bone

„ Calcaneus has been
described as being
like an egg
„ Three articular
facets
„ Posterior, Middle
and Anterior
„ All articulate with
the talus

Slide 5
 Anatomy

„ Lateral anatomy is
important because it
is exposed during
the most common
surgical approach
„ Lateral process of
the tuberosity, origin
of the plantar fascia
„ Peroneal trochlea
„ View of the posterior
facet

Slide 6
 Mechanism of injury

„ Essex-Lopresti - described two basic

fracture types: joint depressed and
tongue type.
„ Axial compression with an oblique
primary fracture line.
„ Anterior-lateral superior to posterior-
medial inferior
„ Involving some portion of the posterior
facet
„ Lateral process acts as a wedge

Slide 7
 Mechanism

„ Fracture is caused by a shearing force

„ The posterior tuberosity is lateral to the

mechanical axis of the leg

„ This primary fracture line divides the

calcaneus into a sustenaculum piece
and a tuberosity piece.

„ The secondary fracture line determines

joint depression versus tongue type

Slide 8
 Joint Depression

„ Secondary fracture line runs superior from the

primary fracture line and exits behind the
posterior facet

Slide 9
 Tongue type

„ Secondary fracture line runs posterior to the

primary fracture line and exits out the back of
the tuberosity

Slide 10
 Physical Exam

„ Heel appears shorter and wider and at

times in a varus position

„ Sural nerve injury is common

„ High incidence of associated injures

Slide 11
 Physical Examination
„ Significant swelling with rapid onset of
fracture blisters and ecchymosis to the heel
and arch

Slide 12
 Associated injuries

„ 70% of calcaneus fractures have an

associated injury

„ L spine 10% (3-12%)

„ Ipsilateral lower extremity fracture 10%

„ Compartment syndrome 10%

Slide 13
 Radiographic Evaluation

„ Plain films

„ Lateral of the foot

and ankle

„ Harris axial view

„ Broden View

Slide 14
 Lateral of the Calcaneus

„ Bohler angle

„ Insertion of a line
from posterior
tuberosity to the
posterior facet and
anterior process to
the posterior facet

„ 25-40 degrees

„ Crucial angle of
Gissane

Slide 15
 Broden’s View

„ Evaluates reduction of the posterior facet

„ IR foot to 45 degrees

„ Angle the x-ray beam vertically toward the horizontal in

10 degree increments form 10-40 degrees

Slide 16
 Broden’s View

Slide 17
 Harris View
„ Passively dorsiflex the ankle to achieve a
tangential radiograph across the plantar
aspect of the heel

Slide 18
 CT Scan
„ Coronal and axial views
„ Commonly saggital reconstructions
„ Three dimensional reconstructions are
available
„ Knee flexed at 90 degrees and foot flat on the
table
„ Both feet simultaneously

Slide 19
 Classification based on Plain
Radiographs

„ Essex Lopresti 1950

„ Rowe in 1963 further subdivided into

comminuted and those that were not

„ Soeur and Remy – 1975 nonthalamic

and thalamic- subdivided in to vertical
compression and shearing and
compression

Slide 20
 Classification based on CT Scans

„ Crosby-Fitzgibbons „ Sanders
– 1990 – 1993

– Type I – – Type I nondiplaced

nondisplaced
– Type II 2 intra-
– Type II – articular fragments
displacement of subtype into A/B/C
posterior facet
– Type III 3 intra-
– Type III – articular fragments
comminuted intra-
articular fx – Type IV 4 fracture
fragments

Slide 21
 Sanders Classification

„ choose the coronal

CT image that
shows the posterior
facet in widest
profile
„ mark two vertical
lines to divide the
posterior facet into
three equal sections
„ final line marks the
vertical border of the
sustentaculum

Slide 22
 Treatment Options

„ Controversial

„ Best surgical outcomes are in Sanders

type II and tongue type

„ Poorer outcome associated with male

patients, men, overweight, and
workman compensation cases

Slide 23
 Surgical Techniques

„ Multiple approaches described including

medial, lateral, combined, sinus tarsi, and
extensile lateral
„ Extensile lateral approach in the most
preferred

Slide 24
 Considerations
„ Soft tissue swelling

„ Initially treat in a bulky Jones splint

„ Goal of surgery is anatomic reduction

of posterior facet and the
calcaneocuboid joint

„ Bone grafting, also controversial, some

studies show no benefit with lateral
plate

Slide 25
 Surgical technique

„ Positioning - Unilateral, then lateral decubitus;

Bilateral, then prone.
„ No touch technique with the skin, K wires in
the talar neck, fibula and cuboid
„ Stieman pin in the posterior tuberosity to
indirectly reduce posterior facet

Slide 26
 Surgical Technique

„ Anterior calcaneus
and posterior facet
reduced and held
with k wires
„ Low profile plate to
hold reduction
„ C-arm with
flouroscopic
Broden’s view to
visualize reduction

Slide 27
 Post operative care

„ Immobilize for 3 weeks, until wound

has healed
„ Early ROM, some recommend out of
splint at week one
„ Nonweight bearing 10-12 weeks,
trabecula bone formation on plain films
„ Progression to full weight bearing
without assistive devices
„ Maximal medical improvement at 18
months

Slide 28
 Primary arthrodesis
„ Recommended for some Sanders type IV fractures
„ Poor results in type IV with both surgical and
nonsurgical treatment
„ Sanders et al reported only one good to excellent result
in 11 type IV fractures treated with ORIF

Slide 29
 Primary arthrodesis

„ Similar to ORIF, restoration of anatomy

„ Removal of the cartilage for the
undersurface of the talus and remnants
of the posterior facet.
„ Iliac crest bone grafting versus allograft
„ Fusion with large fully threaded
canulated screw from the posterior
facet into the talus
„ 16 weeks or longer before complete
fusion

Slide 30