We need you! See something you could improve? Make an edit and help improve WikSM for everyone.
Calcaneus Fracture
From WikiSM
Contents
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
- See: Stress Fractures Main
- Associated with increased physical activity, relative energy deficiency
Associated Conditions
- High thoracic and lumbar vertebral injuries (10%)
- Tibial Plateau Fractures (10%)
- Contralateral calcaneal fractures (10%)
- Extends into Calcaneocuboid Joint (63%)
Pathoanatomy
- Calcaneus
- Along with Talus, forms the hindfoot which articulates with Tibia, Fibula to form Ankle Joint
- Transfers most of the body weight from the limb to the ground
Risk Factors
Differential Diagnosis
- Fractures & Dislocations
- Muscle and Tendon Injuries
- Ligament Injuries
- Bursopathies
- Nerve Injuries
- Arthropathies
- Pediatrics
- Fifth Metatarsal Apophysitis (Iselin's Disease)
- Calcaneal Apophysitis (Sever's Disease)
- Triplane Fracture
- Other
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
- Calcaneal Squeeze Test: can help diagnose calcaneal stress fracture
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)
- 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
- Postoperative complications can be as high as 37%[6]
- Increased risk: Tobacco Use Disorder, Diabetes Mellitus, Open fractures
- Acute Compartment Syndrome
- In 10% of cases (need citation)
- Results in so-called claw toes
- Flexor Hallucis Longus Injury
- Often iatrogenic from placement of lateral to medial screws
- Fracture blisters
- Skin tenting and wound necrosis
- Tarsal Tunnel Syndrome
- Sural Nerve Pathology
- Up to 31% of cases (need citation)
- Malunion/ Non-union
- Osteomyelitis
- Skin and Soft Tissue Infection
- Subtalar Arthritis
- 6 fold more likely to need fusion when managed nonoperatively due to subtalar arthritis[7]
- Chronic pain
- Due to a combination of subtalar arthritis, malalignement, joint stiffness
- Peroneal Tendon Instability
- Due to either direct damage to the tendons themselves fracture fragments that may impinge on the tendon
See Also
- Internal
- External
- Sports Medicine Review Ankle Pain: https://www.sportsmedreview.com/by-joint/ankle/
References
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ 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
- ↑ 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