Calcaneal Fracture

Normughni Fikirudin
 INTRODUCTION
• Joseph-Francois Malgaigne described
intraarticular fracture patterns of the
calcaneus in 1843
• Most commonly fractured tarsal bone
(60%)
• Occurs more commonly in active
working males (peak age 20 to 29)
• Most common mechanism is a fall from
height or MVC
• 25- 50% of have associated injuries.
 Anatomy
• Calcaneus is the largest tarsal bone
• Enveloped in a shell of thin cortical bone
• On the anterior superior aspect of medial
surface  the large sustentaculum tali is
the strongest part of the bone is the key to
reduction and stabilization In fracture of this
bone
• Attached to it is the strong calcaneonavicular
ligament& ant fibers of deltoid ligament
• Passed under it is the FHL & FDL
6 Surfaces
• The superior surface: articulates with the talus
• The distal surface articulates with the cuboid
• The medial surface called the sustentaculum tali
supports the head of the talus.
• The posterior surface provide attachment place for
the Achilles tendon
• The roughed inferior surface forms the major
weight bearing area of the calcaneus
• High fluid content helps the calcaneus to function
as a hydrodynamic shock absorber during impact
(Grimm and Williams, 1997).
Sustentaculum tali
• Supports middle facet of talus
Sustentaculum
• Fulcrum for FHL tendon tali

• Close relationship with posterior tibial

vessels and terminal branches of tibial
nerve
Tarsal Canal and Tarsal Sinus

• Funnel-shaped areas situated anterior to the

posterior talocalcaneal joint and posterior to the
talocalcaneonavicular joint
• The larger tarsal sinus opens laterally, and tarsal
canal extends medially, posterior to the
sustentaculum tali
Load transfer pattern of calcaneus
• Presence of this neutral triangle
however, may simply be a manifestation
of a fracture in the human calcaneus
from axial loading, such as falling from
height (Galluzzo et al., 2018).
• Trabecular pattern & analyzed the stress
transfer
Body weight (BW)
Primary compression lines (PC),
Secondary compression lines (SC)
Primary tensile lines (PT)
Secondary tensile lines (ST)
Achilles tendon lines (AT).
CLASSIFICATION
Classification – Essex-Lopresti
• Based on plain radiographs
• Two main fracture types:
• intra-articular “joint depression”: articular
facet fragment is fractured and separate from
the displaced tuberosity.
• extra-articular “tongue-type”: articular facet
remains attached to the main tuberosity
fragment
• Can be surgical emergency due to skin
compromise
Essex-Lopresti
Sanders Classifications
• The system of Sanders et al is
based on images in the coronal
plane
• Type 1: Nondisplaced post facet
• Type 2: 1 fracture line in the
posterior facet
• Type 3: 2 fracture line in posterior
facet
• Type 4: comminuted more than 3
fracture lines in the posterior facet
Sanders computed tomography
classification of calcaneal fractures.
Initial Assessment - Physical
1. Note condition of skin
• Fracture Blisters?
• Threatened skin?
• Open wounds?

2. Detailed NV exam
3. Associated injuries?
4. Serial exams in the first hours after presentation to monitor for
compartment syndrome Approximately 10% of calcaneal
fractures develop compartment
syndromes of the foot-Myerson
1993
Radiographic Evaluation
• Plain radiographs (XR)
• AP/Lateral/Oblique views of the foot
• Mortise view of ankle to r/o associated ankle pathology
• Axial (Harris) view

• CT scan of the foot

**Consider plain radiographs of the lumbar spine and contralateral foot if warranted to rule
out associated injuries
Bohler’s Angle
• A line from highest point on anterior process
to highest point on posterior facet
• A line from this point to most superior point of
calcaneal tuberosity.
• Normal 25-40˚
• Decreased angle indicates joint depression
Critical Angle of Gissane
• Formed by two cortical struts
that join and intersect to form
an obtuse angle
• Normal 120-145˚
• Lateral XR will typically show a
loss of calcaneal height,
depression and rotation of the
posterior facet, and an increase
in the critical angle of Gissane
 Axial (Harris Heel) View
• Can assess rotation of the
sustentaculum
• Shows increase in calcaneal width
• Shows varus/valgus angulation of the
tuberosity
Broden’s View
• Oblique radiograph of the hindfoot used
intra-op to assess posterior facet
• IR foot 30-40 deg, aim beam at the angle of
Gissane, and take four views angling the
beam 40, 30, 20, 10 cranial
• The sequential views are able to show the
posterior articular facet moving from anterior
to posterior and any associated fracture
displacement, depression, or subluxation.
Saltzman view
• Also known as a hind foot
alignment view.
• 20 degree angulation caudally
towards the ankle joint from the
posterior aspect
• The detector perpendicular at the
anterior aspect of the foot.
 CT
To aid our understanding of the
pathoanatomy of calcaneal fractures

• Coronal: posterior facet, sustentaculum,

lateral wall, fibula impingement
• Axial: CC joint involvement, posterior
facet fracture lines, tuberosity
displacement, lateral wall blowout
• Sagittal: posterior facet depression,
anterior process involvement,
tuberosity assessment
The goal of treatment

• Anatomic reduction
• Correction of deformity-
• Restore length for foot alignment
• Restore height for ankle function

• Stable fixation with the aim of early functional rehabilitation

• Avoiding potentially devastating soft tissue complications
• Allow for shoe wear
Management
Surgical Approach

1. Extensile Lateral Approach (ELA)

2. Sinus Tarsi Approach (STA)
3. Percutaneous Approach (PA)
Surgical Approaches - Extensile Lateral
Pros:
• Visualization of entire lateral calcaneus
• Good view of posterior facet
• Direct reduction of ant. process + tuberosity
• Easy to address lateral wall “blow-out”
• Stable fixation with lateral plate
Cons:
• Increased risk of wound healing problems
Technique - Reduction
• Lateral wall is reflected
• Reduction proceeds from
anterior to posterior typically
• Anterior process to
sustentaculum
• Tuberosity is levered out of varus
• Reduce tuberosity to the
sustentaculum
• Reduce lateral posterior facet
joint fragments to sustentaculum
and to talar facet aboves
Technique - Reduction
Significant variability in the fx pattern
of intraarticular
• BUT there are consistent features:
• The sustentaculum typically remains
attached to the talus
• The anterior process translates
dorsally
• The tuberosity translates laterally,
displaces superiorly (pull of Achilles),
rotates into varus, and shortens into
the fracture calcaneal fx
Surgical Approaches - Sinus Tarsi
Approach(STA)
Pros:
• Lower risk of wound complications
• Operate earlier (fracture mobile)
• Good view of posterior facet
• Direct reduction of anterior process
Cons:
• Indirect reduction of tuberosity
• Harder to address lateral wall blowout
• Limited fixation options
• An incision is made from the tip of the lateral malleolus
toward the base of the fourth metatarsal bone
• EDB is retracted cephalad to permit visualization of
posterior facet
• The peroneus brevis and peroneus longus tendons are
split, allowing exposure to the sinus tarsi and
visualization of the posterior facet of the subtalar joint
• Steinman pin 3.0 is placed through a stab incision in
the calcaneal tuberosity from lateral to medial to
allow for tuberosity manipulation
• Hold reduction with K-Wires. Fixation can be done with
cannulated or solid screws
Non Operative
1. Undisplaced minimally displaced
extra- articular fracture
2. Undisplaced intraarticular fracture
3. Anterior process with less 25%
involvement of calcaneocuboid
articulation
4. Elderly – household ambulator
5. Lack of surgical expertise /
equipment in some areas
Nonoperative treatment
• Displaced intraarticular fracture offers the patient little opportunity to return to normal function
 reduction in the articular surface is never obtained
• the heel remains relatively shortened and widened
• the loss of calcaneal height leaves the talus relatively dorsiflexed in the ankle mortise
• the persistent lateral wall expansion causes impingement of the peroneal tendons

Nondisplaced (Sanders type I) as

demonstrated on CT scan
COMPLICATIONS

• Wound complications--0% to 15.4%

• Sural nerve injuries– 5- 7%
• Subtalar arthritis
Summary
• Calcaneus fractures can be extremely debilitating injuries
• Thorough radiographic assessment needed
• Operative indications must be carefully considered – with particular
attention to patient, injury and surgeon factors
• Host and injury factors affect choice of surgical approaches
• Remember, do no harm.
Thank You