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Updated: Jan 25 2024

Calcaneus Fractures

Images
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https://upload.orthobullets.com/topic/1051/images/47b_moved.jpg
https://upload.orthobullets.com/topic/1051/images/Xray - lat - cal tubosity avulsion fx before-after ORIF_moved.jpg
https://upload.orthobullets.com/topic/1051/images/tongue type lateral.jpg
https://upload.orthobullets.com/topic/1051/images/Case A - Tounge type fx - Lat and Harris view_moved.jpg
https://upload.orthobullets.com/topic/1051/images/Xray foot - bohler angle - normal and decreased_moved.jpg
https://upload.orthobullets.com/topic/1051/images/critical_angle_of_gissane.jpg
  • 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
          • 60-75% of injuries are intra-articular fractures
          • 1-3% are calcaneal tuberosity fractures
    • 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
          • 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%
  • 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
          • the flexor hallucis longus is also at risk of entrapment in the fracture site with marked posterior facet displacement
        • 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
          • Increasing number of fragments is associated with increased fracture severity and the development of post-traumatic arthritis
        • 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
          • 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 dissection
          • 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
      • tongue type fractures at high risk (>20%) for posterior skin necrosis
        • should be splinted in 30 degrees of planarflexion 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
            • 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)
  • 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
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