Calcaneus fracture

 Calcaneus Fracture

Most common fractured tarsal bone


75% ; Intra-articular fracture


Numerous complications and significant long term quality of life issues

Prolonged recovery time 

Wound problem

Nonunion

Potential life-changing nature 



Calcaneus Fracture 1) Injury mechanism  

Traumatic axial loading 

Fall from height, MVA

Associated injury

Lumbar, pelvic, tibial plateau, etc.


Posterior facet is lateral to the weight-bearing axis of the lower extremity

Shear forces are directed through the posterior facet toward the medial wall 


Primary fracture line

From proximal-medial aspect of calcaneal tuberosity

To anterolateral wall

Calcaneus Fracture 1) Injury mechanism 

Medial spike attached to the sustentaculum tali is pushed toward the medial heel skin 

Anterior fracture line exit into the C-C joint 

Additional fractures of the posterior facet

Joint depression type 

Tongue type 






Calcaneus Fracture 2) Radiologic evaluation

Lateral X-ary 

Height loss 

Bohler’s angle

Rotation of posterior facet 


Axial X-ray (Harris view)

Varus position of tuberosity

Width of heel 


Single Broden view

Congruency of posterior facet

Leg 40° I/R + ankle neutral + 10~40’ cephaled beam


Calcaneus Fracture 2) Radiologic evaluation

CT

Axial plane – parallel to the sole

Semicoronal – perpendicular to the normal position of posterior facet 

Calcaneus Fracture 3) Classification

Prognostic value in the treatment 

Essex-Lopresti system

Describing the secondary fracture line

Limitation

Comminution 

Displaced fragments 


Sanders classification (based on CT)

Displacement and comminution of posterior facet

Limitation

Heel height, width

Varus-valgus alignment

Calcaneo-cuboid joint involvement

Soft tissue condition


Calcaneus Fracture 4) Treatment

Decision making principles

Restoration of congruency of subtalar joint  


Restoration of the height of calcaneus 


Reduction of the width of calcaneus 


Decompression of the subfibular space available for peroneal tendons 


Realignment of the tuberosity into a valgus position 


Reduction of the calcaneocuboid joint (if fractured) 

Calcaneus Fracture 5) Operative procedure for O/R & I/F 

Lateral extensile approach 

Directly down to periosteum

No blunt soft-tissue dissection

Superior flap

Supplied by lateral calcaneal branch of peroneal artery

Contains CFL, peroneal tendons



Calcaneus Fracture 5) Operative procedure for O/R & I/F 

Reflect flap with K-wries 

Elevate the entire flap in one piece

Flap not to be touched again during the procedure 


Direct access to 

Entire lateral wall of calcaneus

CC-joint

Subtalar joint 



Calcaneus Fracture 5) Operative procedure for O/R & I/F 

Reduction

“Joystick” technique 

Large threaded Steinmann pin placed into the tuberosity

Calcaneal length & height 

Varus deformity



Constant fragment 

Including sustentaculum tali

Remains attached to the talus 

Due to strong ligamentous attachemnt

Standard of reduction






Calcaneus Fracture 5) Operative procedure for O/R & I/F 

Plate fixation

Avoid injury to tibial nerve & artery

FHL 

Screw length 


Bone defect

Beneath the reduced posterior facet

Can be accepted if stable fixation is obtained. 


Calcaneus Fracture 5) Operative procedure for O/R & I/F 

Closure

Modified Donati-Allgower technique


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