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Calcaneal Fracture

Calcaneal fractures account for 1-2% of all fractures.  They generally result from high energy mechanisms, most commonly falls from heights or road traffic accidents.  The ‘rule of 10’ is useful when assessing these injuries, approximately 10% are bilateral, 10% open injuries and 10% associated with spinal injuries, usually thoracic-lumbar burst fractures.

They are in the main very significant injuries when intra-articular in nature, and require a clear understanding of the fracture anatomy, and patient factors (most importantly compliance and avoidance of smoking) as well as what can be realistically achieved with operative techniques, when forming an opinion and counselling patients on how to be treated.

Controversy surrounds their management, in particular whether open reduction and internal fixation is ever warranted, given a not inconsequential incidence of  complications related to open approaches such as with the extended lateral approach described in some series.   Such complications include wound breakdown, deep infection and pain syndromes related to cutaneous nerve compromise.  This has led to the development of less invasive techniques to reconstruct calcaneal fractures including sinus tarsi approaches and percutaneous techniques.

The extended lateral approach affords excellent visualisation of the components of the injury that require reduction, namely the lateral wall, subatalar and Calcaneo-cuboid joints and peroneal tendons.  It is based one the angiosome of the lateral calcaneal artery, a terminal branch of the peroneal artery.  The use of the extended lateral approach was popularised by, amongst others, Professor Roger Atkins at The Bristol Royal Infirmary, UK. His two seminal papers from 1993, published in the British Journal of Bone and Joint Surgery (and available open access), describe the patho-anatomy, surgical approach and sequence of fixation. They are essential reading for anyone embarking on the surgical fixation of articular depression fractures of the calcaneum, regardless of approach used.

The UK heel fracture and its accompanying headline in the BMJ caused significant controversy with its assertion that open reduction and internal fixation should not be recommended for displaced intra-articular fractures.  The debate over this paper continues but it is certainly true that newer techniques and implants continue to develop which avoid the need for the use of the extended lateral approach. It is also true that these fractures should be managed by surgeons and units used to dealing with large volumes of these injuries-  the median number of operations per surgeon in the study was 2 and this may be related to the high rate of complications specifically a 19% infection rate which any surgeon or unit would deem unacceptable.   As with many aspects of complex trauma, rather than didactically deciding on treatment based on a simple radiological review, the decision making as to the best treatment for an individual patient relies on careful examination of the injured limb, study of the X-rays and scans and a detailed discussion with the patient as to the risks and benefits of each treatment for them in light of other factors such as smoking or medical comorbidities- unfortunately this nuanced process does not lend itself to an RCT.

In this case I have used the Zimmer-Biomet ALPS plating system.  I prefer these implants when fixing calcaneal fractures with an extended lateral approach.  The instrumentation is well designed, there are good screw options including cortical, locking and variable angle screws and crucially the plate and screws have a very low profile once the fixation is completed minimising the risk of soft tissue irritation or impingement.

Readers will also find the following OrthOracle operative techniques of interest:

Percutaneous fixation of Tongue-type calcaneal fracture

Calcaneal fracture fixation : Internal fixation of sustentaculum tali fracture (Acutrak screws)

Calcaneal fracture fixation: Extended lateral approach and locking plate fixation

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 - 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: extra-articular and intra-articular:

- intra-articular fracture:
- 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-articular
- tongue 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;
- more common with severe comminuted fractures.
- 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.
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
The association between subtalar joint motion and outcome satisfaction in patients with displaced intraarticular calcaneal fractures.