Calcaneal Fractures

Question 1

Main goal in management

Answer 1

1. Restore the articular surface
2. Restore the length, alignment and the heel width

–> to improve gait mechanics, shoe wear fitting, and to decrease post-traumatic arthritis

Question 2

Non-operative management plan

Answer 2

1. Rest
2. Ice
3. Elevation
4. Early ROM (ankle and hind foot to prevent stiffness )
5. Discontinue splinting after 5-10 days
6. Non-weightbearing for 6 weeks

Question 3

Gold standard approach for restoring the articular surface, heel length and width

Answer 3

Extended lateral approach

Question 4

Why are full thickness flaps necessary?

Answer 4

1. Avoid risk of skin necrosis

2. Avoid damage to the peroneal and lateral calcaneal arterial blood supply

Question 5

Sanders classification

Answer 5

Types I-IV

Type I nondisplaced posterior facet (regardless of the number of fracture lines)

Type II One fracture line in the posterior facet (2 fragments)

Type III two fracture lines in the posterior facet (3 fragments)

Type IV comminuted with more than 3 fracture lines in the posterior facet

subclassified into A (lateral), B (central), and C (medial) depending on the position of the fracture line through the posterior facet

Question 6

What is related to better long-term outcomes?

Answer 6

Good reduction

Question 7

Indication Non-operative treatment

Answer 7

1. Extra-articular fractures
2. Undisplaced fractures
3. Severly comminuted fractures (Sanders type IV) where the risk of surgical intervention is outweighed

Question 8

Intra-articular fractures

Answer 8

Primary fracture line results from oblique shear and leads to the following 2 primary fragments

1. Superomedial fragment (constant fragment), which includes the sustentaculum tali and is stabilised by strong ligamentous and capsular attachments
   2. Superolateral fragment, which includes an Intra-articular aspect through the posterior facet

Secondary fracture lines dictate whether there is joint depression or tongue-type fracture

Question 9

Extra-articular fractures

Answer 9

Strong association of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus

More common in osteopenic/osteoporotic bone

Question 10

Anterior process fractures

Answer 10

Inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament

Question 11

Associated orthopaedic injuries

Answer 11

1. Extension into the calcaneocuboid joint occurs in 63%
2. Vertebral injuries in 10%
3. Contralateral calcaneus in 10%

Question 12

Prognosis

Answer 12

Poor with 40% complication rate

Increased due to mechanism (fall from height), smoking, and early surgery

Lateral soft tissue trauma increases the rate of complication

Question 13

Major weight-bearing surface

Answer 13

Posterior facet

The flexor hallucis longus tenxon is medial to the posterior facet and inferior to the medial facet and can be injured with errant drills/screws that are too long

Question 14

Sinus tarsi

Answer 14

Between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi

Question 15

Sustentaculum tali

Answer 15

Projects medially and supports the neck of the talus

Flexor hallucis longus passes beneath it

Represented by the constant fragment

Deltoid and talocalcaneal ligament connect it to the talus

Contained in the anteromedial fragment, which remains ‘constant’ due to medial talocalcaneal and interosseous ligaments

Question 16

Symptoms

Answer 16

1. Pain
2. Swelling
3. Inability to bear weight
4. Gross deformity
5. Open fracture

Question 17

Physical exam

Answer 17

1. Inspection
   Ecchymosis and swelling
   Shortened and widened heel (may have apparent varus deformity)
   Open skin lesions or fractures
   Posterior heel skin compromise (tenting, Ecchymosis, or lack of skin blanching with tuberosity fractures) - necessitates urgent surgical reduction and fixation to avoid posterior heel skin necrosis)
   Fracture blisters - must be debrided and epithelialized prior to surgical intervention
2. Palpation
   Diffuse tenderness to palpation
   Lack of heel cord continuity in avulsion fractures
   Lack of posterior heel skin blanching with tenting fractures
   Assess for compartment syndrome secondary to swelling (rare)
   Presence of Langer’s lines and skin wrinkles suggests skin is appropriate for surgical intervention
3. Strength
   Decreased ankle plantar flexion strength with avulsion fractures
4. Neurologic
   Assess for neurologic compromise due to swelling
5. Vascular
   Assess peripheral pulses - severe peripheral vascular disease may preclude surgical treatment due to poor wound healing

Question 18

Radiographic findings

Answer 18

1. Double density sign - represents subtalar incongruity
2. Calcaneal shortening
3. Varus tuberosity deformity
4. Decreased Boehlers angle - represents collapse of the posterior facet
5. Increased angle of Gissane - represents collapse of the posterior facet

Question 19

Gold standard imaging

Answer 19

CT

should perform 2-3mm cuts

Question 20

Primary subtalar arthrodesis

Answer 20

Sanders Type IV

combined with ORIF to restore height

Question 21

Complications

Answer 21

1. Wound complications (10-25%)
2. Subtalar arthritis
3. Lateral impingement with peroneal irritation
4. Sural nerve neuroma
5. Damaged Flexor hallucis longus (at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment)
6. Compartment syndrome (10%)- results in claw toes
7. Malunion

Question 22

Distraction bone block Subtalar arthrodesis

Answer 22

Fusion technique for late complications of calcaneal fractures that were treated conservatively

Involves distraction of the subtalar joint, insertion of a bone block, and rigid screw fixation

If findings of anterior ankle impingement are present