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Calcaneus Fracture

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Other Names

  • Calcaneus Fracture
  • Calc fracture
  • Displaced, intraarticular calcaneal fractures (DIACF)
  • Lovers Fracture
  • Don Juan Fracture
  • Calcaneal stress fractures

Background

  • This page refers to fractures of the Calcaneus including:
    • Acute injuries
    • Stress fractures

History

  • Described by Hippocrates (need citation)

Epidemiology

  • Accounts for 1-2% of all fractures (need citation)
  • Calcaneus fractures account for 50-60% of tarsal bone fractures, 75% of all foot fractures (need citation)
  • 10 - 17% open fractures (need citation)
  • 75% are intra-articular (need citation)
  • Location
    • Peak incidence of calcaneal tuberosity fractures is women in their 70s (need citation)

Pathophysiology

  • General
    • Intra-articular extension common (60-75%)
    • Average patient is male, age 30-60

Intra-articular (75%)

    • Typically a high energy mechanism involving an axial load through the heel
    • Examples include fall from height, motor vehicle crash
    • Less commonly jumping onto hard surfaces, blunt or penetrating trauma, twisting/shearing events
    • Commonly results in superolateral fragment and superomedial "constant fragment"
    • Due to Talus acting as a wedge compressing the calcaneus

Extra-articular (25%)

  • Calcaneal tuberosity fracture from the Achilles Tendon
    • Associated with poor bone quality/osteoporosis
    • Mechanism: violent contraction of the calf muscles with forced dorsiflexion
    • Mechanism: strong concentric contaction of the triceps surae with knee in full extension
  • Anterior process
    • Usually a twisting mechanism
    • Avulsion injury to the bifurcate ligament
  • Avulsion of the sustentaculum tali

Calcaneal Stress Fractures

Associated Conditions

Pathoanatomy

Risk Factors

Differential Diagnosis

Clinical Features

Calcaneal Squeeze Test
  • History
    • Patients should be able to describe a clear mechanism
    • Patients will endorse pain, swelling, inability to bear weight
    • Deformity, open fracture may or may not be present
    • History of significant trauma
  • Physical Exam: Physical Exam Foot And Ankle
    • Bruising, swelling at heel or plantar arch
    • Shortened, widened heel
    • Must look for breaks in the skin
    • Tenderness along bone
    • Achilles tendon may be retracted in avulsion fracture
    • Confirm compartments are soft
    • Loss of plantarflexion strength
  • Special Tests

Evaluation

  • Nondisplaced fracture of calcaneus

  • CT of comminuted intra-articular calcaneal fracture

  • How to calculate Bohler's Angle

Radiographs

  • Standard Radiographs Ankle
    • Initial imaging modality of choice
    • Note: normal Bohler's Angle, Angle of Gissane do not exclude calcaneus fracture
  • Harris view
    • Evaluates calcaneus in axial orientation
    • Visualizes tuberosity fragment widening, shortening, and varus positioning
    • Position: maximal dorsiflexion, x-ray beam at 45°
  • Broden view
    • Evaluates posterior facet
    • Indication: intraoperative reduction of posterior facet
    • Technique: ankle in neutral dorsiflexion, ~45° internal rotation, x-rays at 40, 30, 20, and 10° cranial from neutral
  • Bohler's Angle
    • With fracture of posterior facet, may be depressed (<20°)
    • Angle between two lines drawn on lateral radiograph (normal between 20-40°)
    • First line is the highest point on tuberosity and the highest point of the posterior facet
    • Second line is highest point on the anterior process and highest point on the posterior facet
  • Critical Angle of Gissane
    • Angle between two lines drawn on lateral plain film (normal between 130-145°)
    • Line 1: anterior downward slope of the calcaneus
    • Line 2: superior upward slope
    • Abnormal angle suggests collapse of posterior facet
  • Other findings
    • Double density sign: partial separation of sustentaculum tali suggesting subtalar incongruity
    • Calcaneal shortening
    • Varus tuberosity deformity

CT

  • Gold standard for calcaneal fractures
  • Indications
    • Pre-operative planning
    • Classification of severity
    • Where index of suspicion is high and initial radiographs are negative
  • Mondor's Sign
    • Hematoma that extends along the sole, considered pathognomic for calcaneal fracture

MRI

  • Indications
    • Suspected calcneal stress fracture

Classification

Sanders Classification of Calcaneus Fractures

  • Fracture patterns based on number of fracture lines through the posterior facet (as seen on CT)
    • Type I: non-displaced, irrespective of fracture lines
    • Type II: 1 fracture line with 2 part fracture
    • Type III: 3 parts with centrally depressed articular fragment
    • Type IV: highly comminuted consisting of 4 articular segments
  • Fracture lines are described as A through C with A representing lateral lines, B middle, C medial fracture lines adjacent to sustentaculum tali

Essex-Lopresti Classification

  • Depression type
    • Single vertical fracture line through the angle of Gissane
    • This separates the anterior and posterior portions of the calcaneus.
  • Tongue type
    • Single vertical fracture line as a depression type
    • Second horizontal fracture line running posteriorly, creating a superior posterior fragment
    • Tuberosity fragment may then rotate superiorly.

Beavis Classification

  • Based on calcaneal tuberosity fracture pattern
  • Type 1 (Sleeve fracture): small shell of cortical bone avulses from the tuberosity
  • Type 2 (Beak fracture): oblique fracture line runs posteriorly from most superior portion of the posterior facet
  • Type 3 (Infrabursal fracture): from the middle of the tuberosity

Management

Prognosis

  • Overall
    • Prognosis is poor with up to 40% of patients having complications (need citation)
  • Displaced, intraarticular calcaneal fractures (DIACF)
    • Nonoperative vs operative management is controversial
    • Several prospective-randomized controlled trials (RCT's) have failed to show a significant overall superiority of either treatment[1][2]
    • One small study showed better outcomes with ORIF[3]
  • Sanders classification
    • Type III fractures were 4 times more likely to need a fusion than type II fractures at minimum of 10 year follow up[4]
  • Predictors of better outcome[5]
    • Women
    • Younger Adults
    • Light workload occupation
    • Not receiving workers compensation
    • Higher initial Bohler's angle

Acute

  • Inital management often ATLS protocol given high energy nature of injuries
  • After life-threatening injuries ruled out, complete neurovascular exam of the lower extremity
  • Aggressive wound care, antibiotics for open fractures
  • Analgesia
  • Immobilization and bulky splint/dressing
  • Non-weight bearing status

Nonoperative

  • Indications
    • Sanders type I
    • Calcaneal stress fracture
    • Small extra-articular fracture (<1 cm) with intact Achilles tendon and <2 mm displacement
    • Normal Bohler's Angle
    • Minimally displaced tuberosity fractures (< 1cm) in elderly folks with reduction function/ physical capacity
    • Poor surgical candidates
  • Immobilization
    • Initially in fiberglass or plaster splint with neutral ankle
    • Conversion to Short Leg Cast with neutral ankle after swelling has subsided
  • Non-weight bearing for 10-12 weeks, until fracture union confirmed on x-ray
    • Stress fractures can likely maintain NWB status for around 6 weeks

Operative

  • Indications
    • Open fractures or fracture dislocation
    • Displaced tongue-type fractures at risk for tissue breakdown
    • Displaced (>2mm) intra-articular fractures
    • Joint depression with articular comminution or anterior process involvement
    • Bohler's angle of <5 degrees on initial presentation
    • Anterior process fractures with >25% of the calcaneocuboid articulation involved
    • Calcaneal body fractures with significant
      • Varus /valgus malalignment
      • Lateral impingement
      • Loss of calcaneal height
      • Significant translation of the posterior tuberosity.
    • Surgical fixation may be delayed in cases of concurrent life-threatening injuries, edema, poor tissue envelopes, and others
  • Technique
    • Closed reduction with percutaneous pinning
    • Open reduction, internal fixation
    • Primary subtalar arthrodesis

Rehab and Return to Play

Rehabilitation

  • Postoperative
    • POD 0: Posterior Short Leg Splint
    • Elevation for several weeks
    • Splint off somewhere between weeks 1 and 2
    • Weight bearing delayed for 8-12 weeks
    • Serial radiographs to demonstrate union

Return to Play

  • Needs to be updated

Complications

See Also

References

  1. ↑ Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, et al. Operative compared with nonoperative treatment of displaced intraarticular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84-A:1733–44.
  2. ↑ Agren PH, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative treatment of displaced intraarticular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2013;95:1351–7.
  3. ↑ Thordarson DB, Krieger LE. Operative vs. nonoperative treatment of intraarticular fractures of the calcaneus: A prospective randomized trial. Foot Ankle Int. 1996;17:2–9
  4. ↑ Sanders R, Vaupel ZM, Erdogan M, Downes K. Operative treatment of displaced intraarticular calcaneal fractures: long-term (10-20 Years) results in 108 fractures using a prognostic CT classification. J Orthop Trauma. 2014 Oct;28(10):551-63.
  5. ↑ Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002 Oct;84(10):1733-44.
  6. ↑ Hsu AR,Anderson RB,Cohen BE, Advances in Surgical Management of Intra-articular Calcaneus Fractures. The Journal of the American Academy of Orthopaedic Surgeons. 2015 Jul
  7. ↑ Csizy M, Buckley R, Tough S, Leighton R, Smith J, McCormack R, Pate G, Petrie D, Galpin R. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma. 2003 Feb;17(2):106-12.
Created by:
Parker.young on 17 December 2020 20:46:45
Authors:
Last edited:
16 January 2023 19:34:43
Categories:
Lower Extremity | Trauma | Leg | Ankle | Fractures | Acute | Overuse

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