Calcaneal # + Talar #

Question 1

What is most common # tarsal bone?

Answer 1

• Calcaneum
• From fall from height
• Then axial loading

Question 2

Tarsal bones

Answer 2

Question 3

Classification of calcaneum #

Answer 3

• Intra-articular vs extra-articular
• Intra-articular - involve subtalar joint, Sanders Classification
• Extra-articular - spare subtalar joint, inc avulsion of calcaneal tuberosity

Question 4

Sanders classification

Answer 4

• I - non-displaced posterior facet (any number of # lines)
• Type II - one fracture line in posterior facet (two fragments)
• III - two fracture lines in posterior facet
• IV - comminuted with more than 3 fracture lines in posterior facet (4 or more fragments)

Question 5

Clinical features calcaneal #

Answer 5

• Recent trauma eg fall from height, or RTA
• Pain and tenderness around calcaneal region
• Inability to weight bear
• Swollen, bruised
• Shortened and widened heal
• Varus deformity

Question 6

Examination - what to check for with calcaneal #

Answer 6

• Skin integrity
• Any tenting or blanching skin needs emergency surgical intervention - risk of open #

Question 7

Differentials for swollen and painful ankle

Answer 7

• Talar #
• Ankle #
• Soft tissue injury

Question 8

X-ray frinding for calcaneal #

Answer 8

• Need AP, lateral and oblique views
• Calcaneal shortening
• Varus tuberosity deformity
• Decreased Bohlers angle

Question 9

What is Bohlers angle?

Answer 9

• Angle formed between one line from anterior to middle facet and another line from posterior to middle fact
• Normally 20-40 degrees

Question 10

Gold standard imaging calcaneal #

Answer 10

• CT imaging - GOLD STANDARD

Question 11

Management calcaneal #

Answer 11

• Surgical intervention usually
• Those with <2mm displacement or near normal Bohlers angle may be conservative

Question 12

Conservative management calcaneal #

Answer 12

• Reserved for <2mm displacement, near normal Bohlers, non-displaced extra-articular
• Cast immobilisation and non weight bearing for 10-12 weeks

Question 13

Surgical intervention for calcaneal #

Answer 13

• Closed reduction with percutaenous pinning - if large but minimally displaced #
• ORIF if not
• Any # with skin compromise –> emergency fixation

Question 14

Complication calcaneal #

Answer 14

• Subtalar arthiritis –> analgesia and physio
• Can have arthrodesis if required (fusion)

Question 15

MOI for talar #

Answer 15

• High energy trauma
• Forced dorsiflexion - hits tibial plafond
• Mostly occur through talar neck

Question 16

Risk with talar #

Answer 16

• Extraosseous blood supply mostly
• Highly suceptible to interruption
• So risk of AVN after #

Question 17

Presentation of talar #

Answer 17

• High impact trauma
• Immediate pain and swelling of ankle
• Clear deformity
• Unable to weight bear

Question 18

Examination of talar #

Answer 18

• Unable to dorsiflex or plantarflex ankle
• Check for open #
• White, tenting skin = threatened

Question 19

X-ray for talar #

Answer 19

• Need AP and lateral view
• Lateral view in full dorsi and plantarflexion to differentiate between type I and II
• If complex –> CT

Question 20

Classification of talar #

Answer 20

• Hawkins

Question 21

Hawkins classification of calcaneal #

Answer 21

• I - undisplaced
• II - subtalar dislocation
• III - subtalar and tibiotalar dislocation
• IV - subtalar, tibiotalar and talonavicular dislocation

Higher risk of AVN as higher the class

Question 22

Management talar #

Answer 22

• Dependent on Hawkins classification
• All undisplaced –> conservative in NWB orthosis
• Displaced –> immediate reduction and surgical repair afterwards

Question 23

Type I Hawkins #

Answer 23

• Conservative
• Non weight bearing crutches for 3 months
• Assess for union and AVN in # clinic

Question 24

Type II to IV Hawkins #

Answer 24

• Attempted closed reduction in A&E
• Plaster of paris cast
• Repeat radiographs ensure remains in poisition
• If not possible –> open reduction OOH
• Then definitive surgical fixation ASAP with referral to tertiary centre if needed
• Post op –> EXTENDED non weight bearing period

Question 25

Complications of talar #

Answer 25

• AVN - 17%, most common type II-IV
• OA secondary to AVN or malunion
• If severe may need arthrodesis

Question 26

What is Hawkins sign?

Answer 26

• Line of subchondral lucency of talar dome on x-ray
• Seen 6-8 weeks following injury
• Indicative or bone resorption indicating sufficient vascularity of talus
• Suggests low risk of AVN