Fraaktur Calcaneus

Calcaneal Fracture
Anatomy
White TO, et al (eds). McRae’s Orthopaedic Trauma and Emergency Fracture Management Third Edition. Elsevier, 2016.
MEDIAL
LATERAL
Calcaneal Fractures
The calcaneum is the most commonly
fractured tarsal bone, and in 5–10% of cases
both heels are injured simultaneously.
Crush injuries, although they always heal in

the biological sense, are likely to be followed
by long-term disability.
This was followed by attempts to modify the

outcome through open reduction and internal
fixation of these fractures.
Blom A, et al (eds). Apley and Solomon’s System of Orthopaedics and Trauma tenth Edition. CRC Press; 2018.
Epidemiology
Tarsal fractures account for 2% of all fractures.
Calcaneal fractures account for 50-60% of all fractured tarsal bones.
Less than 10% present as open fractures.
Traditionally, there is a male predominance of injuries due to the industrial nature of the accidents.
Most patients with calcaneus fractures are young, with the 20-39 age group the most common.
Comorbidities such as diabetes and osteoporosis may increase the risk of all types of fractures.
Calcaneal fractures are rare in children.
Davis D, Seaman TJ, Newton EJ. Calcaneus Fractures. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020.
Mechanism of injury
In most cases the patient falls from a height, often from a
ladder, onto one or both heels.
The calcaneum is driven up against the talus and is split or

crushed.
Over 20% of these patients suffer associated injuries of the

spine, pelvis or hip.
Avulsion fractures sometimes follow traction injuries of the

tendo Achilles or the ankle ligaments.
Occasionally the bone is shattered by a direct blow.
Most calcaneal fractures are high-energy injuries
caused by a fall from a occurring in men of
height working age
These are impaction-type fractures exacerbated by a

substantial overlying soft tissue injury.
They result in considerable disability and are

challenging injuries to treat
with a relatively high complication rate.
White TO, et al (eds). McRae’s Orthopaedic Trauma and

Emergency Fracture Management Third Edition. Elsevier, 2016.
Essex-Lopresti classification
Extra-articular Intra-articular
fractures fractures
• Anterior process • The primary
• Tuberosity fractures fracture line (of
• Achilles tendon Palmer)
avulsion fractures • The secondary
• Sustentacular fracture line
fractures
Sanders classification
The location of the primary
The number of fragments is first fracture line(s) through the
indicated by a numeral posterior facet is indicated by a
letter
I. all undisplaced fractures A. a fracture through the lateral

portion of the posterior facet
II. two fragments

B. a fracture through the middle
of the posterior facet
III. three fragments
C. a fracture passing medially, at

IV. any comminuted fracture the neck of the sustentaculum
History & Physical Examination
There is usually a history of a high-energy mechanism, such as a fall from a
height, and other associated injuries must be excluded by primary and
secondary surveys
• Commonly associated injuries  ipsilateral fractures of the tibia, femur and hip, and
fracture of the spine. 10% of calcaneal fractures are bilateral
Examine the skin to look for deformity, swelling and open wounds (open
fractures are usually medial burst injuries)
• The foot is painful and swollen and a large bruise appears on the lateral aspect of the heel
• The heel may look broad and squat
• The surrounding tissues are thick and tender, and the normal concavity below the lateral
malleolus is lacking.
• The subtalar joint cannot be moved but ankle movement is possible.
Excessive pain, very extensive bruising and swelling, diminished sensation,

with pain on passive toe movement in the foot may indicate a foot
compartment syndrome
Radiologic examination
Lateral calcaneus radiograph
• Inspect the outline of the calcaneus
• Assess the degree of flattening of the calcaneus by measuring the angles
of Bohler and Gissane
• The ‘double density’ sign is an increased density within the calcaneal
body due to depression of a portion of the posterior facet.
Harris view
• This will often display greater displacement than the lateral view
CT Scan
• A CT scan is invaluable for displaced calcaneal fractures and allows
assessment according to the Sanders classification
Blom A, et al (eds). Apley and
Solomon’s System of
Orthopaedics and Trauma tenth
Edition. CRC Press; 2018.
White TO, et al (eds). McRae’s Orthopaedic Trauma and
Emergency Fracture Management Third Edition. Elsevier, 2016.
Initial treatment
Aggressive wound care and antibiotics as needed for contaminated wounds.
Analgesics.
ICE and elevation.
Immobilization with splinting, Bulky Jones type splints are commonly

applied.
All patients who are candidates for outpatient treatment are non-weight bearing
at discharge.
Davis D, Seaman TJ, Newton EJ. Calcaneus Fractures. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020.
Management
Closed reduction and immobilization
• There is no closed reduction manœuvre for calcaneal fractures but they should be
immobilized in a below-knee backslab.
Inpatient referral
• All displaced calcaneal fracture are referred to Orthopaedics.
Outpatient follow-up
• Undisplaced fractures are treated with a non-weight-bearing orthosis and referred to
the fracture clinic.
Non-operative
• Non-operative management is indicated for most extra-articular fractures and for
undisplaced intra-articular fractures.
• Patients are provided with an orthosis (moon boot) and crutches, with non-weight-
bearing restrictions until fracture union at between 6 and 10weeks.
Surgical technique
Approaches
Extended lateral
approach
Tarsal sinus
approach
Fusion
Ishikawa SN. Calcaneal fracture — open reduction and internal fixation, percutaneous fixation. In: Canale ST, et al (eds.). Campbell’s Core Orthopaedic Procedures. Elsevier, 2016.
Post-Operative Care
Closed suction drainage is used for 24 to 48 hours.
Strict icing and elevation protocols should be maintained to minimize swelling

and pain.
No weight bearing is allowed for 12 weeks.
Protection is provided by the use of a removable posterior splint.
To minimize wound complications, closed reduction and percutaneous fixation of

calcaneal fractures has become popular.
Tarsal sinus approach
An oblique incision is made over the tarsal sinus, starting just distal to the tip of
the fibula.
The incision lies between the peroneal tendons and sural nerve inferiorly, and the
peroneus tertius and extensor digitorum longus superiorly.
The fascia is divided in line with the skin, leaving the peroneal tendons within
their sheath distally. The posterior facet joint is exposed.
If a plate is to be used, a periosteal elevator is used to lift the peroneal sheath,

periosteum and skin away from the lateral wall of the calcaneus. The fracture is
reduced and fixed as above.
Fusion
Where there is extensive posterior

facet comminution, articular
reconstruction may not be feasible.
Reconstruction of the height and

width of the calcaneus and a primary
fusion may provide the best results.
Complications
Early complication Late complication
Malunion
Swelling and blistering
Peroneal tendon impingement
Insufficiency of the tendo Achilles

Compartment syndrome
Talocalcaneal stiffness and
osteoarthritis
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Calcaneal Fracture

Crush injuries, although they always heal in

This was followed by attempts to modify the

Calcaneal fractures account for 50-60% of all fractured tarsal bones.

Less than 10% present as open fractures.

Calcaneal fractures are rare in children.

The calcaneum is driven up against the talus and is split or

Over 20% of these patients suffer associated injuries of the

Avulsion fractures sometimes follow traction injuries of the

Occasionally the bone is shattered by a direct blow.

These are impaction-type fractures exacerbated by a

They result in considerable disability and are

with a relatively high complication rate.

White TO, et al (eds). McRae’s Orthopaedic Trauma and

I. all undisplaced fractures A. a fracture through the lateral

II. two fragments

C. a fracture passing medially, at

Excessive pain, very extensive bruising and swelling, diminished sensation,

Aggressive wound care and antibiotics as needed for contaminated wounds.

ICE and elevation.

Immobilization with splinting, Bulky Jones type splints are commonly

Closed suction drainage is used for 24 to 48 hours.

Strict icing and elevation protocols should be maintained to minimize swelling

No weight bearing is allowed for 12 weeks.

Protection is provided by the use of a removable posterior splint.

To minimize wound complications, closed reduction and percutaneous fixation of

If a plate is to be used, a periosteal elevator is used to lift the peroneal sheath,

Where there is extensive posterior

Reconstruction of the height and

Early complication Late complication

Insufficiency of the tendo Achilles

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