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Calcaneal Fractures Michael Kotzen, DPM Overview This injury has proven to be one of the most challenging fractures of the lower extremity Many treatment options are available due to the various presentations of these fractures The advent of modern imaging techniques and fixation devices has assisted the well trained surgeon in obtaining satisfactory results General Anatomy The calcaneus is a highly cancellous bone surrounded by a thin cortical shell. It can withstand the forces transmitted through the body during ambulation and exercise The trabecular patterns exhibit the direction of forces through this bone by forming parallel to the forces General Anatomy The Calcaneus articulates with the Talus forming the Subtalar joint Fractures that disrupt this articulation can have devastating effects on the function of the foot The Talocalcaneal relationship is the most important anatomic feature when dealing with pathoanatomy, treatment and prognosis of Calcaneal fractures General Anatomy The articulation between the Calcaneus and the Cuboid also is altered in many Calcaneal fractures The Peroneal tendons course over the lateral aspect of the Calcaneus and can become involved during lateral wall blowout and or Calcaneal widening The foot flexors and neurovascular bundle can become impinged and disrupted by the Sustentaculum Tali The plantar fat pad can become herniated and disrupted leading to long term disability Clinical Evaluation The initial assessment should include a complete assessment of the entire body

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The initial assessment should include a complete assessment of the entire body Other presenting injuries might include contralateral Calcaneal fractures, Ankle, vertebral, wrist, Femur fractures along with internal organ damage The soft tissue surrounding the Calcaneus can show severe edema, ecchymosis, fracture blisters and possible development of compartment syndrome
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Clinical Evaluation The perioperative management fracture blisters are is still a hot debate Some oppose making an incision in an area with obvious soft tissue deficits Others feel that delaying the surgery in order to allow the blisters to heal makes open reduction of the Calcaneus more difficult due to fibrosis of the fracture fragments The skin turgor and texture is the primary concern when addressing the time of the surgery A sign of compartment syndrome is a severe, relentless, burning pain that involves the entire foot with compartment pressures that exceed or are equal to 30mm Hg Treatment for this condition is immediate fasciotomy Radiographic Evaluation Evaluation on plain films is best performed by lateral and axial views The medial oblique view can give good evaluation of the anterior process of the Calcaneus Examination of plain films should focus on Bohlers angle (25-40), and Gissanes crucial angle (120-140) Essex-Lopresti and Rowes classifications were based on plain film radiographs CT imaging has become the study of choice for assessing Calcaneal fractures CT Imaging Offers complete evaluation of the Calcaneal body The number of fracture fragments and the degree of articular involvement are visualized easily using coronal and axial views Another option is 3D reconstruction which has yet to be more

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involvement are visualized easily using coronal and axial views Another option is 3D reconstruction which has yet to be more effective than two dimensional Sanders et al based there classification on CT imaging Types I-IV represent the severity of the injury with type IV being a four part or highly comminuted fracture Extra-Articular Fractures These fractures are typically non-displaced because of the strong ligamentous attachments between that Talus and Calcaneus medially Cast immobilization for 3-4 weeks, followed by a walking cast or boot for another 1-2 weeks should allow healing of the fracture Anterior process fractures can be classified as extra-articular but can often involve the Calcaneal-Cuboid joint. Asymptomatic fractures with non-displacement and no articular involvement can usually be treated with cast immobilization Intra-Articular Fractures A Calcaneal body fracture that doesnt involve the Subtalar joint is a rare injury Open reduction and internal fixation is often needed to repair these types of fractures Treatment options for these types of fractures may include: percutaneous fixation, open reduction with and without bone grafting, and primary arthrodesis Closed Treatment Advancement of imaging and surgical techniques has decreased the indications for a closed reduction of these injuries Closed treatment is still a valuable tool when surgical intervention is contraindicated Axial pin manipulation and fixation based on the principle of liagmentotaxis has provided good results in patients under the age of 50 Closed reduction for a displacement of greater than 2mm has shown poor results Surgical Treatment Surgical intervention aims at restoring the Subtalar joint

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Surgical intervention aims at restoring the Subtalar joint complex and Calcaneal-Cuboid joint to preserve normal foot function Maintenance of the height, length, width, and correction of the varus deformity of the Calcaneus should be addressed The optimum time to perform surgery is 6 to 8 hours after the injury Surgical Treatment Early intervention can decrease the chances of fracture blister formation and compartment syndrome If surgery cant be performed during this time the patient should be placed in a well padded compressive dressing and posterior splint until edema subsides and skin wrinkles are present (approximately 3 to 4 days) Primary reduction is usually an option up to 3 to 4 weeks after the injury, after that the fracture should be allowed to consolidate with later surgical correction Surgical Treatment