Updated: 6/14/2020

Calcaneus Fractures

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Introduction
  • Overview
    • most commonly fractured tarsal bone with high mordibity and disability associated with displaced intra-articular fractures
      • surgical treatment involves reestablishing calcaneal height, width, length, and alignment to improve gait mechanics, shoewear fitting, and decrease post-traumatic subtalar arthritis
  • Epidemiology
    • incidence
      • most frequent tarsal fracture
        • 60-75% of injuries are intra-articular fractures
        • 1-3% are calcaneal tuberosity fractures
      • 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
  • Pathophysiology
    • mechanism
      • intra-articular fractures
        • traumatic axial loading is the primary mechanism of injury
          • fall from height
          • motor-vehicle accidents
      • calcaneal tuberosity fractures
        • poor bone quality/osteoporosis
          • violent contaction of the triceps surae with forced dorsiflexion
          • strong concentric contaction of the triceps surae with knee in full extension
        • intrinsic tightness of the gastrocnemius and achilles tendon
        • peripheral neuropathy leading to decreased pain sensation and proprioception resulting in recurrent microtrauma
      • calcaneal stress fractures 
        • increased physical activity in the setting of relative energy deficiency 
      • anterior process fractures 
        • twisting injury mechanism
        • avulsion injury of the bifurcate ligament 
    • pathoanatomy
      • intra-articular fractures
        • primary fracture line results from oblique shear and leads to the following two primary fragments
          • superomedial fragment (constant fragment)
            • includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments
          • superolateral fragment
            • includes an intra-articular aspect through the posterior facet
        • secondary fracture lines
          • dictate whether there is joint depression or tongue-type fracture
      • extra-articular fractures
        • strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus
        • more common in osteopenic/osteoporotic bone
      • anterior process fractures 
        • inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament
  • Associated injuries
    • orthopaedic
      • extension into the calcaneocuboid joint occurs in 63%
      • vertebral injuries in 10%
      • contralateral calcaneus in 10%
  • 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
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
        • the flexor hallucis longus tendon is medial to the posterior facet and inferior to the medial facet and can be injured with errant drills/screws that are too long 
      • 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
        • the axial plane beneath the facet exiting posteriorly in tongue-type fractures  
          • when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly
        • behind the posterior facet in joint depression fractures 
    • Sanders classification
      • based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet
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
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
        • may have apparent varus deformity
      • open skin lesions or fractures
      • posterior heel skin compromise
        • tenting, ecchymosis, or lack of skin blanching with tuberosity fractures
          • neccessitates urgent sugical reduction and fixation to avoid posterior heel skin necrosis
      • fracture blisters
        • must be debrided and epithelialized prior to surgical intervention
    • 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
        • rare
      • 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
        • severe peripheral vascular disease may preclude surgical treatment due to poor wound healing potential
Imaging
  • Radiographs
    • recommended views
      • AP
      • lateral
      • oblique
    • optional views
      • Broden
        • allows visualization of posterior facet
        • useful for evaluation of intraoperative reduction of posterior facet
        • with ankle in neutral dorsiflexion and ~45 degrees internal rotation, take x-rays at 40, 30, 20, and 10 degrees cephalad from neutral
      • Harris
        • visualizes tuberosity fragment widening, shortening, and varus positioning
        • place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees
      • AP ankle
        • demonstrates lateral wall extrusion causing fibular impingement
    • findings
      • double-density sign
        • represents subtalar incongruity
        • indicates partial separation of facet from sustentaculum
          • lateral portion of the posterior facet 
      • calcaneal shortening
      • varus tuberosity deformity
      • decreased Böhler's angle
        • angle between line from highest point of anterior process to highest point of posterior facet + line tangential to superior edge of tuberosity
        • measured on lateral view
        • normal 20-40°
        • represents collapse of the posterior facet
      • increased angle of Gissane  
        • angle between line along lateral margin of posterior facet + line anterior to beak of calcaneus
        • measured on lateral view
        • normal 120-145°
        • represents collapse of the posterior facet
  • CT
    • indications
      • gold standard
      • should perform 2-3 mm cuts
    • views
      • 30-degree semicoronal
        • demonstrates posterior and middle facet displacement
      • axial
        • demonstrates calcaneocuboid joint involvement
      • sagittal
        • demonstrates tuberosity displacement
  • MRI
    • indications
      • used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis  
Treatment
  • Nonoperative
    • cast immobilization with nonweightbearing for 6 weeks 
      • indications
        • calcaneal stress fractures
    • cast immobilization with nonweightbearing for 10 to 12 weeks
      • indications
        • small extra-articular fracture (<1 cm) with intact Achilles tendon and  <2 mm displacement
        • Sanders Type I (nondisplaced)
        • near normal Böhler's angles (20-40°)
        • anterior process fracture involving <25% of calcaneocuboid joint
        • comorbidities that preclude good surgical outcome (smoker, diabetes, PVD)
          • avoids the high wound complications seen with these fractures
        • minimally displaced tuberosity fractures (<1 cm of displacement) without threatened soft-tissue envelope in elderly patients with reduced function or physical capacity
      • techniques
        • begin early range of motion exercises once swelling allows
  • Operative
    • closed reduction with percutaneous pinning 
      • indications
        • minimally displaced tongue-type fxs or those with mild shortening
        • large extra-articular fractures (>1 cm)
        • early reduction prevents skin sloughing and need for subsequent flap coverage
        • ideal in patients with sever peripheral vascular disease or severe soft-tissue compromise
      • techniques
        • lag screws from posterior superior tuberosity directed inferior and distal
    • ORIF
      • indications
        • displaced tongue-type fractures 
          • >1 cm displacement
          • threatened soft tissue
            • require urgent reduction and fixation to avoid skin necrosis (disastrous consequence)
          • open fractures
            • open reduction allows for sufficient debridement of contaminated tissue
          • inability to participate in closed treatment
        • large extra-articular > 2 mm displacement
        • Sanders Type II and III 
          • posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity
        • anterior process fracture with >25% involvement of calcaneocuboid joint
        • displaced sustentaculum fractures
      • timing
        • wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days 
          • no benefit to early surgery due to significant soft tissue swelling 
        • displaced tuberosity fractures with posterior skin compromise should be addressed urgently   
      • outcomes 
        • surgical outcome correlates with the number of intra-articular fragments and the quality of articular reduction
        • surgical treatment decreases the risk of post-traumatic arthritis 
        • factors associated with a poor outcome    
          • age > 50 (similar outcomes with surgical and nonsurgical treatment)
          • obesity
          • initial Böhler's angle <0° (these injuries do poorly regardless of treatment)
            • lower Böhler angles suggest greater energy absorbed
          • manual labor
          • open fractures (significant soft tissue injury and engery absorbed)
          • workers comp
          • smokers (poor wound healing)
          • bilateral calcaneal fractures (significant gait problems following bilateral injuries)
          • multiple trauma
          • vasculopathies
          • men do worse with surgery than women
        • factors associated with most likely need for a secondary subtalar fusion 
          • male worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees
    • primary subtalar arthrodesis
      • indications
        • Sanders Type IV
      • techniques
        • combined with ORIF to restore height
Techniques
  • Cast immobilization with nonweightbearing for 6 weeks
    • techniques:
      • standard short-leg cast for calcaneal stress fractures
        • nonweight bearing cast
        • well-padded heel
  • 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
        • high incidence of vascular insufficiency and diabetes in this population
  • 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
        • pins placed in calcaneal tuberosity, cuboid, and distal tibia
        • restor calcaneal height, width, and alignment
      • can be combined with percutaneous cannulated screws
  • ORIF
    • extensile lateral or medial approach
      • techniques:
        • extensile lateral L-shaped incision is most popular 
          • vertical portion inbetween posterio fibula and achilles tendon 
          • horizontal portion in line with 5th metatarsal base
          • a more inferior incision protects the sural nerve
          • high rate of wound complications
          • provides access to the calcaneocuboid and subtalar joints
        • full-thickness skin, soft tissue, and periosteal flaps are developed
          • flap supplied by lateral calcaneal branch of peroneal artery  
          • superior flap contains the calcaneofibular ligaments and peroneal tendon sheath
        • sural nerve and peroneal tendons are retracted superiorly
        • lateral calcaneal wall visualized
        • fracture opened and medial wall reduced going medial to lateral
          • reduction confirmed indirectly via fluoroscopy
        • tuberosity reduction is done under direct visualization
          • manual traction, Schanz pins, and minidistractors
            • pin in tuberosity aids with reduction 
          • height and length of tuberosity is recreated
          • quality of reduction affects outcomes
        • provisional fixtaion was K-wires
        • definitive fixation with plates and screws
        • bone grafting provided no added benefit
      • goals:
        • restore congruity of subtalar joint
        • restore Böhler's angle and calcaneal height
        • restore width
        • correct varus malalignment
    • sinus tarsi approach
      • minimally invasive incision that minimizes soft tissue dissesction
        • reduces wound complications associated with extensile lateral incision
        • allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall
        • lower incidence of sural nerve neuralgia
        • same incision can be utilized for secondary subtalar arthrodesis or peroneal tendon debridement
        • decreased surgical time
      • techniques:
        • patient placed in lateral decubitus position
        • incision made in line with the tip of the fibula and the base of the 4th metatarsal 
          • 2-4 cm in length
        • extensor digitorum brevis retracted cephalad to expose sinus tarsi and posterior facet
        • peroneal tendons retracted posteriorly
        • Schanz pin inserted percutaneously in posteroinferior tuberosity going from lateral to medial
          • provides distraction and aids with reduction
        • fibrous debris and fat removed from sinus tarsi
        • small elevator or lamina spreader placed under posterior facet fragment to aid in reduction
        • K-wires inserted for provisional fixation aimed towards the sustentaculum
        • two screw are placed lateral-to-medial to engage sustentaculum and support facet
        • one large fully threaded screw from posterior-to-anterior to support axial length of calcaneus
        • low-profile plate is applied underneath a well developed soft tissue envelope with screws engaging anterolateral and tuberosity fragments  
        • nonweight bearing for 6-8 weeks post-op with ankle range-of-motion exercises beginning 2 weeks post-op
        • Essex-Lopresti manuever
          • manipulate the heel to increase the calcaneal varus deformity
          • plantarflex the forefoot
          • manipulate the heel to correct the varus deformity with a valgus reduction
          • stabilize the reduction with percutaneous K-wires or open fixation as described above
    • arthroscopic-assisted reduction and internal fixation
      • benefits:
        • decreased soft-tissue dissection
        • preservation of local blood supply
        • removal of loose bone fragments
        • improved visualization of articular surface and carilage lesions
      • cons:
        • increased set-up
        • increased swelling from fluid extravasation
        • technically challenging
      • can be combined with sinus tarsi approach
      • technqiues:
        • patient positioned in lateral decubitus position
        • fluoroscopy unit positioned posterior and oblique to patient
          • allows for axial hindfoot views
        • anterolateral and posterolateral portals are used to visualize posterior facet 
          • 2.4 mm 0° arthroscope
        • interosseous ligament is preserved 
        • hematoma is irrigated
        • loose bodies and cartilage fragments are removed with a shaver
        • Freer elevator is introduced into one of the portal sites and used to elevate the posterior facet
          • reduction can be visualized directly 
        • Schanz pin to control tuberosity fragment
        • cannulated screws from the posterior aspect of the calcaneal tuberosity to the anterior aspect of the calcaneus 
          • restores and stabilizes length
        • lateral-to-medial screws placed in sustentaculum
        • buttress screw from the posterior aspect of the calcaneal tuberosity to the subchondral bone of the posterior facet
    • posterior approach for calcaneal tuberosity fractures
      • techniques:
        • patient positioned prone on table
        • posterior midline incision
        • fracture fragment is mobilized and debrided 
        • plantar flexion of foot aids with reduction
          • presence of gastrocnemius tightness may preclude reduction
            • Strayer procedure may be performed to aid in reduction 
        • provisional fixation with K-wires
        • final fixation with either
          • lag screws
          • tension-band constructs
            • figure-of-8 tension-band wire passed around ends of K-wires or cannulated screws 
          • suture fixation 
            • Krackow sutures passing through bone tunnels
        • restricted weight bearing for 6 weeks followed by progression of weight bearing an additional 6 weeks
  • 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
    • keep all hardware away from the corner of the incision
    • delayed wound healing is the most common complication 
  • 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
        • indications      
          • chronic pain from subtalar joint
          • incongruous subtalar joint/post-traumatic DJD
          • loss of calcaneal height
          • mechanical block to ankle dorsiflexion
            • results from posterior talar collapse into the posterior calcaneus
      • technique
        • goal is to correct  
          • hindfoot height
          • ankle impingement 
          • subfibular impingement
          • subtalar arthritis
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)
 

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(SBQ12FA.56) A 25-year-old woman began training for a marathon and she reports a 2-week history of heel pain. She has pain throughout the day that worsens with prolonged weight-bearing. On exam, the location of maximal tenderness is indicated by the white arrow in Figure A. The patient denies point tenderness at the location of the yellow arrow in Figure A. Which of the following MRI images (Figures B to F) would you expect to find in this patient? Tested Concept

QID: 3863
FIGURES:
1

Figure B

8%

(205/2656)

2

Figure C

51%

(1343/2656)

3

Figure D

15%

(401/2656)

4

Figure E

8%

(201/2656)

5

Figure F

18%

(484/2656)

L 4 B

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(SBQ12FA.1) Figure A is a radiograph of a healthy, independent 51-year-old male. He is treated with immediate open reduction internal fixation to prevent which of the following complications? Tested Concept

QID: 3808
FIGURES:
1

Fracture non-union

1%

(17/1705)

2

Avascular necrosis

2%

(35/1705)

3

Skin necrosis

92%

(1568/1705)

4

Plantar flexion weakness

3%

(57/1705)

5

Ankle stiffness

1%

(9/1705)

L 1 B

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(OBQ12.265) A 25-year-old, training for a marathon, presents with persistent heel pain over the past several weeks. He has difficulty with ambulation and has an antalgic gait. A squeeze test of the heel is positive. A lateral foot radiograph is shown Figure A. Of the options listed below, what is the most appropriate next step in management? Tested Concept

QID: 4625
FIGURES:
1

EMG/NCV study

1%

(19/3172)

2

Heel pad cortisone injection

2%

(62/3172)

3

Physical therapy with Graston techniques to plantar fascia

8%

(248/3172)

4

MRI of the foot

74%

(2347/3172)

5

Non-weight bearing cast for 4-6 months

15%

(482/3172)

L 3 C

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(OBQ12.83) A 19-year-old military recruit complains of 7 weeks of right heel pain. He notes the pain is worse with jumping and long distance running. He has completed a course of plantar fascia and Achilles tendon stretching with no significant improvement in his symptoms. He denies constitutional symptoms. On examination, his body mass index is 22, he has a normal foot posture and can perform a single leg heel rise without difficulty. There is no pain with palpation of the lateral border of the foot or with external rotation stress to the midfoot. There is tenderness with medial and lateral compression of the hindfoot and there is a negative syndesmosis squeeze test. There is a negative Tinel's sign at the tibial nerve. Axial and lateral radiographs are shown in Figures A and B. What is the most appropriate next step in management? Tested Concept

QID: 4443
FIGURES:
1

Heel pad cortisone injection

3%

(157/5137)

2

Platelet rich plasma injection and 6 weeks of physical therapy

1%

(77/5137)

3

Restricted weight bearing and magnetic resonance imaging of the foot

84%

(4291/5137)

4

Release of the first branch of the lateral plantar nerve

2%

(102/5137)

5

ASTYM or Graston physical therapy techniques to the achilles and plantar fascia

9%

(475/5137)

L 2 B

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(OBQ11.116) A 47-year-old male presents with a one month history of heel pain after starting marathon training. The heel is tender when squeezed. A foot radiograph is shown in Figure A, and an MRI is obtained which is shown in Figures B and C. What is the most likely diagnosis? Tested Concept

QID: 3539
FIGURES:
1

Osteomyelitis

0%

(7/3339)

2

Acute fracture

1%

(19/3339)

3

Subtalar arthritis

1%

(34/3339)

4

Achilles tendinitis

9%

(286/3339)

5

Stress fracture

89%

(2982/3339)

L 1 C

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(OBQ10.208) A 26-year-old male sustains a comminuted, intra-articular calcaneus fracture and subsequently undergoes operative intervention as shown in Figure A. Postoperatively in the recovery room, he presents with an isolated, fixed flexed great toe. What is the most likely etiology of this finding? Tested Concept

QID: 3301
FIGURES:
1

Use of a lateral extensile approach to the calcaneus

2%

(73/4191)

2

Calcaneal tuberosity varus malalignment

3%

(125/4191)

3

Use of screws in the constant fragment that are too long

88%

(3678/4191)

4

Missed foot compartment syndrome

5%

(198/4191)

5

Plantar nerve palsy

2%

(93/4191)

L 1 C

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(OBQ10.19) A 47-year-old male sustained a comminuted calcaneus fracture in a motorcyle accident. He subsequently develops the post-traumatic condition shown in Figure A. All of the following would be indications for a subtalar distraction arthrodesis using a bone graft instead of an in-situ subtalar arthrodesis EXCEPT: Tested Concept

QID: 3107
FIGURES:
1

Decreased calcaneus height

2%

(61/2547)

2

Decreased talocalcaneal angle

3%

(71/2547)

3

Decreased talar declination angle

5%

(115/2547)

4

Presence of a collapsed subtalar joint from AVN

18%

(453/2547)

5

Presence of full ankle dorsiflexion with no tibiotalar impingement

72%

(1831/2547)

L 2 C

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(OBQ09.73) A 42-year-old male sustains the injury seen in figure A. What negative sequelae would occur with displacement of this fracture in the characteristic fashion? Tested Concept

QID: 2886
FIGURES:
1

Post-traumatic subtalar arthrosis

4%

(43/1122)

2

Stress fracture of the fibula

0%

(0/1122)

3

Reflex sympathetic dystrophy

0%

(5/1122)

4

Achilles tendon rupture

3%

(31/1122)

5

Posterior skin necrosis

93%

(1041/1122)

L 1 C

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(OBQ08.76) A 28 year-old-male presents with the injury pattern seen in Figure A. Which of the following is a risk factor for wound complications following operative treatment? Tested Concept

QID: 462
FIGURES:
1

Open injury

86%

(627/727)

2

Workers' Compensation involvement

9%

(65/727)

3

Adjunct use of allograft

1%

(6/727)

4

Contralateral calcaneus fracture

1%

(10/727)

5

Male sex

2%

(18/727)

L 1 C

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(OBQ08.43) A patient sustains a comminuted calcaneus fracture. Three months after the injury the patient complains of shoewear problems secondary to clawing of the lesser toes. What is the most likely explanation for this deformity? Tested Concept

QID: 429
1

Sural nerve injury

1%

(18/1303)

2

Tethering of the flexor hallucis longus by fracture fragments

6%

(73/1303)

3

Medial plantar nerve neuropathy

4%

(53/1303)

4

Weakness of the tibialis posterior

2%

(26/1303)

5

Unrecognized foot compartment syndrome

86%

(1127/1303)

L 1 C

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(OBQ07.269) Which of the following patients who sustained a calcaneal fracture will most likely undergo an eventual subtalar fusion? Tested Concept

QID: 930
1

Male worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees

84%

(791/945)

2

Female worker's compensation patient who participates in heavy labor work with an initial Böhler angle >15 degrees

1%

(13/945)

3

Male non-worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees

5%

(45/945)

4

Male worker's compensation patient who participates in heavy labor work with an initial Böhler angle >15 degrees

7%

(68/945)

5

Female non-worker's compensation patient who participates in heavy labor work with an initial Böhler less than 0 degrees

2%

(17/945)

L 1 C

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(OBQ07.183) A 55-year-old male sustained a Sanders IV intra-articular calcaneus fracture two years ago that was treated nonoperatively. He presents to your office with a mechanical block preventing his ankle from dorsiflexing to neutral, continued severe pain and a widened heel. Radiographs show significant loss of calcaneal height and an incongruous subtalar joint. What is the most appropriate surgical treatment at this time? Tested Concept

QID: 844
1

Arthroscopic debridement of the subtalar joint and subfibular recess with in situ subtalar joint arthrodesis

6%

(68/1166)

2

Distraction bone block subtalar arthrodesis

75%

(880/1166)

3

Tibiotalocalcaneal arthrodesis

11%

(129/1166)

4

Corrective intra-articular osteotomy of the calcaneus

3%

(36/1166)

5

Arthroscopic debridement of the subtalar joint and subfibular recess with lateral distraction opening wedge calcaneal osteotomy

4%

(48/1166)

L 1 C

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(OBQ07.211) In the treatment of intra-articular calcaneal fractures, surgical reduction and fixation has been shown to have improved outcomes over nonoperative treatment in all of the following patient groups EXCEPT: Tested Concept

QID: 872
1

Sedentary job

16%

(178/1094)

2

Sanders IIb fractures

7%

(75/1094)

3

Women

6%

(63/1094)

4

Younger age (<29 years old)

6%

(71/1094)

5

Previous calcaneus fracture

64%

(701/1094)

L 2 B

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(OBQ07.176) The flexor hallucis longus tendon is at greatest risk of injury with a lateral-to-medial drill or screw during fixation of what structure? Tested Concept

QID: 837
1

Lisfranc fracture-dislocation

4%

(80/1971)

2

Navicular body fracture

4%

(79/1971)

3

Intra-articular calcaneus fracture

79%

(1552/1971)

4

Nutcracker cuboid fracture

2%

(31/1971)

5

Talar neck fracture

11%

(224/1971)

L 2 C

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(OBQ06.272) A 42-year-old female undergoes a subtalar bone block distraction arthrodesis as sequelae of a nonoperatively treated calcaneus fracture ten years prior. This procedure improves which of the following issues? Tested Concept

QID: 283
1

Subtalar joint stiffness

20%

(350/1759)

2

Midfoot supination

7%

(117/1759)

3

Sinus tarsi impingement

32%

(561/1759)

4

Anterior ankle impingement

40%

(708/1759)

5

Hammertoe deformity

1%

(9/1759)

L 4 C

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(OBQ06.126) A 27-year-old male sustains closed injuries to his right foot in a motor vehicle collision. He is a nonsmoker. A radiograph and computed tomography scan are provided in Figures A and B. All of the following are prognostic of a superior outcome with operative treatment EXCEPT: Tested Concept

QID: 312
FIGURES:
1

Male

73%

(1553/2117)

2

Works as an attorney

14%

(303/2117)

3

Nonsmoker

1%

(16/2117)

4

Twenty-seven years old

6%

(129/2117)

5

He was injured while off his job

5%

(106/2117)

L 2 C

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(OBQ06.143) A 48-year-old female sustains the injury seen in Figure A. Which of the following preoperative variables has been shown to be associated with improved outcomes following surgical treatment of this injury pattern? Tested Concept

QID: 329
FIGURES:
1

Patients with a heavier workload

2%

(26/1692)

2

Patients receiving Worker's Compensation

2%

(30/1692)

3

Gissane angle of 140°

27%

(465/1692)

4

Böhler angle of > 15°

54%

(919/1692)

5

Comminuted posterior facet

14%

(240/1692)

L 4 C

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(OBQ05.168) A 42-year-old male sustains the closed injury shown in Figure A. Which of the following factors is associated with improved outcomes with open reduction and internal fixation? Tested Concept

QID: 1054
FIGURES:
1

Age > 40

2%

(20/1240)

2

Smoking

1%

(9/1240)

3

Male sex

4%

(50/1240)

4

No worker's compensation involvement

92%

(1140/1240)

5

Career as construction worker

1%

(18/1240)

L 1 B

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(OBQ04.163) A 35-year-old patient sustains a left calcaneus fracture. Which of the following fractures has the highest risk of post-traumatic arthritis? Tested Concept

QID: 1268
1

Male patient, Sanders Type III fracture, treated with ORIF

51%

(768/1497)

2

Male patient, Sanders Type II fracture, treated with ORIF and bone graft

1%

(16/1497)

3

Female patient, workers compensation, Sanders Type I fracture, treated non-operatively

2%

(25/1497)

4

Female patient, Sanders Type II fracture, treated non-operatively

31%

(467/1497)

5

Female patient, workers compensation, Sanders Type II fracture, treated with ORIF

14%

(215/1497)

L 4 D

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(OBQ04.261) Which of the following statements is true regarding the superomedial fragment of an intra-articular calcaneus fracture? Tested Concept

QID: 1366
1

Fragment typically does not move due to its attachment to the Achilles tendon

2%

(22/1088)

2

Fragment has the flexor hallucis longus wrap inferiorly around it

66%

(723/1088)

3

Fragment typically does not move due to its attachment to the navicular

21%

(232/1088)

4

Fragment typically displaces superior and laterally

4%

(41/1088)

5

Fragment has the tibialis posterior wrap inferiorly around it

6%

(64/1088)

L 3 D

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