Calcaneus Fracture

Randy Susanto
• Fractures of calcaneus has been observed and
documented for centuries but consensus
regarding the management has eluded
practitioners
• Norris in 1839 described a compression
mechanism in calcaneus fracture.
• Essex-Lopresti in 1951-2, sought to distinguish
intra-articular from extra-articular and correctly
associated intra-articular variety with poorer
long-term prognosis.
• Based on CT appearance, Sanders provide
more reliable indicators of prognosis and
selection of amenable to surgical cases.
• CT has capability to evaluate accurately
complex calcaneus injuries.
 Anatomy
• The calcaneus is the largest of tarsal bones
• It has 4 articular facets which articulate with
talus superiorly and cuboid anteriorly. Any
fracture that interrupts their alignment is an
intra-articular fracture and posterior facet is
major weight bearing.
• The body of calcaneus is composed of
cancellous bone and having a comparatively
thin cortex. The area of increased bony
density that amenable to screw placement
are:
– Angle of Gissane
– Plantar posterior tubercle
– Anterior aspect of the anterior process
– Sustentaculum tali
• Tibial artery, nerve, posterior tibial tendon
and flexor hallucis longus tendon course along
medial wall and being protected by
sustentaculum tali, which held in place by
medial talocalcaneal interosseous ligaments
during fracture.
• Laterally, peroneal tubercle provides groove
for tendon of peroneal longus (inferior ) and
peroneal brevis (superior).
 Pathophysiology
• Mechanism of fracture : high energy axial load
applied to heel which drives the talus
downward onto calcaneus.
• Fracture line exteds from lateral aspect of the
angle of Gissane in posteromedial initiate an
oblique fracture line as the primary fracture
line. This become the source of multiple
secondary fraacture line and mosly (75%)
involving subtalar joint.
According to it, Essex-Lopresti described two calcaneus
fractures subtype:
• Joint-depression fractures
– Secondary fracture line begins at the angle of Gissane
extends posteriorly but deviates dorsally to exit just
posterior to posterior articular facet.
– This fracture fragment contains most of posterior facet.
• Tounge-type fractures
– Secondary fracture line extends in posterior direction
– Producing large superior, posterior and lateral fragmen,
with calcaneal body forming the inferior fragment
 Etiology
• Nearly all Intra-articular fractures caused by axial load
direct through the laterally situated plantar tuberisity of
calcaneus (weightbearing axis of LE)
• The causes of fracture are:
– Fall from height (usually ≥6ft)
– Motor vehicle collisions
– Impact on a hard surface while running or jumping
– Extra-articular fracture of calcaneal body and plantar tuberosity
caused by blunt-force injury
– Avulsion injuries with abrupt contraction of the Achilles tendon
– Overuse injury or stress fracture in athletes
– Extra-articular injuries likely occur with sudden twisting force
applied to hindfoot than other mechanism.
 Epidemiology
• The calcaneal fracture is the most frequently
tarsal bone fractured (60% of tarsal fracture and
2% of all fractures in adult).
• Commonly seen in in young men.
• Intraarticular constitute 70% of all calcaneus fx
and extra-articular fx constitute for 30% in adults.
• The most common extra-articular fx is calcaneal
body fx, fracture of superior tuberosity
beak/avulsion fx represent 10%, and anterior
process (10-15%) which is commonly happen in
women than in men .
 Prognosis
• Essex-Lopresti noted, intra-articular fx has higher
morbidity than extra-articular.
• Zhang et al concluded that minimal invasive
approach resulted lower complication rather
than sinus tarsi for Sanders type II and III injuries
of intrra-articular fx but has same functional
outcome. The sinus tarsi approach statistically
giving better functional outcome than minimal
invasive approach in patient with Sanders type IV
of intra-articular calcaneal fx.
• Schuberth et al concluded that minimally
invasive approach can improve radiograph
parameters consistent with the goal:
– To restore articular congruity
– Calcaneal morphology
– Calcaneal height and achieve satisfactory result
with minimal risk of complication.
• Grala et al shows that using distractor prior to
surgery, shorter operting time and less effort
while performing surgery. Bone distractor help us
to retracted the soft tissue flap, reduce the
articular and tuberosity fragment and improved
visualization by distracting the posterior
talocalcaneal joint.
• Dhillon et al concluded that MIS can achieve
acceptable reduction and can serve as primary
definitive option for open Fx of the calcaneus
 Clinical Presentation
• History
– Fall from height, MVA (patient sitting in front of vehicle
and contact with floorboards) or injury involving hindfoot.
– More likely young male with intra-articular injuries.
– Pain, discomfort.
– Associates innjury of Compression fracture of spine or
femoral head
– Comorbid: diabetes, peripheral vascular disease,
malignancy or prior surgery or injuries to the same site and
application of orthopaedic hardware.
– Current medical use and social habits (tobacco or alcohol)
• Physical Examination
– Pain, especially when the heel was squeezed.
– edema, ( adding with pallor , paresthesia, diminished
pulses or severe pain might suggest compartment
syndrome)
– ecchymosis (tracks distally to the sole of the foot called
Mondor signwhich pathognomonic) and laceration
– deformity of the heel or plantar arch
– inability to bear weight on the injured foot.
check posterior tibialis dan dorsalis pedis pulses. Capillary
refil should be less than 2 second. In relation, inspect and
palpate medial, lateral and posterior malleoli as well as base
of the fifth metatarsal.
 Laboratory Studies
• It use for preoperative and screening which
depends on the extent of injuries and
presence of comorbid.
• Complete blood count (CBC), blood typing,
coaagulation profile evaluation and
electrocardiography (ECG).
 Imaging Studies
• Plain radiograph
– Indication: suspected calcaneus injury
– AP view to evaluate calcaneocuboid joint
involvement, talonavicular subluxation and lateral
widening. It is also usefull for assess subfibular
impingement as result of lateral displacement of
lateral wall of calcaneus
– Lateral view is use for evaluation the Bohler angle.
The angle defined by two intersecting lines, one from
the anterior process of calcaneus to the peak of
posterior articulate surface and second line from the
peak of posterior articular surface to the peak of
posterior tuberosity. Normally 25o-40o. In fracture
involving subtalar joint the angle may decrease or
negative.
– Oblique view shows degree of displacement of
primary fracture line and lesser facets.
– Axial View depict primary fracture line, varus
malposition, posterior facet stepoff, lateral-wall
displacement and fibular abutment.
– Broden Views obtained by internally rotating the
leg 45o with the ankle in neutral position. The
beam then be directed toward lateral malleolus
and advanced cephalad at interval of 10o, 20o, 30o
and 40o to fully evaluate posterior facet.
Axial
• Computed Tomography
– It helps detection of the fracture, plan for the
treatment, classifying the calcaneal fracture and
ability to render accurate prognosis.
– It classified intra-articular fracture according to
comminution and displacement of posterior facet.
– patient is possitioned on imaging table with hips and
knees flexed. Axial and coronal sectional imaged are
obtained with minimum interval 2 mm
• Axial section enable visualization anteroinferior aspect of
posterior facet, sustentaculum tali and lateral calcaneal wall.
• Coronal section oriented perpendicular to posterior facet
that important to distinguish injury to posterior faceet.
 Treatment
• The goals of treatment are:
– Restoration of heel height and length
– Realignment of posterior facet of subtalar joint
– Restoration of mechanical axis of hindfoot.
• Extra-articular fx are treated with closed
manner, except fracture of sustentaculum tali
with displacement more than 2 mm, posterior
avulsion fracture and significant fracture of
calcaneal body
• Intra-articular fracture most commonly treated
with combination open reduction, ostectomy,
osteotomy, internal fixation and/or arthrodesis.
– Nondisplaced (Sanders type I) generally treated in
closed fashion
– Severely (Sanders type IV) treated with ORIF and
arthrodesis subtalar joint
Other factor that might be considered choice between
surgery and non surgery procedure are:
– Patient age
– Comorbid health condition
– Concurrent injuries
 Medical Therapy
(Nonoperative)
Requiring multidiciplinary team: orthosist, physical
therapist, occupational therapist and the surgeon.
– Extra-articular fracture managed nonoperatively
doesn’t change the weightbearing surface of foot and
not alter hindfoot biomechanics.
– Sever Intra-articular fracture might be treated
nonoperatively if the reconstruction is likely to be
unsuccessfull.
– Closed reduction is attempted by plantarly placing
hindfoot and forefoot to reverse mechanism of injury
that allow elevation of posterior facet. Short leg Cast
maintained for 2 weeks followed by active ROM and
progressive weightbearing begins at 8 weeks with full
weightbearing by 12 weeks
 Surgery
• Multiple surgical exposure are available (MIS, open
technique using medial, lateral or combine approach)
which all depends on the extent of injury and location
of fracture.
• ORIF is difficult because the complex anatomy, the
presence of soft calcaneous bone and high incidence of
postoperative wound infection and breakdown.
• The function outcome is depended on accuracy
subtalar joint reduction, restoration normal heel
morphology, the status regarding subfibular
decompression and implementation postoperative
measures to decrease swelling.
 Operation details
• Preoperative
– Comprehensive physical exam must be
undertaken because 10-15% related to spinal
injury. Documentation of preexisting medical
condition such as diabetes or vascular disease.
– Multidisciplinary team (anesthesiologist and the
physician) to plan the procedure. Imaging to know
the relevant anatomy for planning surgical
approach and staged procedure.
• Timing surgery ideally within 3 weeks after injury. The
period allows blister and swelling subside but still early
for the healing and coalescence of fracture fragment.
Wrinkled skin is the sign of swelling subside.
• Closed reduction with percutaneous fixation has lower
risk of complication, shorting operating time and more
rapid healing. It is indicated for patient with significant
comorbidities, soft tissue compromise or impaired
healing, and tongue–type fx. The goals are improve the
heel alignment and reduce the posterior facet.
Adequate reduction and fixationis difficult to achieve
due to limited exposure
• Calcaneal ORIF surgical success rate has improved with
enhancement evaluation using CT, equipment and
surgical technique. Another development is subtalar
arthroscopy which accurately evaluate the posterior
facet after initial reduction.
• The most popular incision is extensile lateral approach
because it is allowing the surgeon visualize entire fx , a
full-thickness skin flap and complete the reduction
from tuberosity to anterior process and
calcaneocuboid joint, but indirect reduction of the
medial wall and sustentaculum tali.
• Gentle tissue handling is a must. Flap closure
should avoid excessive tension to prevent skin
necrosis and use thin plates for calcaneal
fixation to addressed the issue of skin tension,
hardware prominance and subsequent wound
breakdown.
 Postoperative Care
• Drain post ORIF is removed when less than 10 ml of
drainage fluid over 8 hours.
• Postoperatively, the foot is elevated in neutral position
of 90o angle between foot and tibia and maintained it
for up to 72 hours to reduce the swelling.
• Early ROM post surgery usually started 10-12 days after
surgery. The sutures is removed 2-3 weeks after
operation.
• A well-fitting orthosis is provided to prevent
gastrocnemius-soleus contracture and comfort.
• Weightbearing is delayed for up to 12 weeks depends
on degree of comminution and rigidity of fixation.
 Complication
• The frequent complication is chronic disability due to
pain of an improper subtalar or calcaneocuboid joint.
• Infection
• Swelling
• Delayed wound healing
• Nonunion of fracture fragment
• Lateral impingement of peroneal tendon resultant of
decrease calcaneal height and damage of the sural
nerve if using lateral surgical approach
THANK YOU FOR YOUR ATTENTION