Calcaneal Fracture

Question 1

What is the most commonly fractured tarsal bone?

Answer 1

Calcaneum

Question 2

Mechanism of injury

Answer 2

Fall from height whereby there is significant axial loading directly onto the bone.

Question 3

Associated injuries of calcaneal fracture

Concurrent fractures (particularly spinal or contralateral calcaneus)

Severe visceral injuries

Around 15% of all calcaneal are open fractures

Answer 3

Due to the mechanism of injury.

Question 4

Classification

Answer 4

Divided into intra-articular and extra-articular fractures.

Intra-articular = 75%

Extra-articular = 25%

Question 5

Explain intra-articular calcaneal fractures

Answer 5

Involves the articular surface of the subtalar joint and can be further classified by the Sanders classification

Question 6

Explain extra-articular calcaneal fractures

Answer 6

Commonly avulsion fractures with sparing of the articular surface of the subtalar joint.

This includes avulsion of the calcaneal tuberosity by the achilles tendon.

Question 7

Explain Sanders classification

Answer 7

Management is guided by Sanders classification.
Intra-articular fractures will likely require definitive fixation.

Type I - Nondisplaced posterior facet (regardless of number of fracture lines)

Type II - One fracture line in the posterior facet (two fragments)

Type III - Two fracture lines in the posterior facet (three fragments)

Type IV - Comminuted with more than three fracture lines in the posterior facet (four or more fragments)

Question 8

Clinical features

Answer 8

Recen trauma such as fall from a heigh or RTC

Pain and tenderness around the calcaneal region with an inability to weight bear.

Question 9

Examination findings

Answer 9

Swollen and bruised heel

Potentially shortened and widened heel.

Varus deformity

Assess for posterior heel skin integrity.
Any tenting or blanched skin will warrant emergency surgical intervention.

Question 10

Dx

Answer 10

Talar fracture

Ankle fracture

Soft tissue injury

Question 11

Ix

Answer 11

Should be investigated and managed according to ATLS protocol.
Urgent bloods + coag and G&S

Plain X-ray using AP, lateral and oblique views.

CT is gold standard for assessing calcaneal fractures and should be performed in any suspected case

Question 12

X-ray findings

Answer 12

Calcaneal shortening

Varus tuberosity deformity

Decreased Böhler’s angle

Question 13

Explain Böhler’s angle

Answer 13

The posterior angle formed between one line from the anterior to middle facet and one line from the posterior to middle facet.
Normally 20-40 degrees

Reduced Böhler’s angle can indicate calcaneal fracture

Question 14

Indications of conservative management

Answer 14

Intraarticular that is < 2mm displacement or near normal Böhler’s angle

Extraarticular fractures may be treated conservatively.

Most intra-articular will be surgically

Question 15

Explain conservative management

Answer 15

Cast immobilisation and non-weight bearing for 10-12 weeks

Question 16

Indications for surgical management.

Answer 16

All intra-articular fractures unless they are mild.

Extra-articular fractures that have significant displacement.

Question 17

Explain surgical interventions

Answer 17

Closed reduction with percutaneous pinning

ORIF

Emergency surgical fixation

Question 18

When is closed reduction with percutaneous pinning indicated.

Answer 18

It can be attempted for large (>1cm) but minimally diplaced fractures

Question 19

Usually ORIF is indicated as the surgery method of choice.

Which fractures warrants ORIF?

Answer 19

Open fractures

Posterior facet displacement

Reduced Böhler’s angle

Calcaneocuboid joint involvement

Question 20

Complications

Answer 20

Subtalar arthritis

Analgesia

Physiotherapy