Fractures of the Calcaneus

Written by Dominic Ruwe and Dr. Nabil Ebraheim

Dr. Nabil Ebraheim’s Related Educational YouTube Video

Fractures of the calcaneus can be open or closed.1 Open fractures are more serious than closed fractures.1 The primary fracture line is caused by an axial load injury.1 The primary fracture line goes from anterolateral to posteromedial.1 The primary fracture line divides the calcaneus into two main fragments: the superomedial fragment which is also called the constant or sustentacular (SAS) fragment and the superolateral or tuberosity fragment.1 The superomedial fragment includes the sustentaculum tali and is stabilized to the talus by ligaments. So, the talus is attached to the constant fragment.1 The sustentacular fragment is a useful reference point for fracture reduction.2 The flexor hallucis longus tendon lies underneath the sustentaculum. If screw placement to the sustentacular fragment is too long, the flexor hallucis longus tendon could be affected, causing fixed flexion of the big toe.3

                The Essex-Lopresti classification system is a useful way to differentiate between different joint fractures. There are two types of Essex-Lopresti fractures: a tongue-type fracture and a joint depression type fracture.1 In the tongue-type, the posterior facet is attached to the tuberosity. In the joint depression type, the posterior facet is not attached to the tuberosity.4 In the tongue-type, the primary fracture line exits anterolaterally and posteromedially.5 The secondary fracture line appears beneath the posterior facet and exits posteriorly through the tuberosity.5 The superolateral fragment and posterior facet are attached to the tuberosity. The tongue-type fracture can be treated with open reduction and internal fixation.6

                In the joint depression type, the primary fracture line splits the calcaneus obliquely through the posterior facet and exits anterolaterally and posteromedially.1 The secondary fracture line exits superiorly just behind the posterior facet.1 The posterior facet is a free fragment. The lateral portion of the posterior facet is usually involved and depressed.4

The Sander’s classification of calcaneal fractures is used to guide the treatment and predict the outcome of the treatment. This classification system is based on the number of posterior facet fracture fragments seen on a coronal CT scan.7 Type I is a nondisplaced fracture which requires nonoperative treatment.7 Type II is a two-part fracture of the posterior facet.7 Type III is a three-part fracture of the posterior facet.7 Type II and III calcaneal fractures benefit from surgery of reduction and fixation.1 Type III fractures normally result in more arthritis because it has more fracture fragments and may end by fusion.8 Type IV fractures are highly comminuted.9 They may require primary subtalar arthrodesis.1

Calcaneal avulsion fractures are typically serious. These types of fractures require urgent reduction and internal fixation to prevent skin complications.10 In joint depression fractures of the calcaneus, the swelling must go down before surgery. Avulsion fractures of the calcaneus are emergencies, so emergency surgery is performed before the swelling goes down. Open reduction and internal fixation of the calcaneus is generally delayed for 1-2 weeks to allow for improvement of the soft tissue swelling, except with avulsion fractures.1 Avulsion fractures can cause skin tenting and urgent reduction is recommended.10

There are many associated conditions with calcaneal fractures. Ten percent are associated with spinal fractures.11 Ten percent are associated with compartment syndrome of the foot.12 If this is neglected, it will lead to claw toes due to contracture of the intrinsic flexor muscles.12 Approximately ten percent are associated with bilateral fractures.13 Sixty percent are associated with calcaneocuboid joint fractures.14 Calcaneal fractures may also be associated with peroneal tendon subluxation. Peroneal tendon subluxation may be detected on axial CT scans or it may be seen as an avulsion fracture of the fibula on x-rays.15

                Complication rates for calcaneal fractures are high. Factors associated with poor outcomes are age greater than 50, smoking, early surgery, history of a fall, heavy manual labor, males, bilateral injury, workman’s compensation, and peripheral vascular disease.1,16,17 Men do worse with calcaneal fractures than women. Calcaneal fractures in men are normally associated with workman’s compensation, heavy labor, and a 0˚ Bohler angle.1 These fractures typically need subtalar fusion.18 Calcaneal fractures in females have a simple fracture pattern. Since calcaneal fractures in males are usually more severe, it follows that better outcomes are seen in females with calcaneal fractures.19

                The Bohler angle is measured on lateral x-rays.1 This angle is normally between 20˚-40˚.1 The Bohler angle is formed by a line drawn from the highest point of the anterior process of the calcaneus to the highest point of the posterior facet and a line drawn tangential to the superior edge of the tuberosity.1 A decrease in this angle indicates a collapse of the posterior facet.1 When viewing calcaneal fractures with the Harris view, the calcaneus appears to be shortened and widened with varus.1 When viewing calcaneal fractures through CT scans, the axial cut shows the calcaneocuboid joint and peroneal tendon subluxation.1,20 The sagittal view shows the subtalar joint and its depression.21 The coronal view shows the displacement of the posterior facet.22 Coronal CT scans can also show the number of the joint fracture fragments.1 The surgical outcome of calcaneal fractures correlate with the number of the joint fracture fragments and the quality of reduction.1 MR imaging shows stress fractures of the calcaneus and the integrity of the peroneal tendons.23,24

Stress fractures of the calcaneus may be misdiagnosed as plantar fasciitis.25 Stress fractures usually occur in female runners.26 It is characterized by swelling and tenderness with medial and lateral compression of the hindfoot during the squeeze test.27 If the X-ray is negative, an MRI should be obtained. The fracture will be seen in T1 MR imaging as a linear streak or a band of low signal intensity in the posterior calcaneal tuberosity.28 In T2 imaging, the signal will be increased.28

                There are several complications with calcaneal fractures. Wound-related complications are the most common complication.29 Wound-related complications occur more in smokers, diabetics, and patients with open fractures.1 Open fractures of the calcaneus is another common complication. Open fractures of the calcaneus can lead to amputation.30 There is also a high risk of infection with open fractures.30 Grade I and Grade II open fractures have wounds that open medially. Open reduction and internal fixation (ORIF) can be done to treat this complication.30 Open reduction and internal fixation should not be done in Grade III medial wounds and in most lateral wounds.30 Another complication is malunion of the calcaneus.31 This is characterized by widening of the heel, varus deformity, and loss of height.31 The talus is dorsiflexed, limiting dorsiflexion of the ankle.31 Peroneal tendon irritation and impingement from the lateral wall is another complication.32

                Surgery on the calcaneus decreases the risk of post-traumatic arthritis.33 Tongue-type and joint depression type fractures may benefit from open reduction and internal fixation.6 Subtalar distraction arthrodesis is a good operation to treat calcaneal fractures associated with loss of height and limited dorsiflexion of the ankle.31 This operation improves talar inclination and decreases anterior ankle impingement.31 Additionally, it takes care of arthritis in the subtalar joint.31 Another surgical approach is extensile lateral approach. The lateral calcaneal artery provides blood supply to the lateral flap associated with the calcaneal extensile approach.34 It is important to be aware that the Sural nerve is in the vicinity of the surgical area.35 Delayed wound healing is a common complication in the extensile lateral approach.35


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