Surgical Treatment ofIntra-articular Calcaneal

Fractures

John J. Stapleton, DPMa,b,*, Thomas Zgonis, DPMc

KEYWORDS

� Intra-articular calcaneal fractures � Internal fixation � External fixation � Surgery� Reconstruction

KEY POINTS

� The timing of surgery for intra-articular calcaneal fractures is determined by the evaluationof the soft tissue envelope and the anticipated surgical approach to achieve fracturereduction.

� Open calcaneal fractures can present with simple to complex wounds, neurovascularinjury, osseous defects, and additional body injuries.

� The surgical management of a calcaneal malunion and/or posttraumatic subtalarjoint arthritis is managed with the realignment of calcaneal osteotomies and arthrodesisprocedures.

PREOPERATIVE EVALUATION AND SURGICAL PLANNING

Calcaneal fractures mandate meticulous preoperative assessment of the fracturepattern, soft tissue envelope, and assessment of patients to determine the optimalmethod in which the fracture can be reduced while minimizing the risks of postoper-ative complications. The notion that all intra-articular calcaneal fractures should betreated with the same approach is not feasible, and outcomes should be focusedon anatomic reduction, functional outcome, and avoidance of major complications.The severity of injury is directly related to the amount of applied axial load to the calca-neus at the time of injury; even among high-energy injuries, a variety of spectrum

Disclosures: none.a Foot and Ankle Surgery, VSAS Orthopaedics, Lehigh Valley Hospital, 1250 South Cedar CrestBoulevard, Suite # 110, Allentown, PA 18103, USA; b Penn State College of Medicine, 500 Uni-versity Drive, Hershey, PA 17033, USA; c Reconstructive Foot and Ankle Surgery, Division ofPodiatric Medicine and Surgery, Department of Orthopaedic Surgery, University of Texas HealthScience Center San Antonio, 7703 Floyd Curl Drive MSC 7776, San Antonio, TX 78229, USA* Corresponding author. Foot and Ankle Surgery, VSAS Orthopaedics, Podiatric Surgery, LehighValley Hospital, 1250 South Cedar Crest Boulevard, Suite # 110, Allentown, PA 18103.E-mail address: jostaple@hotmail.com

Clin Podiatr Med Surg 31 (2014) 539–546http://dx.doi.org/10.1016/j.cpm.2014.06.003 podiatric.theclinics.com0891-8422/14/$ – see front matter � 2014 Elsevier Inc. All rights reserved.

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exists. The degree of fracture displacement and/or comminution along with the extentof soft tissue injury has to be evaluated. A high index of suspicion is paramount forassociated body injuries, including fractures of the lumbar spine and concomitantlower extremity fractures.Evaluation of certain patient characteristics may affect the surgical approach or de-

cision making toward a nonoperative treatment. Patients with uncontrolled diabetesmellitus, severe peripheral arterial disease in the presence of dense peripheral neurop-athy, and existence of multiple medical comorbidities may require particular attentionto the overall management of calcaneal fractures. In certain case scenarios, limitedopen reduction and internal fixation techniques, closed reduction, percutaneouspinning, external fixation, and/or delayed primary subtalar joint arthrodesis may beperformed among this complex patient population.1,2 Medical optimization of severelyuncontrolled diabetic patients with multiple comorbidities and vascular surgeryconsultation in the presence of critical limb ischemia is paramount in cases whenoperative treatment might be necessary.Plain radiographic evaluation of calcaneal fractures includes a lateral view of the

hindfoot and ankle, anteroposterior view of the foot, axial view of the calcaneus,and anteroposterior and mortise views of the ankle. The lateral view of the hindfootand ankle typically reveals most of the displaced intra-articular calcaneal fractures.The lateral view will reveal joint-depressed and tongue-type fractures that involvethe posterior facet of the subtalar joint. The anteroposterior view of the foot will detectcalcaneal fractures that extend into the calcaneocuboid joint. The axial view of thecalcaneus reveals the associated widening of the calcaneus, medial wall, anddisplacement of the tuberosity (typically varus angulation and shortening), with limitedevaluation of fractures involving the sustentaculum tali. The anteroposterior view ofthe ankle will reveal avulsion rim fractures of the fibula, suggesting possible peronealtendon subluxation, whereas the mortise view of the ankle will reveal the involvementof the posterior facet of the subtalar joint. Once an intra-articular calcaneal fracture isdetected on plain radiographs, a computed tomography (CT) scan is required toadequately evaluate the fracture pattern. The coronal views are performed perpen-dicular to the posterior articular surface of the subtalar joint. Understanding theanatomic variants of calcaneal fractures is paramount to achieving proper anatomicfracture reduction and to aid in the diagnosis and prognosis of the patients’outcomes.The timing of surgery is determined by the evaluation of the soft tissue envelope and

the anticipated surgical approach to achieve fracture reduction. When an extensilelateral approach is to be performed, surgical reconstruction may have to be delayeduntil the associated edema has subsided. The soft tissue envelope is evaluated forthe presence of skin lines, a positive pinch test (the ability to pinch the skin over theproposed incision), and presence of fracture blisters if present. Edema control shouldbe obtained through strict elevation of the lower extremity at rest and layeredcompression dressings. If a minimal incisional approach is to be performed, surgicalreconstruction may be considered sooner because a delay in treatment with a minimalincisional approach may increase the risk for malreduction.

OPEN CALCANEAL FRACTURES

Open calcaneal fractures can present with simple to complex wounds, neurovascularinjury, and/or osseous defects. Open fracture treatment protocols may include and arenot limited to intravenous antibiosis, tetanus prophylaxis, irrigation and thoroughwound debridement, fracture stabilization, delayed wound closure, and delayed

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osseous reconstruction. A standardized approach to open calcaneal fractures is para-mount to minimize postoperative complications.Most often, open calcaneal fractures are associated with a simple medial wound

that can be closed following serial debridements. Simple wounds are usually lineartraumatic small lacerations and without any evidence of nerve or arterial injury. Com-plex wounds are usually very large in size and may involve the plantar surface of thefoot, are associated with nerve and/or arterial injury that may require free tissue trans-fer, and may present with degloving injuries of the heel pad. The wounds associatedwith open calcaneal fractures are usually covered with standard moist to dry dressingsversus an application of negative-pressure wound therapy after the initial debridementand irrigation. Wound closure is usually delayed after a series of irrigation and debride-ment procedures if the wound is simple, clean, and can be closed without significanttension (Fig. 1). Complex wounds with soft tissue loss may require delayed soft tissuecoverage using split-thickness skin grafts and/or free flap coverage.

Fig. 1. Lateral (A) radiograph of an open displaced intra-articular joint-depressed calcanealfracture. Reduction was performed through the medial open fracture wound 48 hours afterthe initial surgical debridement. Postoperative lateral (B) and calcaneal axial (C) radiographsdemonstrating reduction with percutaneous transarticular pinning. Final lateral (D) andcalcaneal axial (E) radiographs demonstrating the alignment and osseous union.

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Fracture stabilization for an open calcaneal fracture can be performed with externalfixation and/or Steinmann pins. Delayed open reduction and internal fixation can beperformed in weeks from the initial injury and if the soft tissue envelope permits withsimilar outcomes to closed calcaneal fractures. If external fixation is applied, carefulattention has to be made to the placement of pins into the calcaneus. An external fix-ator can be applied with tibio-metatarsal transfixation avoiding the calcaneus, but thisform of fixation often only limits the Achilles contracture on the heel. Meticulous place-ment of calcaneal transfixation must consider the fracture pattern and definitive frac-ture management.At times, fracture reduction using a medial approach through the open medial

wound, if present, can be performed. Internal fixation can be placed at the time ofwound closure, and/or definitive fixation can be achieved by reducing the medialwall and posterior facet of the subtalar joint. This technique allows for adequate frac-ture reduction and stability while minimizing further soft tissue injury. Limitations withthis technique include not addressing the lateral wall widening and depressed and/ordisplaced superolateral fracture fragments involving the posterior facet of the subtalarjoint. In certain cases, a second small lateral sinus tarsi incision can be used to facil-itate the reduction of the superolateral fracture fragment of the posterior facet and tofacilitate the intra-articular joint reduction.Prolonged delay of treatment can lead to posttraumatic calcaneal reconstruction

that is focused on realignment calcaneal osteotomies, decompression ostectomy ofthe lateral wall and subtalar joint in situ, or distraction arthrodesis combined withadjunctive soft tissue procedures to address concomitant peroneal tendon pathology.

MINIMAL INCISION VERSUS EXTENSILE LATERAL APPROACH

Minimal incision techniques are used when urgent reduction and fracture stabilizationis required because of soft tissue compromise from severely displaced fracture frag-ments or when associated with rare calcaneal dislocations. This technique can be per-formed with closed, percutaneous, and limited incision reduction and pinning (Fig. 2).In addition, fracture reduction can be supplemented with external fixation and beforethe definitive open treatment is performed. Definitive fixation with percutaneousscrews can be performed if anatomic reduction is achieved and usually in the pres-ence of tongue-type calcaneal fractures. The minimal incisional approach involves

Fig. 2. Lateral postoperative radiograph demonstrating reduction of a calcaneal fracturewith a minimal incision approach and placement of cannulated screws.

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the utilization of small incisions for percutaneous placement of fixation, a sinus tarsiincision, and/or a medial incision.3

A minimal incisional approach is suitable for certain intra-articular calcaneal fracturepatterns. Tongue-type fractures that involve only 2 fracture fragments of the posteriorfacet may be reduced with a minimal incisional approach. In addition, minimally dis-placed intra-articular fractures of the posterior facet can be reduced with a minimalincisional approach and if the soft tissue envelope allows for timely intervention.Tongue-type fractures should be confirmed on CT images to determine that the dis-placed intra-articular fracture fragment is attached to the posterior superior calcanealtuberosity. CT images also allow the surgeon the ability to evaluate the displacementof the medial wall and alignment across the primary fracture line among joint-depressed fractures to determine if an indirect reduction can be achieved.The extensile lateral approach still remains the gold standard for the operative man-

agement of intra-articular calcaneal fractures (Fig. 3). The advantages to an extensilelateral approach include direct anatomic reduction of the posterior facet and calcanealbody. In addition, the peroneal tendons can be inspected for subluxation and repaired

Fig. 3. Lateral (A) radiograph demonstrating an intra-articular joint-depressed calcanealfracture. Long-term lateral (B) and (C) calcaneal axial radiographs demonstrating anatomicreduction achieved with an extensile lateral approach.

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if required. This approach is usually indicated in the 3-part fractures of the posteriorfacet of the subtalar joint, joint-depressed fractures, significant shortening and varusposition of the calcaneal tuberosity, and displacement of the medial wall and isdelayed in treatment fractures that require a larger surgical incision to achieve properanatomic alignment.

POSTOPERATIVE COMPLICATIONS

Calcaneal fractures can be associated with various complications, including wounddehiscence and infection. Superficial wound dehiscence without drainage or exposedhardware is typically managed with frequent local wound care treatments and oral an-tibiotics. The presence of a hematoma should be managed with early incision anddrainage to avoid soft tissue loss and/or deep infection. Purulent drainage shouldbe addressed with early irrigation and debridement along with intraoperative culturesto guide antibiotic treatment. Retained hardware may be maintained if the hardware isstable without subsidence and the infection is addressed acutely. Initial wound man-agement typically involves the utilization of negative-pressure wound therapy.Delayed primary closure can be performed if the surgical wound can be reapproxi-mated with minimal tension. For larger soft tissue defects with exposed hardware,early flap coverage should be performed once the infection has been addressedand after meticulous debridement of all nonviable tissues. Wounds with exposedhardware and deep structures mandate early surgical debridement and soft tissuecoverage to avoid limb loss.The surgical management of a calcaneal malunion and/or posttraumatic subtalar

joint arthritis is managed with realignment calcaneal osteotomies and subtalar versustriple arthrodesis, respectively. The goal of a calcaneal osteotomy is to realign theweight-bearing axis of the calcaneus to the lower leg. Most commonly, a calcanealvarus malunion will require a closing wedge or lateral displacement calcaneal osteot-omy to reestablish this alignment. A neglected lateral calcaneal wall blowout will resultin a widened heel along with possible peroneal tendon entrapment or subluxation. Alateral wall calcaneal ostectomy can adequately address the malunited lateral walland decompress the peroneal tendons. Peroneal tendon subluxation, if present, canbe addressed with reconstruction of the superior peroneal retinaculum with a fibulargroove deepening when performed independently. However, when combined withcalcaneal osteotomies, ostectomies, and/or subtalar joint arthrodesis, a lateral anklereconstruction by using a split portion of the peroneal brevis or longus is required toaddress the peroneal tendon subluxation.Subtalar joint arthrodesis can be performed in situ to address symptomatic post-

traumatic arthritis without malalignment. Joint depression involves a subtalar jointbone block distraction arthrodesis. A subtalar joint arthrodesis can be performed inconjunction with a calcaneal osteotomy, ostectomy, and adjunctive soft tissueprocedures.4

DISCUSSION

Displaced intra-articular calcaneal fractures are commonly associated with some formof functional limitations and discomfort postoperatively. The severity of the initial injuryhas been historically determined by the degree of impaction of the posterior facet ofthe subtalar joint and quantified by measuring the Bohler angle (plain radiographs)and Sanders classification through CT imaging.5,6 The Bohler angle can be used toaccess the degree of initial injury and severity of the fracture but is not usually usedin evaluating postoperative fracture reduction. Postoperative fracture reduction

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should focus on the articular joint congruency surface along with reconstruction of thecalcaneal body. The Bohler angle on initial presentation of less than 0� was associatedwith a significant increase of patients that will require a secondary subtalar jointarthrodesis. In addition, Sanders type 4 fractures are associated with a poor functionaloutcome after open reduction and internal fixation and a high incidence of secondarysubtalar joint arthrodesis; therefore, primary arthrodesis has been advocated despitethe surgical challenge (Fig. 4).Themost common constant fragment in displaced intra-articular calcaneal fractures

is the sustentacular fragment and operative treatment typically consisted of a lateralapproach, with the subtalar joint being reconstructed back to the sustentaculumtali. Reduction of the sustentaculum tali is achieved by anatomic reduction of the pri-mary fracture line and medial wall. A medial approach is typically required when thesustentaculum tali is fractured and gapped from the posterior medial articular portionof the posterior facet. However, in a study by Berberian and colleagues,7 after CT re-view of 100 displaced intra-articular calcaneal fractures, it was found that the susten-tacular fragment was displaced in 42 fractures and more common with the 3- and4-part calcaneal fractures.

Fig. 4. Lateral (A) radiograph demonstrating an intra-articular joint-depressed calcanealfracture. Lateral (B) and calcaneal axial (C) radiographs postoperatively demonstrating a pri-mary subtalar joint arthrodesis with open reduction and internal fixation of the calcaneus.

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SUMMARY

The surgical treatment of intra-articular calcaneal fractures requires understandingand a thorough evaluation of the fracture pattern and patient characteristics thatmay compromise the surgical outcome. An appropriate surgical approach is an impor-tant factor in obtaining a patient’s successful outcome.

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3. Fu TH, Liu HC, Su YS, et al. Treatment of displaced intra-articular calcaneal frac-tures with combined transarticular external fixation and minimal internal fixation.Foot Ankle Int 2013;34:91–8.

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