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Introduction
  • Epidemiology
    • incidence
      • most frequent tarsal fracture
      • 17% open fractures
  • Pathophysiology
    • mechanism
      • traumatic axial loading is the primary mechanism of injury
        • fall from height
        • motor-vehicle accidents
    • 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 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 runs just inferior to it 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   
      • 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)
 
Presentation
  • Symptoms
    • pain
  • Physical exam
    • inspection
      • diffuse tenderness to palpation
      • ecchymosis and swelling
      • shortened, widened, heel with a varus deformity
Imaging
  • Radiographs
    • recommended views
      • required
        • AP, lateral, and oblique foot
      • optional
        • 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 view 
          • 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
        • reduced Bohler angle
        • increased angle of Gissane
        • calcaneal shortening
        • varus tuberosity deformity
    • measurement
      • Bohler angle (normal is 20-40 degrees) 
        • measured from lateral foot x-ray
        • flattening (decreased angle) represents collapse of the posterior facet
        • double-density highlights subtalar incongruity
      • angle of Gissane (normal is 120-145 degrees)   
        • an increase represents collapse of posterior facet
  • CT
    • indications
      • gold standard
    • 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)
        • anterior process fracture involving <25% of calcaneocuboid joint
        • comorbidities that preclude good surgical outcome (smoker, diabetes, PVD)
      • 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
      • techniques
        • lag screws from posterior superior tuberosity directed inferior and distal
    • ORIF
      • indications
        • displaced tongue-type fractures  
        • large extra-articular fractures (>1 cm) with detachment of Achilles tendon and/or > 2 mm displacement
          • urgent if skin is compromised
        • 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 
      • outcomes
        • surgical outcome correlates with the number of intra-articular fragments and the quality of articular reduction
        • factors associated with a poor outcome    
          • age > 50
          • obesity
          • manual labor
          • workers comp
          • smokers
          • bilateral calcaneal fractures
          • 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
Surgical Techniques
  • ORIF with extensile lateral or medial approach
    • goals
      • restore congruity of subtalar joint
      • restore Bohler angle and calcaneal height
      • restore width
      • correct varus malalignment
    • approach
      • extensile lateral L-shaped incision is most popular 
        • provides access to calcaneocuboid and subtalar joints
        • high rate of wound complications
      • medial approach can also be used 
        • full-thickness flap is created to maintain soft tissue integrity
    • technique
      • place a pin in the tuberosity to assist the reduction
      • provisional fixation with Kirschner wires
      • hold reduction with low profile implants
      • bone grafting provides no added benefit
    • postoperative care
      • bulky posterior U splint
      • early supervised subtalar range of motion exercises
      • nonweightbearing for 10 weeks
  • ORIF with sinus tarsi approach and Essex-Lopresti maneuver
    • technique
      • 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
Complications
  • Wound complications (10-25%)  
    • increased risk in smokers, diabetics, and open injuries
  • Subtalar arthritis 
    • increased with nonoperative management
  • Lateral impingement with peroneal irritation
  • 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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Average 4.3 of 63 Ratings

Technique Guides (1)
Questions (41)

(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? Review Topic

QID: 3301
FIGURES:
1

Use of a lateral extensile approach to the calcaneus

2%

(62/3371)

2

Calcaneal tuberosity varus malalignment

3%

(104/3371)

3

Use of screws in the constant fragment that are too long

87%

(2940/3371)

4

Missed foot compartment syndrome

5%

(168/3371)

5

Plantar nerve palsy

2%

(79/3371)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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(OBQ07.269) Which of the following patients who sustained a calcaneal fracture will most likely undergo an eventual subtalar fusion? Review Topic

QID: 930
1

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

84%

(458/547)

2

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

1%

(7/547)

3

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

4%

(23/547)

4

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

8%

(43/547)

5

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

2%

(9/547)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 1268
1

Male patient, Sanders Type III fracture, treated with ORIF

48%

(551/1139)

2

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

1%

(12/1139)

3

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

1%

(11/1139)

4

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

35%

(397/1139)

5

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

14%

(164/1139)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 283
1

Subtalar joint stiffness

21%

(288/1401)

2

Midfoot supination

6%

(91/1401)

3

Sinus tarsi impingement

31%

(435/1401)

4

Anterior ankle impingement

41%

(572/1401)

5

Hammertoe deformity

0%

(6/1401)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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? Review Topic

QID: 844
1

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

5%

(48/885)

2

Distraction bone block subtalar arthrodesis

79%

(699/885)

3

Tibiotalocalcaneal arthrodesis

10%

(85/885)

4

Corrective intra-articular osteotomy of the calcaneus

3%

(24/885)

5

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

3%

(25/885)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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: Review Topic

QID: 872
1

Sedentary job

14%

(114/827)

2

Sanders IIb fractures

7%

(57/827)

3

Women

6%

(51/827)

4

Younger age (<29 years old)

7%

(60/827)

5

Previous calcaneus fracture

66%

(542/827)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 4625
FIGURES:
1

EMG/NCV study

0%

(12/2850)

2

Heel pad cortisone injection

2%

(57/2850)

3

Physical therapy with Graston techniques to plantar fascia

7%

(205/2850)

4

MRI of the foot

74%

(2110/2850)

5

Non-weight bearing cast for 4-6 months

16%

(454/2850)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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? Review Topic

QID: 4443
FIGURES:
1

Heel pad cortisone injection

3%

(128/4565)

2

Platelet rich plasma injection and 6 weeks of physical therapy

1%

(66/4565)

3

Restricted weight bearing and magnetic resonance imaging of the foot

84%

(3825/4565)

4

Release of the first branch of the lateral plantar nerve

2%

(89/4565)

5

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

10%

(437/4565)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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: Review Topic

QID: 312
FIGURES:
1

Male

74%

(1259/1709)

2

Works as an attorney

15%

(256/1709)

3

Nonsmoker

1%

(9/1709)

4

Twenty-seven years old

6%

(105/1709)

5

He was injured while off his job

4%

(74/1709)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 1054
FIGURES:
1

Age > 40

2%

(17/957)

2

Smoking

1%

(8/957)

3

Male sex

4%

(41/957)

4

No worker's compensation involvement

92%

(877/957)

5

Career as construction worker

1%

(14/957)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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? Review Topic

QID: 329
FIGURES:
1

Patients with a heavier workload

2%

(18/1188)

2

Patients receiving Worker's Compensation

1%

(15/1188)

3

Gissane angle of 140°

27%

(318/1188)

4

Böhler angle of > 15°

50%

(597/1188)

5

Comminuted posterior facet

20%

(234/1188)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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? Review Topic

QID: 837
1

Lisfranc fracture-dislocation

4%

(65/1697)

2

Navicular body fracture

4%

(66/1697)

3

Intra-articular calcaneus fracture

79%

(1346/1697)

4

Nutcracker cuboid fracture

2%

(28/1697)

5

Talar neck fracture

11%

(190/1697)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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? Review Topic

QID: 2886
FIGURES:
1

Post-traumatic subtalar arthrosis

5%

(41/895)

2

Stress fracture of the fibula

0%

(0/895)

3

Reflex sympathetic dystrophy

0%

(4/895)

4

Achilles tendon rupture

2%

(22/895)

5

Posterior skin necrosis

92%

(827/895)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 3539
FIGURES:
1

Osteomyelitis

0%

(4/2796)

2

Acute fracture

0%

(12/2796)

3

Subtalar arthritis

1%

(26/2796)

4

Achilles tendinitis

8%

(222/2796)

5

Stress fracture

90%

(2524/2796)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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

QID: 1366
1

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

3%

(21/758)

2

Fragment has the flexor hallucis longus wrap inferiorly around it

68%

(515/758)

3

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

22%

(169/758)

4

Fragment typically displaces superior and laterally

2%

(18/758)

5

Fragment has the tibialis posterior wrap inferiorly around it

4%

(32/758)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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: Review Topic

QID: 3107
FIGURES:
1

Decreased calcaneus height

2%

(34/1886)

2

Decreased talocalcaneal angle

2%

(47/1886)

3

Decreased talar declination angle

5%

(94/1886)

4

Presence of a collapsed subtalar joint from AVN

18%

(347/1886)

5

Presence of full ankle dorsiflexion with no tibiotalar impingement

72%

(1351/1886)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(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? Review Topic

QID: 462
FIGURES:
1

Open injury

87%

(374/430)

2

Workers' Compensation involvement

8%

(34/430)

3

Adjunct use of allograft

1%

(5/430)

4

Contralateral calcaneus fracture

2%

(7/430)

5

Male sex

2%

(10/430)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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? Review Topic

QID: 429
1

Sural nerve injury

1%

(14/984)

2

Tethering of the flexor hallucis longus by fracture fragments

5%

(47/984)

3

Medial plantar nerve neuropathy

4%

(35/984)

4

Weakness of the tibialis posterior

2%

(19/984)

5

Unrecognized foot compartment syndrome

88%

(865/984)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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