We need you! See something you could improve? Make an edit and help improve WikSM for everyone.

Calcaneus Fracture

From WikiSM
Jump to: navigation, search


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

  • 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

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:
4 October 2021 15:00:51
Categories:
Lower Extremity | Trauma | Leg | Ankle | Fractures | Acute | Overuse