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Duke Orthopaedics
Wheeless' Textbook of Orthopaedics

Calcaneal Fracture

 - See:  
      - Calcaneal Frx in Children 
      - Fatigue Fractures of the Calcaneus
      - Fractures of the Anterior Process 
      - Sub-Talar Joint
      - Sustentaculuum Tali Fractures 

- Discussion:

    - typically results from fall from height (see mechanism)
    - 2 types of frx may occur: extr-articular and intra-articular:
    - intra-articular frx: includes a primary frx line and often a secondary frx line;
          - primary frx line:
                 - most of these involve the posterior facet (but can involve anterior and middle facets);
                 - sustentacular fragment (constant fragment)
                         - anteromedial (sustentacular) frag is rarely comminuted but varies in size;
                         - it remains attached to the talus by strong deltoid ligament and by the interosseous ligament lies in the interosseous sulcus
                                     between the posterior and middle facets; 
                         - Displacement of the Sustentacular Fragment in Intra-Articular Calcaneal Fractures 
                 - tuberosity fragment (posterolateral fragment)
                         - displaces superiorly & laterally resulting in incongruity of posterior facet and widening & shortening of heel;
                         - further axial loading may fracture tuberosity fragment creating a supero-lateral fragment of posterior facet;
                 - thalamic fragment: depressed portion of the posterior facet;
          - misc characteristics:
                 - anteriorly frx may exit laterally, usually at angle of Gissane, but it can also involve the calcaneocuboid joint;
                 - heel becomes shortened and widened;
                 - tuberosity fragment tilts into varus and is pulled proximally by the Achilles tendon;
                 - displaced supero-lateral fragment can impinge upon peroneal tendons;
                 - lateral wall becomes comminuted;
                 - frx extends thru posterior facet which becomes incongruous;
                 - talus become dorsiflexed;
    - fracture classification:
          - Sander's Classification:
          - Rowe: types 1-5 (types 4-5 intra-articular)
          - Essex Lopresti:
                 - extra-articular 
                 - intra-artiulcar 
                 - tounge fracture 
                 - joint depression calcaneal fracture 
    - associated injuries:
          - frx of contra-lateral foot;
          - spinal compression frx;
          - soft tissue injury:
                 - compartment syndrome deep central compartment is involved most often in calcaneal frx;
                 - frx blisters:
                 - references:
                        - The management of soft-tissue problems associated with calcaneal fractures.
                        - Compartment syndrome of the foot after intraarticular calcaneal fracture.
                        - Open Fractures of the Calcaneus: Soft-Tissue Injury Determines Outcome.
                        - Open calcaneal fractures: results of operative treatment.
                        - Wound healing complications in closed and open calcaneal fractures.

- Radiographic Evaluation:

- Treatment Options:
     - Non operative treatment: 
             - contraindications to open reduction:
                      - smoking patient who is unwilling to immediately quit smoking;
                      - vasculopath:
                      - with advanced age, diabetes, or questionable vascular exam, order non invasive vascular studies; 
             - most crucial measurement is degree of continuity of posterior facet, which is best determined by CT scan;
             - all frx are initially treated by strict bed rest, elevation, until acute swelling has subsided;
             - nondisplaced frx w/ mild or moderate decrease in Bohler's < are initially treated by early mobilization, avoidance of wt bearing for 6 weeks;
             - early mobilization with protection from wt bearing is maintained until frx union occurs;
             - historical treatment has included closed reduction (Bohler) w/ distraction and medial lateral compression;
             - may need to be supplemented by orthotic support with a custom-molded insole, rocker-bottom shoe, or ankle-foot orthosis;
             - when nonoperative treatment fails, consider sub-talar arthrodesis is often indicated;
             - references:
                   - Intra-articular fractures of the calcaneum treated operatively or conservatively. A prospective study.
                   - Intraarticular calcaneal fractures. Results of closed treatment.
                   - Operative Versus Nonoperative Treatment of Displaced Intra-Articular Calcaneal FracturesA Prospective, Randomized, Controlled Multicenter Trial.

     - ORIF using lateral approach:
           - in the review by Tufescu TV and Buckley R, the authors conducted a prospective cohort study of 169 patients who sustained intra-articular calcaneal fractures;
                  - they found that operatively treated fractures returned to work quicker (av 87 days sooner);
                  - in patients that performed heavy work:
                  - non op patients returned to work at 273 days vs ORIF patients who returned at av 171 days;
                  - ref: Age, Gender, Work Capability, and Worker's Compensation in Patients with Displaced Intraarticular Calcaneal Fractures

     - Primary Subtalar Fusion for Calcaneal Fracture

     - Percutaneous Fixation:
           - may be indicated for patients with inadequate soft tissues (diabetics with frx blisters) where risk of dehissence is high;
           - main goal is to regain calcaneal height and width and to take the calcaneus out of varus alignment;
           - no attempt is made to reconstruction the articular surface;
           - technique:
                  - manual position across the calcaneal body;
                  - large threaded Steinman pin is placed through the posterior superior portion of the calcaneal tuberosity; 
                  - distraction helps restore calcaneal width and height
                  - longitudinal traction is applied across the Steinman pin w/ a valgus vector applied as well;
                  - threaded Steinman pin is inserted through the posterior inferior corner of the calcaneus, across  posterior facet and into the talar body; 
                  - this stabilizes the valgus reduction;
                  - threaded Steinman pin is inserted through the posterior calcaneus into the cuboid; 
          - technique:
                  - prone position;
                  - distraction screws: ex fix across the calcaneal tuberosity, distal tibia, and/or cuboid and the talus;
                  - transcalcaneal rod (from below) which pushes and elevated fracture fragments;
                  - this pushes up depressed parts of subtalar joint;
                  - may also use lateral pin to manipulate the fracture fragments;
                  - cannulated screw: inserted from latearal to medial into the sustentaculum tali;
                  - Bruce Ziran/P. Bosch: of 25 frxs, 12 patients reported little or no pain, 7 patients had moderate pain, and 2 patients had severe pain;
           - references:
                  - Closed reduction and percutaneous pinning for comminuted intra-articular fractures of the calcaneus: Preliminary results.
                            Bruce Ziran and P. Bosch. 15th Annual Meeting of the Orthopaedic Trauma Association, 1999. 
                  - Treatment of Displaced Intra-Articular Calcaneal Fractures with Closed Reduction and Percutaneous Screw Fixation 
     - Complications of Treatment

- Calcaneal Frx in Children

 Current Concepts Review.  Intra-Articular Fractures of the Calcaneus

 The medical approach for calcaneal fractures. 

 Intra-articular fractures of the calcaneus. A critical analysis of results and prognostic factors.

 Intra-articular fractures of the calcaneum. Part I: Pathological anatomy and classification.

 Mechanism and pathoanatomy of the intraarticular calcaneal fracture.

 Anatomy of the calcaneus.

 Fractures of the calcaneum: the anterolateral fragment.

 Computed tomographic assessment of soft tissue abnormalities following calcaneal fractures.

 Magnetic resonance imaging evaluation of calcaneal fat pads in patients with os calcis fractures.

 Intra-articular fractures of the calcaneus: Present state of the art.       

 Intra-articular fractures of the calcaneus.       

 Fractures of the calcaneus: open reduction and internal fixation from the medial side a 21-year prospective study

Operative Compared with Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures. A Prospective, Randomized, Controlled Multicenter Trial 

Open Fractures of the Calcaneus: Soft-Tissue Injury Determines Outcome.

Long-Term Functional Outcomes After Operative Treatment for Intra-Articular Fractures of the Calcaneus


Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, August 12, 2013 10:31 am

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