CALCANEAL FRACTURES

By Philip Parr
INTRODUCTION
 Calcaneal fractures were first described by Malgaigne in
1843, but were not consistently diagnosed until the
development of plain radiography in the late 1890’s.10
 The industrial revolution led to the development of taller
buildings, and the automobile, so that falls from heights
and MVA’s became increasingly more common, and
remain the most common cause of calcaneal fractures.10
INTRODUCTION
 Calcaneal fractures account for 2% of all fractures.
 Displaced intraarticular fractures represent 60-75% of all
calcaneal fractures.
 10% of patients with calcaneal fractures have associated
spine fractures, and 26% have other extremity injuries.
 90% of calcaneal fractures occur in young men in their
working prime.
HISTORICAL TREATMENT OF
CALCANEAL FRACTURES
• As early as 1908, Cotton and Wilson suggested that
ORIF of a calcaneal fracture was contraindicated.1
• McLaughlin likened attempts of operative fixation as
“nailing custard pie to a wall”.2
• Cotton and Wilson recommended closed treatment with
use of a medially placed sandbag, a laterally placed felt
pad, and a hammer to reduce the lateral wall and
“reimpact” the fracture.
• This treatment was abandoned in the 1920’s.
HISTORICAL TREATMENT OF
CALCANEAL FRACTURES
• Bohler in 1931 recommended operative treatment.
• However, operative treatment was rarely done due to
technical problems associated with it.
– Anesthesia not always effective
– Radiology not well-developed
– Abx did not exist
– Sound understanding of internal fixation was lacking
HISTORICAL TREATMENT OF
CALCANEAL FRACTURES
 Throughout the 1940’s and 1950’s treatment varied
between ORIF attempts and subtalar joint arthrodesis.
 In the 1960’s and 1970’s, as the result of an article by
Lindsay and Dewar showing operative intervention was
unnecessary, calcaneal fractures were mostly treated
non-operatively.
HISTORICAL TREATMENT OF
CALCANEAL FRACTURES
 In the last 30 years, better anesthesia, Abx, the AO
principles, CT, and fluoroscopy, have allowed surgeons
to obtain good outcomes with operative intervention in
most fractures3.
 Even with improvement, the treatment still remains
challenging and with many complications.4
 To operate or not to operate???
RADIOGRAPHIC ANATOMY
 Bohler’s Angle- Formed by line from highest
point of anterior process to highest point of
posterior facet and the line running along the
superior portion of the calcaneal tuberosity.
RADIOGRAPHIC ANATOMY
 Gissanes angle: Formed by a line that runs
along the lateral border of the posterior
facet, and a line extending along the beak of
the calcaneus.
Radiographic Anatomy
Compression Trabeculae

Traction Trabeculae

- THICKENED THALAMIC PORTION

- COMPRESSION TRABECULAE
- TRACTION TRABECULAE
http://radiographics.rsna.org/content/25/5/1215.long
ANATOMY
 Neurovascular Bundle
 Sustentaculum Tali

 Medial Talocalcaneal
Ligament
QUICK CLASSIFICATION REFRESHER:
 Rowe 1a: Plantar  Rowe 1b: ST secondary to
Tuberosity inversion
 Rowe 1c: ant  Rowe IIa: Beak fx

process  Rowe IIb: Avulsion fx

 Rowe IIIa  Rowe IVa&b

 Rowe IIIb

 Rowe Va  Rowe Vb
SANDERS CLASSIFICATION
 Based on Posterior Facet
 After coronal CT,
Sanders typically used to
classify.
 A Non-displaced fracture,
regardless of the amount
of fracture lines is a
Sanders Type I
MECHANISM OF INJURY OF
CALCANEAL FRACTURES
MECHANISM OF INJURY OF
CALCANEAL FRACTURES
 High-energy
 Force through subtalar
joint driving talus lateral
process into everted
calcaneus to create
fracture patterns
described by Essex-
Lopresti.5
MECHANISM OF INJURY OF
CALCANEAL FRACTURES
 The “axe” of the lateral
process of talus is driven
into lateral wall of
calcaneus.
 The force extends
posteriomedially into the
ST and medial wall.
 This produces a fracture
that runs superior lateral
to inferior medial.5
MECHANISM OF INJURY OF
CALCANEAL FRACTURES
 The lateral process of the talus is impacted at the crucial
angle of Gissane, which divides the lateral wall and the
body of the calcaneus9.
 Residual force is then dissipated medially into the
sustentaculum tali which may be sheared off.
 If the momentum stops here then part or all of the fissure
described is what we see.
 If the momentum continues however…
MECHANISM OF INJURY OF
CALCANEAL FRACTURES
 A secondary fracture line is then resulted from increased
force9:
 Tongue-type fracture:
 Secondary fracture line runs
straight back to the posterior
border of the tuberosity, from
the crucial angle of Gissane.
MECHANISM OF INJURY OF
CALCANEAL FRACTURES
 The final stage9:
 The front end of the tongue is driven down, but the tuberosity
is forced upwards by the ground. It separates from the body
as the primary fracture line opens up.
OPERATIVE VS NON-OPERATIVE CARE
 Parmar et al, in a 1993 study of 56 patients who had been
randomized by DOB to either operative or non-operative
care, demonstrated that there was…
 NO DIFFERENCE between the groups at one year of
follow-up.
OPERATIVE VS NON-OPERATIVE CARE
 In another 1993 study by O’Farell et al, twelve patients
were assigned, without randomization, to operative care
and twelve were assigned to non-operative care.6 After
fifteen months of follow-up, the patients who had been
managed operatively had returned to work sooner and
walked better than those who had been managed…
 NON-OPERATIVELY
OPERATIVE VS NON-OPERATIVE CARE
 In a meta-analysis published in 2000, Randle et al stated
that “there is a trend for surgically treated patients to
have better outcomes; however, the strength of evidence
for recommending operative treatment is weak.”7
 OPERATIVE TREATMENT WITH *
OPERATIVE COMPARED WITH NON-
OPERATIVE TREATMENT OF DISPLACED
INTRA-ARTICULAR CALCANEAL
FRACTURES8

 Buckley et al published in 2002 JBJS a prospective randomized

multicenter trial comparing operative treatment with non-
operative treatment for displaced intra-articular calcaneal
fractures.
 206 patients with 249 fractures treated operatively
 218 with 262 fractures treated nonoperatively
 Certain subgroups showed better results treated operatively including:
 Women
 Younger patients
 Patients with a lighter workload
 Patients not involved in workers’ comp claims
 Patients with a higher initial Bohler’s angle
 Those with an anatomic reduction on post-op CT evaluation.
OPERATIVE COMPARED WITH NON-
OPERATIVE TREATMENT OF DISPLACED
INTRA-ARTICULAR CALCANEAL
FRACTURES8

 Buckley et al study showed that overall, there was no

significant difference in outcome between the operative and
nonoperative groups.
 However, patients undergoing nonoperative treatment of their
fracture were 5.5 times more likely to require a STJ arthrodesis
than those treated operatively.
OPERATIVE TREATMENT SUMMARY
 Operative treatment is generally indicated for displaced
intra-articular fractures involving the posterior facet.10
 Incision is an extensile lateral approach.
 Consistently allows reduction of the calcaneal body and
restoration of calc height, length, and width, regardless of the
extent of comminution, as well as reduction of the intra-
articular surface when possible.*
 Lag screw fixation, lag screw technique, and lateral
neutralization plate of the calcaneal body.
 Learning curve of 50 cases or 2 years of experience.
 Sanders also concluded that articular surface in Type IV
fractures was not salvageable and primary arthrodesis following
calc reduction was indicated.
OPERATIVE TREATMENT SUMMARY
 Immediately elevate in the ED with Jones Compression
and splint.
 Profore!

 Surgery should be within 3 weeks.

 Positive wrinkle test
REFERENCES
 1. Cotton, F. J., and Wilson, L. T.: Fractures of the os calcis. Boston Med. J., 159: 559-565, 1908.
 2. McReynolds, I. S.: Trauma to the os calcis and heel cord. In Disorders of the Foot and Ankle, edited by M. H.
Jahss. Vol. 2, pp. 1497-1538. Philadelphia, W. B. Saunders, 1982.
 3. Sanders, R: Intra-articular fractures of the calcaneus:present state of the art. J. Orthop. Trauma. 6: 252-265,
1992.
 4. Sanders, R: Displaced Intra-articular Fractures of the Calcaneus. JBJS. 2 Feb 2000 p. 225-250
 5. Essex Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg
1952;39:395-419.
 6. Parmar HV, Triffitt PD, Gregg PJ. Intra-articular fractures of the calcaneum
treated operatively or conservatively. A prospective study. J Bone Joint Surg
Br. 1993;75:932-7.
 7. O’Farrell DA, O'Byrne JM, McCabe JP, Stephens MM. Fractures of the os
 calcis: improved results with internal fixation. Injury. 1993;24:263-5.
 8. Buckley RE, Tough S, McCormack R, et al: Operative compared to nonoperative treatment of displaced
intraarticular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am
84:1733-1744, 2002
 9. Essex-Lopresti, P (March 1952). "The mechanism, reduction technique, and results in fractures of the os
calcis.". Br J Surg. 39 (157): 395–419.
 10. Coughlin and Mann. Surgery of the foot and ankle, 8 th edition. “Fractures of the Calcaneus”. Pp 2017-2073.