Fractures of the Calcaneus

Fractures of the calcaneus could be open or closed. Open fractures can be a big problem. The primary fracture line is caused by an axial load injury. The primary fracture line goes from anterolateral to posteromedial. The primary fracture line divides the calcaneus into two main fragments. A superomedial fragment is a constant fragment also called the sustentacular fragment. A superolateral fragment is a tuberosity fragment. Superomedial fragment includes the sustentaculum tali, and it is stabilized to the talus by ligaments. The talus is attached to constant fragment. The sustentacular fragment is a useful reference point for fracture reduction.

The flexor hallucis longus tendon lies underneath the sustentaculum, and if screw placement to the sustentacular fragment is too long, this could affect the flexor hallucis longus tendon, causing fixed flexion of the big toe. A tongue-type fracture affects the posterior facet attached to the tuberosity. A joint depression fracture affects the posterior facet not attached to the tuberosity. Primary fracture line exits anterolaterally and posteromedially. Secondary fracture line appears beneath the posterior facet and exits posteriorly through the tuberosity. The superolateral fragment and posterior facet are attached to the tuberosity. Primary fracture line exits anterolaterally and posteromedially. The tongue-type fracture could be treated with closed reduction and screw fixation. Primary fracture line splits the calcaneus obliquely through the posterior facet and exits anterolaterally and posteromedially. Secondary fracture line exits superiorly just behind the posterior facet. The posterior facet is a free fragment.

Lateral portion of the posterior facet is usually involved and depressed. Sander’s classification is used to guide the treatment and to predict the outcome of treatment. Based on the number of fracture fragments of the posterior facet as seen on coronal CT scan. Type I is nondisplaced and requires nonoperative treatment. Type II is a two-part fracture of the posterior facet. Type III is a three part fracture of the posterior facet. Sander’s Type II & Type III calcaneal fractures will benefit from surgery of reduction and fixation. Type III usually gets more arthritis because it has more fracture fragments and may end by fusion. Type IV is highly comminuted and may require primary subtalar arthrodesis. Calcaneal avulsion fractures are an emergency. Calcaneal avulsion fractures need urgent reduction and internal fixation to prevent skin complications. Avulsion fracture of the calcaneus is an emergency. Do not wait; do emergency surgery. With a joint depression fracture, wait for the swelling to go down before surgery. Open reduction and internal fixation of the calcaneus is generally delayed for 1-2 weeks to allow for improvement of the soft tissue swelling, except with fractures of the posterior tuberosity (avulsion fracture) which can cause skin tenting and urgent reduction is recommended. Associated conditions of fractures of the calcaneus include spine fractures (10%), compartment syndrome of the foot (10%), calcaneocuboid joint fractures (60%), bilateral fractures of the calcaneus (10%), and peroneal tendon subluxation (may be detected on axial CT scan, may be seen as an avulsion fracture of the fibula on x-rays).

The complication rate is high. Factors associated with poor outcomes are age, smoking, early surgery, history of all, heavy manual labor, obesity, males, bilateral injury, workman’s compensation, and peripheral vascular disease. Men do worse with calcaneal fractures than women. The Bohler Angle is formed by a lie drawn from the highest point of the anterior process of the calcaneus to the highest point of the posterior facet and a line drawn tangential to the superior edge of the tuberosity. A decrease in this angle indicates the collapse of the posterior facet. Calcaneus is shortened, widened with Varus. An axial CT scan cut will show the calcaneocuboid joint and the peroneal tendon subluxation. The sagittal view will show the subtalar joint and its depression. Coronal view will show the posterior facet displacement. A CT scan can show the number of the joint fracture fragments as seen on coronal CT scan. The surgical outcome of calcaneal fractures correlate with the number of the joint fracture fragments and the quality of reduction. An MRI will show stress fracture of the calcaneus and the integrity of the peroneal tendons. A stress fracture of the calcaneus may be misdiagnosed as plantar fasciitis. Stress fractures occur in female runners. It will present as swelling and tenderness with medial and lateral compression of the hindfoot.

 A positive squeeze test could mean there is a stress fracture of the calcaneus. You should get an MRI if x-ray is negative. We will see fracture in T1 as a linear streak or a band of low signal intensity in the posterior calcaneal tuberosity. T2 will find an increased signal. Wound related complications are the most common complications (20%). They occur more in smokers, diabetics, and in patients with open fractures. Open fractures of the calcaneus are Grade I, Grade II, and Grade III. Grade I and Grade II open fractures medially; do lateral incisions. Do not do open reduction internal fixation (ORIF) in Grade III medial wounds and in most lateral wounds. Open fractures may lead to amputation. There is a high risk of infection. Malunion of the calcaneus will lead to widening of the heel, Varus deformity, and loss of height. The talus is dorsiflexed, limiting dorsiflexion of the ankle. Peroneal tendon irritation and impingement from the lateral wall is another complication. Surgery definitely decreases the risk of post-traumatic arthritis. Tongue type fractures may benefit from closed reduction and percutaneous fixation or open reduction and internal fixation. Joint depression type usually needs open reduction. Some surgeons advocate conservative treatment of the calcaneus (nonoperative treatment). Subtalar distraction arthrodesis plus insertion of a bony block and rigid internal fixation. Good operation that is usually done for calcaneal fractures that are associated with loss of height and limited dorsiflexion of the ankle. Improves talar inclination and decreases anterior ankle impingement. This will take care of arthritis in the subtalar joint. The lateral calcaneal artery provides blood supply to the lateral flap associated with the calcaneal extensile approach. Be aware that the Sural nerve is in the vicinity of the surgical area. The extensile approach has delayed wound healing in about 20% of cases.

Nabil Ebraheim, MD

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