Summary Calcaneus fractures are the most common fractured tarsal bone and are associated with a high degree of morbidity and disability. Diagnosis is made radiographically with foot radiographs with CT scan often being required for surgical planning. Treatment is nonoperative versus operative based on fracture displacement and alignment, associated soft tissue injury, and patient risk factors. Epidemiology Incidence common most frequent tarsal fracture login to view 2 more bullets Anatomic location 17% are open fractures no significant increase in infection rates increased risk for wound complications calcaneal tuberosity fractures peak incidence in women in seventh decade of life Etiology Pathophysiology mechanism intra-articular fractures login to view 3 more bullets calcaneal tuberosity fractures login to view 5 more bullets calcaneal stress fractures login to view 1 more bullet anterior process fractures login to view 2 more bullets pathoanatomy intra-articular fractures login to view 7 more bullets extra-articular fractures login to view 2 more bullets anterior process fractures login to view 1 more bullet Associated injuries orthopaedic extension into the calcaneocuboid joint occurs in 63% vertebral injuries in 10% contralateral calcaneus in 10% disruption of superior peroneal retinaculum leading to possible peroneal tendon instability Anatomy Osteology articular facets superolateral fragment contains the articular facets superior articular surface contains three facets that articulate with the talus posterior facet is the largest and is the major weight bearing surface login to view 2 more bullets middle facet is anteromedial on sustentaculum tali anterior facet is often confluent with middle facet sinus tarsi between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi sustentaculum tali projects medially and supports the neck of talus FHL passes beneath it represented by the constant fragment deltoid and talocalcaneal ligament connect it to the talus contained in the anteromedial fragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments bifurcate ligament connects the dorsal aspect of the anterior process to the cuboid and navicular Classification Extra-articular (25%) avulsion injury of anterior process by bifurcate ligament sustentaculum tali calcaneal tuberosity (Achilles tendon avulsion) Intra-articular (75%) Essex-Lopresti classification the primary fracture line runs obliquely through the posterior facet forming two fragments the secondary fracture line runs in one of two planes login to view 3 more bullets Sanders classification based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet login to view 1 more bullet Sanders classification Type I Nondisplaced posterior facet (regardless of number of fracture lines) Type II One fracture line in the posterior facet (two fragments) Type III Two fracture lines in the posterior facet (three fragments) Type IV Comminuted with more than three fracture lines in the posterior facet (four or more fragments) Beavis classification based on fracture morphology of the calcaneus tuberosity Beavis Classification (based on fracture of tuberosity) Type 1 Sleeve fracture - small shell of cortical bone avulses from the tuberosity Type 2 Beak fracture - oblique fracture line runs posteriorly from most superior portion of the posterior facet Type 3 Infrabursal fracture from the middle of the tuberosity Presentation Symptoms pain swelling inability to bear weight gross deformity open fracture Physical exam inspection ecchymosis and swelling shortened and widened heel login to view 1 more bullet open skin lesions or fractures posterior heel skin compromise login to view 2 more bullets fracture blisters login to view 1 more bullet palpation diffuse tenderness to palpation lack of heel cord continuity in avulsion fractures lack of posterior heel skin blanching with tenting fractures assess for compartment syndrome secondary to swelling login to view 1 more bullet presence of Langer's lines and skin wrinkles suggests skin is appropriate for surgical intervention strength decreased ankle plantarflexion strength with avulsion fractures neurologic assess for neuologic compromise due to swelling vascular assess peripheral pulses login to view 1 more bullet Imaging Radiographs recommended views AP lateral oblique optional views Broden login to view 3 more bullets Harris login to view 2 more bullets AP ankle login to view 1 more bullet findings double-density sign login to view 3 more bullets calcaneal shortening varus tuberosity deformity decreased Böhler's angle login to view 4 more bullets increased angle of Gissane login to view 4 more bullets CT indications gold standard should perform 2-3 mm cuts views 30-degree semicoronal login to view 1 more bullet axial login to view 1 more bullet sagittal login to view 1 more bullet MRI indications used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis findings edema on the T2 sequence see first and then later develops a fracture line visible on the T1 sequence Treatment Nonoperative cast immobilization with nonweightbearing for 6 weeks indications login to view 1 more bullet cast immobilization with nonweightbearing for 10 to 12 weeks indications login to view 7 more bullets techniques login to view 1 more bullet Operative closed reduction with percutaneous pinning indications login to view 4 more bullets techniques login to view 1 more bullet ORIF indications login to view 12 more bullets timing login to view 3 more bullets outcomes login to view 17 more bullets primary subtalar arthrodesis indications login to view 1 more bullet techniques login to view 1 more bullet Techniques Cast immobilization with nonweightbearing for 6 weeks techniques: standard short-leg cast for calcaneal stress fractures login to view 2 more bullets Cast immobilization with nonweightbearing for 10-12 weeks techniques: standard short-leg cast applied with mild equinus windowed over posterior heel to allow for frequent skin checks requires close follow-up to determine if pull of gastrocnemius-soleus dispaces fracture weekly cast changes are necessary due to high incidence of skin complications login to view 1 more bullet Closed reduction and percutaneous pinning ideal for poor soft tissue coverage or patients with peripheral vascular disease techniques: Steinmann pin placed into the fracture site anteromedially-to-posterolateral to leverage fragments into place additional K-wires and Steinmann pins are placed from posterior-to-anterior and lateral-to-medial to secure remaining bone fragments calcaneal transfixin pin can be used to distract fracture percutaneus tamps and elevators can be used to raise the articular surface pins are cut flush with the skin and removed 8-10 weeks post-op can be combined with distracting external fixator login to view 2 more bullets can be combined with percutaneous cannulated screws ORIF extensile lateral or medial approach techniques: login to view 21 more bullets goals: login to view 4 more bullets sinus tarsi approach minimally invasive incision that minimizes soft tissue dissection login to view 5 more bullets techniques: login to view 19 more bullets arthroscopic-assisted reduction and internal fixation benefits: login to view 4 more bullets cons: login to view 3 more bullets can be combined with sinus tarsi approach technqiues: login to view 15 more bullets posterior approach for calcaneal tuberosity fractures techniques: login to view 14 more bullets Primary subtalar arthrodesis performed in highly comminuted Sanders IV intraarticular fractures high rate of secondary fusion after ORIF with these injuries avoids added treatment costs and decreases time off from work techniques: can be performed through an extensile lateral or sinus tarsi approach fracture reduction is perfromed in a similar fashion as ORIF articular cartilage of the subtalar joint denuded to bleeding subchondral bone cannulated compression screws are placed from the posterio calcaneal tuberosity to the talar dome lateral fixation plate applied to hold reduction Complications Wound complications (10-25%) increased risk in smokers, diabetics, and open injuries may consider nonoperative treatment in these patients tongue type fractures at high risk (>20%) for posterior skin necrosis should be splinted in 30 degrees of plantarflexion to relieve soft tissue tension keep all hardware away from the corner of the incision delayed wound healing is the most common complication increased wound complication rate correlated with decreased surgeon experience Subtalar arthritis increased with nonoperative management can be addressed with ankle bracing (gauntlet type), NSAIDs, injections, and physical therapy may require bone block subtalar arthrodesis to address loss of calcaneal height important when there are symptoms of anterior ankle impingement in-situ arthrodesis with preserved calcaneal height Lateral impingement with peroneal irritation Sural nerve neuroma Damaged FHL at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment) Compartment syndrome (10%) results in claw toes Malunion introduction loss of height, widening, and lateral impingement physical exam limited ankle dorsiflexion due to dorsiflexed talus with talar declination angle <20 classification (see below) treatment distraction bone block subtalar arthrodesis login to view 6 more bullets technique login to view 5 more bullets Malunion CT Classification & Treatment Type I Lateral exostosis with no subtalar arthritis Treat with lateral wall resection Type II Lateral exostosis with subtalar arthritis Treat with lateral wall resection and subtalar fusion Type III Lateral exostosis, subtalar arthritis, and varus malunion Treat with lateral wall resection, subtalar fusion, and +/- valgus osteotomy (controversial) Prognosis Poor with 40% complication rate increased due to mechanism (fall from height), smoking, and early surgery lateral soft tissue trauma increases the rate of complication higher Sanders classification and increased intraarticular comminution associated with poor outcomes