• Fractures of the calcaneus account for approximately 60% of tarsal injuries and usually are the result of a fall from a height.

• Other injuries to the appendicular and axial skeleton occur frequently

anatomy• The superior surface has three articular facets supported by a complex corticocancellous bony structure.

• The large posterior facet and the smaller middle and anterior facets function as a single articulation with the talus and together compose the inferior portion of the subtalar joint

• Changes in the relationships among the facets affect subtalar joint mechanics and are analogous to an intra-articular fracture even when the fracture line does not traverse a cartilage surface

• Laterally the tarsal canal opens into a recessed area anterior to the posterior facet known as the sinus tarsi.

• The middle and anterior facets frequently are contiguous and, although smaller than the posterior facet, bear more weight per unit area

• The dense bone of the sustentaculum tali supports the lesser facets and provides an optimal site for rigid screw fixation.

• The medial wall is sharply sloped and is in close proximity to the medial neurovascular structures and flexor group of tendons.

• It is less surgically accessible and more vulnerable to neurovascular injury.

• The lateral wall of the calcaneus is relatively flat and is covered primarily by skin and subcutaneous tissue; this allows easier surgical access and facilitates placement of fixation devices.

• The lateral aspect of the calcaneus is subject to soft tissue complications

• Distally the anterior portion of the calcaneus articulates with the cuboid creating a mobile joint

A, Bohler’s angle, the complement of the angle subtended by thetwo lines demonstrated, decreases with depression of the posterior facet orshortening of the heel. B, The angle of Gissane is densely corticated and is a common exit point of the primary fracture line along the lateral aspect of the calcaneus.

• Calcaneal fractures typically result from axial loading mechanisms

• pattern depends on numerous variables, including the lateral position of the calcaneus beneath the talus, the changing position of the foot at impact, the quality of bone, and the direction and magnitude of the resultant force.

• Although its position varies, a primary fracture line or separation fracture is common to most intra-articular fractures of the calcaneus.

Fracture anatomy

• Begins in the sinus tarsi near the lateral wall and propagates obliquely across the posterior facet to the medial wall

• The anterolateral exit point is at the angle of Gissane but may extend anteriorly as far as the calcaneocuboid joint.

• The posteromedial exit point is posterior to the sustentaculum

• Additional secondary fracture lines invariably occur. These include a medial fracture extension that divides the middle facet from the posterior facet andan anterior fracture extension that divides the anterior process, producing a common anterolateral fragment.

• The direction of the primary fracture line on the lateral view is typically vertical. When secondary posterior fracture line is transversely oriented and exits the tuberosity on its posterior surface, a separate “tongue” fragment is created.

• This fragment is composed of a portion of the posterior facet and the tuberosity.

• Understanding this relationship facilitates reduction of the posterior facet in “tongue-type” fracture patterns

• When the secondary fracture line exits on the superior aspect of the tuberosity, a “joint depression” fragment is created. Typically, this fragment is depressed and rotated into the body of the calcaneus.

# classification-Essex-loprestiTongue type(extra-articular) Joint depression(intra-articular)A fracture line that travels in a transverse plane and exits the calcaneal tuberosity on the upper posterior surface results in a tongue-type fragment. The relationship of the lateral posterior facet and the superior aspect of the tuberosity remains intact.

the secondary fracture line separatesthe lateral posterior facet from the body and tuberosity of the calcaneus. This fragment is rotatedor depressedinto the body. The relationship between the depressed fragment and the tuberosity is altered

The Essex-Lopresti system is simpleto use and relies on readily available radiographs,but the category joint depression isnot detailed enough to facilitate prognosis

Sander’s classification

• The CT classification system of Sanders et al is used widely and is based on the number and location of calcaneal posterior facet fracture lines relative to the widest portion of the posterior facet of the talus

• Although the subtalar joint has three facets that function as a single complex articular surface, none of the current classifications considers displacement that disturbs the relationships between the three facets. This independent variable may account for discrepancies in the reliability of the classification systems

radiography

• dorsoplantar, lateral, and oblique plain radiographs.

• The addition of the axial view generally completes the plain radiographic investigation.

• The dorsoplantar view shows involvement of the calcaneocuboid joint and lateral wall displacement.

• The lateral view allows assessment of posterior facet position and loss of calcaneal height (Bohler’s angle) and gives a general impression of overall comminution.

• The axial view is informative and shows the direction and displacement of the tuberosity along the primary fracture line.

Comparative lateral and axial views of the contralateral uninjured calcaneus facilitate the assessment of displacement and help guide fracture reduction. Multiple hindfoot oblique views may be obtained to image the posterior facet further.Although these views largely have been replacedby CT scanning, they may be helpful intraoperatively

• CT facilitates the preoperative plan and shows previously unrecognized fracture comminution.

• Surrounding soft tissue injury, particularly of the peroneal tendons, is occasionally observed

• include 2 planes: a transverse plane that parallels the plantar surface of the foot and a semicoronal plane perpendicular to the posterior facet.

• The transverse plane images show secondary fracture lines traversing the sustentacular segment and anterior process and calcaneocuboidjoint involvement.

• Sagittal andcor onal reconstructions further enhance comprehension of the complex fracture and bony anatomy

Closed Treatment

• The principles of closed functional treatment are acute pain relief, control of swelling, and early motion.

• Rest, ice, compression, and elevation are emphasized initially .

• Early motion aids functional recovery and seems to be more important than maintaining position with immobilization

• the injured foot and lower leg are placed in a compression dressing followed by a removable splint

• The patient should be non–weight bearing• Progressive wt bearing is started when the fracture

is healed, generally between 6 and 12 weeks.• Range of- motion exercises are instituted as soon

as the swelling and pain are under control.• Then graduated stretching and strengthening

exercises are begun.• Custom orthoses may improve standing and

walking tolerance

Closed manipulative reduction

• Closed manipulative reduction also has been recommended. The goal of this treatment is to restore the overall shape of the calcaneus, with emphasis on restoring Bohler’s angle, obtaining posterior facet congruency, and restablishing normal heel width.

• This method has limited indications but may be useful in managing patients who are not candidates for open treatment

Surgical treatment

• Method and need for extra-articular and intra-articular reduction, the choice of surgical approach, bone graft requirements, patient position, implant selection, and outcome assessment, all are controversial issues

• The principles of bony reconstruction, particularly in weight-bearing joints, include anatomic reduction and rigid fixation of intraarticular fractures and accurate restoration of coronal, sagittal, and transverse mechanical axes.

• Adherence to these principles maximizes the chance for optimal outcome, but application of these principles to the calcaneus has been slow

• Complex bony and fracture anatomy, a tenuous soft tissue envelope, and the difficulty of achieving anatomic reduction and rigid fixation are important complicating issues. Although clinical experience suggests that there are some instances in which open management is superior to closed management, exact indications are elusive

• studies suggest several concepts.• Displaced fractures seem to have a worse outcome than

nondisplaced fractures.• Increasing numbers of fracture lines and displacement of

the posterior facet typically are the result of high-energy forces, and these fractures have worse outcomes than those with less involvement of the posterior facet.

• Anatomic restoration of the posterior facet correlates with, but does not guarantee, a good result.

• Obtaining an anatomic posterior facet reduction becomes more difficult with Increased articular comminution.

• Posterior facet incongruity and degeneration, as measured by CT scan, have been correlated with a loss of subtalar motion and are strong predictors of a poor clinical outcome.

Indications

• Incongruous subtalar joint with more than 2 mm displacement;

• gross displacement of the heel, particularly with subfibular impingement;

• Depression of the talus into a horizontal position;• or bony pressure points likely to ulcerate or give

mechanical pain. • The status of the surrounding soft tissue envelope and

the patient’s lifestyle and expectations further modify the decision-making process.

contraindications

• peripheral vascular disease,• peripheral neuropathy, • advanced age,• sedentary lifestyle,• inadequate soft tissue envelope, • and patient unwillingness to proceed with

unproven treatment.• Other relative contraindications

Timing

• Most calcaneal fractures are repaired surgically in a delayed fashion to allow for the initial swelling to resolve.

• Acute intervention through the significantly traumatized zone has resulted in early wound breakdown and complications.

• Most definitive interventions can be performed between 7 and10 days.

• Injuries with associated marked edema and fracture blisters may require delays of 2 to 3 weeks.

Surgical Approach

• Several surgical methods are available including minimally invasive and open techniques.

• Modern percutaneous reduction and screw fixation techniques are an extension of closed manipulative reductions described by Essex-Lopresti and are successful in properly chosen fracture patterns

• Minimal open procedures combined with circular ring external fixation also have been described.

• These techniques and others, such as the use of bioabsorbable implants, currently are being investigated.

• Open calcaneal fracture surgery can be performed using medial, lateral, or combined approaches

• Medial approach described by McReynolds has the most historical support. The advantage of the medial approach is direct visualization of the posteromedial extent of the primary fracture line.

• Because of the slope of the medial wall and its close relationship to the medial tendinous andneurovascular stuctures, application of rigid implants along this surface is difficult

• The lateral approach currently is the most popular

• The lateral approach allows direct examination of the posterior, middle, and calcaneocuboid joint surfaces,

• Depressed fragments are accessed and elevated under direct vision, and the lateral surface is suited best for application of rigid fixation.

• Intraoperative axial and lateral views are used to assess reduction of the tuberosity and anterior process

• Reduction achieved under direct vision and by palpation using a semicurved instrument, such as a small periosteal elevator.

• Provisional Kirschner wire fixation is performed strategically in anticipation of definitive plate and screw placement.

• A second set of intraoperative lateral and axial radiographs confirms the adequacy of all elements of reduction.

• Numerous implants are available for application along the lateral calcaneal wall, including locking screw/plate devices and multilimbed plates.

• A pelvic reconstruction plate contoured into a gentle arc, with the concavity plantarward, is frequently sufficient.

Postoperative Management

• Active range-of-motion exercises of the foot and ankle are begun when the surgical incision is secure, typically within 3 to 5 days. The patient initially is supplied with a removable, well-padded splint to minimize gastrocnemius-soleus contracture and for comfort

• Weight bearing on the affected extremity is delayed for 8 to 12 weeks, depending on the fracture pattern,

• Weight bearing is resumed according to patient tolerance, and the patient usually is transitioned from a removable cast boot to supportive cushioned shoes. The use of ambulation aids is discontinued by 16 weeks.

COMPLICATIONS

• Compartmental syndromes are reported to occur in 10% of displaced calcaneal fractures

• open wounds are typically on the medial aspect of the foot and are invariably the result of penetration from the sustentacular fragment

• Major and minor complications attributable to open reduction and internal fixation through a lateral approach are found in 10% to 20% of patients

• Using the standard lateral approach, the reported infection rate is 2% to 3%

COMPLICATIONS• Marginal skin loss at the apex of the incision has

diminished since the more gently curving classic approach has been modified to include a sharper curve.

• Smoking, diabetes, and open fractures all are independent risk factors for wound complications after open reduction and have a cumulative effect

• Sural nerve symptoms occur in a few patients and resolve within a few months in most. The incidence of sural nerve symptoms seems to have lessened with the use of the extended lateral incision

• Neurapraxia of the tibial nerve usually have return of nerve function by 8 months.

Summary The ideal treatment for calcaneal fractures is unknown.

The natural history of displaced calcaneal fractures is unfavorable

The results are not nearly as predictable.

For fractures with significant intraarticular displacement, subfibular abutment, anterior ankle impingement, pressure points, or difficulty in shoe fitting, open reduction may be appropriate.

A careful lateral extensile approach allows reduction and fixation of all of the key elements of the fracture with sufficient rigidity to allow early motion