Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Calcaneus Fractures
Updated: Oct 9 2017

Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws

Preoperative Patient Care
Operative Techniques

Preoperative Plan


Template fracture with radiographs

  • identify fracture pattern based on xrays (AP/Lat/Oblique and Harris/Broden views) and CT scan
  • analyze direction and number of fracture lines (Sanders classification)
  • evaluate joint depression, articular comminution, Bohlers angle, and angle of Gissane
  • if severe articular comminution may need to concurrently fuse subtalar joint
  • if tongue-type with mild displacement and shortening can perform closed reduction with percutaneous pinning
  • goal is to restore calcaneus height, width, alignment, and articular surface


Execute surgical walkthrough

  • describe the steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • Calcaneus Plating System (Stryker Veriax Calcaneus System)


Room setup and equipment

  • standard OR table with radiolucent end
  • c-arm in from contralateral side end of bed at ~20° to get Harris heel view


Patient positioning

  • patient lateral decubitus on beanbag with feet at end of bed
  • place sheets between ipsilateral and contralateral extremities to make elevated flat working surface ~1’ in height
  • make sure body and legs are taped down (need flat surface to work on)
  • can alternatively place patient supine with table tilted away from surgeon
  • thigh tourniquet placed high on thigh with webril underneath

Lateral Approach to Calcaneus


Mark out lateral malleolus and lateral border of Achilles

  • exsanguinate limb and inflate tourniquet


Start incision 2-4 cm proximal to lateral malleolus on the posterior border of the fibula

  • extend incision down posterior fibula and bend around lateral maleolus over the peroneal tubercle
  • curve distally to a point 4 cm inferior and 2.5 cm anterior to lateral malleolus
  • follow the course of the peroneal tendons


Mobilize skin flaps

  • be careful to avoid sural nerve and short saphenous vein that run posterior to the lateral malleolus


Expose the peroneal tendons

  • incise the deep fascia to uncover the peroneal tendons
  • incise the inferior peroneal retinaculum over peroneus brevis
  • must repair at end of case to prevent dislocation
  • incise sheath of peroneus longus
  • mobilize peroneal tendons and retract them anteriorly over the lateral malleolus

Deep dissection


Identify calcaneofibular ligament and incise

  • locate the posterior talocalcaneal joint capsule and incise it transversly
  • inverting the foot will expose the articular surface
  • to expose lateral surface of calcaneus perform subperiosteal dissection inferiorly


Isolate peroneal tendons

  • divide superficial and deep fascia
  • if necessary and there is no infection may divide tendons by Z-plasty and repair at end of case


Perform subperiosteal dissection

  • incise and elevate the periosteum below the tendons
  • subperiostally elevate tissues (including tendons) superiorly and inferiorly off the lateral surface of the calcaneus


Use “no touch” technique avoiding skin using three .062 kwires into ant/med/post aspect of talus

  • bend kwires with driver into two 90° angles as fixed internal retractors for subcutaneous and skin retraction

Bony Preparation


Identify the fracture lines

  • delineate fracture lines with knife and clean out using freer, curettes, and rongeur


Identify the fracture fragments

  • identify lateral wall that is often broken off, remove piece, clean and mark orientation for later use, and place in saline on back table
  • next find constant anteromedial fragment and build off of it
  • check to see how remaining fragments fit together
  • break apart fragments with curved osteotome and lever to regain calcaneus height
  • identify if there is a central void of comminution due to bone loss



Restore ant/med/post facet of subtalar joint

  • remove fragments if needed and temporarily pin into place with multiple kwires
  • use kwires to join pieces together
  • check Bohlers angle and angle of Gissane with fluoro
  • use kwires through bottom of calcaneus to pin constant fragment to remaining fragments


Place large shantz pin

  • drill large Shantz pin into posteroinferior aspect of calcaneus perpendicular to bone to gain traction through fragment
  • use bolt cutter to remove sharp end, T-handle to apply traction through pin and distract fragments


Reduce the periphery of the calcaneous

  • build periphery of calcanues and later fill in central void with allograft chips, tamp in gently


Check AP/Lat/Harris fluoro to check calcaneus reduction in terms of height, width, alignment, and articular surface

  • use blue handle of lap around forefoot to pull foot into dorsiflexion for heel view



Place lag screw

  • use a 3.5mm lag screw to join largest pieces lateral to medial (2.7mm drill, 3.5mm screws)
  • be careful of iatrogenic injury to FHL from long screws


Check calcaneus plate sizing on Lat fluoro


Fill central void of the calcaneous

  • use bone chips allograft, then place lat wall fragment back into place


Fix the plate to the calcaneous

  • first place bicortical nonlocking screws into the anterior and posterior aspects of plate to compress plate down to bone
  • check position on fluoro


Place locking screws around periphery of plate

  • check on heel and Lat xrays
  • if performing simultaneous fusion of subtalar joint, place threaded guidepins for 8.0mm cannulated screws x2 through posterior facet of subtalar joint
  • use heel view 2cm apart for placement
  • check on fluoro Lat for placement into talar body
  • measure, drill calcaneus cortex, just into talar body
  • place screw on power followed by hand
  • can use fully threaded (if significant comminution of subtalar joint) or partially threaded screws (for compression)
  • confirm hardware position


Check with fluoro on AP/Lat/Harris views

  • exchange screws that are too long medially to avoid tendon irritation (FHL) and damage

Wound Closure


Irrigation, hemostasis, and drain

  • irrigate wounds thoroughly and deflate tourniquet
  • cauterize any bleeders carefully, watching out for saphenous vein
  • hemovac drain deep exiting superolateral from incision



  • subcutaneous closure with 2-0 vicryl
  • skin closure with 3-0 nylon horizontal mattress or Allgower-Donati stitch to reduce skin tension (diabetics, smokers)


Dressing and immediate immobilization

  • dress the incision(gauze, webril) followed by postmold splint with extra padding under heel for immobilization
  • crutches or walker for ambulation
Postoperative Patient Care
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options