Fractures of the Calcaneus: Everything You Need to Know
Fractures of the calcaneus can be open or closed.1
Open fractures are more serious than closed fractures.1 The primary
fracture line is caused by an axial load injury.1 The primary
fracture line goes from anterolateral to posteromedial.1 The primary
fracture line divides the calcaneus into two main fragments: the superomedial
fragment which is also called the constant or sustentacular (SAS) fragment and
the superolateral or tuberosity fragment.1 The superomedial fragment
includes the sustentaculum tali and is stabilized to the talus by ligaments.
So, the talus is attached to the constant fragment.1 The sustentacular
fragment is a useful reference point for fracture reduction.2 The
flexor hallucis longus tendon lies underneath the sustentaculum. If screw
placement to the sustentacular fragment is too long, the flexor hallucis longus
tendon could be affected, causing fixed flexion of the big toe.3
The
Essex-Lopresti classification system is a useful way to differentiate between
different joint fractures. There are two types of Essex-Lopresti fractures: a
tongue-type fracture and a joint depression type fracture.1 In the
tongue-type, the posterior facet is attached to the tuberosity. In the joint
depression type, the posterior facet is not attached to the tuberosity.4
In the tongue-type, the primary fracture line exits anterolaterally and
posteromedially.5 The secondary fracture line appears beneath the
posterior facet and exits posteriorly through the tuberosity.5 The
superolateral fragment and posterior facet are attached to the tuberosity. The
tongue-type fracture can be treated with open reduction and internal fixation.6
In
the joint depression type, the primary fracture line splits the calcaneus
obliquely through the posterior facet and exits anterolaterally and
posteromedially.1 The secondary fracture line exits superiorly just
behind the posterior facet.1 The posterior facet is a free fragment.
The lateral portion of the posterior facet is usually involved and depressed.4
Calcaneal avulsion fractures are typically serious. These
types of fractures require urgent reduction and internal fixation to prevent
skin complications.10 In joint depression fractures of the
calcaneus, the swelling must go down before surgery. Avulsion fractures of the
calcaneus are emergencies, so emergency surgery is performed before the
swelling goes down. Open reduction and internal fixation of the calcaneus is
generally delayed for 1-2 weeks to allow for improvement of the soft tissue
swelling, except with avulsion fractures.1 Avulsion fractures can
cause skin tenting and urgent reduction is recommended.10
There are many associated conditions with calcaneal
fractures. Ten percent are associated with spinal fractures.11 Ten
percent are associated with compartment syndrome of the foot.12 If
this is neglected, it will lead to claw toes due to contracture of the
intrinsic flexor muscles.12 Approximately ten percent are associated
with bilateral fractures.13 Sixty percent are associated with
calcaneocuboid joint fractures.14 Calcaneal fractures may also be
associated with peroneal tendon subluxation. Peroneal tendon subluxation may be
detected on axial CT scans or it may be seen as an avulsion fracture of the
fibula on x-rays.15
Complication
rates for calcaneal fractures are high. Factors associated with poor outcomes are
age greater than 50, smoking, early surgery, history of a fall, heavy manual
labor, males, bilateral injury, workman’s compensation, and peripheral vascular
disease.1,16,17 Men do worse with calcaneal fractures than women.
Calcaneal fractures in men are normally associated with workman’s compensation,
heavy labor, and a 0˚ Bohler angle.1 These fractures typically need
subtalar fusion.18 Calcaneal fractures in females have a simple
fracture pattern. Since calcaneal fractures in males are usually more severe,
it follows that better outcomes are seen in females with calcaneal fractures.19
The
Bohler angle is measured on lateral x-rays.1 This angle is normally
between 20˚-40˚.1 The Bohler angle is formed by a line drawn from
the highest point of the anterior process of the calcaneus to the highest point
of the posterior facet and a line drawn tangential to the superior edge of the
tuberosity.1 A decrease in this angle indicates a collapse of the
posterior facet.1 When viewing calcaneal fractures with the Harris
view, the calcaneus appears to be shortened and widened with varus.1
When viewing calcaneal fractures through CT scans, the axial cut shows the
calcaneocuboid joint and peroneal tendon subluxation.1,20 The
sagittal view shows the subtalar joint and its depression.21 The
coronal view shows the displacement of the posterior facet.22
Coronal CT scans can also show the number of the joint fracture fragments.1
The surgical outcome of calcaneal fractures correlate with the number of the
joint fracture fragments and the quality of reduction.1 MR imaging shows
stress fractures of the calcaneus and the integrity of the peroneal tendons.23,24
Stress fractures of the calcaneus may be misdiagnosed as
plantar fasciitis.25 Stress fractures usually occur in female
runners.26 It is characterized by swelling and tenderness with
medial and lateral compression of the hindfoot during the squeeze test.27 If
the X-ray is negative, an MRI should be obtained. The fracture will be seen in
T1 MR imaging as a linear streak or a band of low signal intensity in the
posterior calcaneal tuberosity.28 In T2 imaging, the signal will be
increased.28
There
are several complications with calcaneal fractures. Wound-related complications
are the most common complication.29 Wound-related complications
occur more in smokers, diabetics, and patients with open fractures.1
Open fractures of the calcaneus is another common complication. Open fractures
of the calcaneus can lead to amputation.30 There is also a high risk
of infection with open fractures.30 Grade I and Grade II open
fractures have wounds that open medially. Open reduction and internal fixation
(ORIF) can be done to treat this complication.30 Open reduction and
internal fixation should not be done in Grade III medial wounds and in most
lateral wounds.30 Another complication is malunion of the calcaneus.31
This is characterized by widening of the heel, varus deformity, and loss
of height.31 The talus is dorsiflexed, limiting dorsiflexion of the
ankle.31 Peroneal tendon irritation and impingement from the lateral
wall is another complication.32
Surgery
on the calcaneus decreases the risk of post-traumatic arthritis.33 Tongue-type
and joint depression type fractures may benefit from open reduction and
internal fixation.6 Subtalar distraction arthrodesis is a good
operation to treat calcaneal fractures associated with loss of height and
limited dorsiflexion of the ankle.31 This operation improves talar
inclination and decreases anterior ankle impingement.31
Additionally, it takes care of arthritis in the subtalar joint.31
Another surgical approach is extensile lateral approach. The lateral calcaneal
artery provides blood supply to the lateral flap associated with the calcaneal
extensile approach.34 It is important to be aware that the Sural
nerve is in the vicinity of the surgical area.35 Delayed wound
healing is a common complication in the extensile lateral approach.35
References:
1. Trompeter A, Razik A, Harris M. Calcaneal fractures:
Where are we now? Strategies in Trauma and Limb Reconstruction.
2017;13(1):1–11.
2. Berberian W, Sood A, Karanfilian B, Najarian R, Lin S,
Liporace F. Displacement of the SUSTENTACULAR fragment in INTRA-ARTICULAR
CALCANEAL FRACTURES. Journal of Bone and Joint Surgery. 2013;95(11):995–1000.
3. Carr JB. Complications of CALCANEUS fractures
entrapment of the Flexor hallucis longus. Journal of Orthopaedic Trauma.
1990;4(2):166–8.
4. Rothberg DL, Yoo BJ. Posterior facet cartilage injury
in OPERATIVELY Treated Intra-articular CALCANEUS FRACTURES. Foot & Ankle
International. 2014;35(10):970–4.
5. White EA, Skalski MR, Matcuk GR, Heckmann N, Tomasian
A, Gross JS, et al. Intra-articular tongue-type fractures of the calcaneus:
Anatomy, injury patterns, and an approach to management. Emergency Radiology.
2018;26(1):67–74.
6. Chhabra N, Sherman SC, Szatkowski JP. Tongue-type
calcaneus fractures: a threat to skin. The American Journal of Emergency
Medicine. 2013;31(7).
7. Jiménez-Almonte JH, King JD, Luo TD, Aneja A,
Moghadamian E. Classifications in Brief: Sanders classification OF
INTRAARTICULAR fractures of the calcaneus. Clinical Orthopaedics & Related
Research. 2018;477(2):467–71.
8. Rammelt S, Marx C. Managing severely malunited
calcaneal fractures and fracture-dislocations. Foot and Ankle Clinics.
2020;25(2):239–56.
9. Piovesana LG, Lopes HC, Pacca DM, Ninomiya AF, Dinato
MC, Pagnano RG. Assessment of reproducibility of sanders classification for
calcaneal fractures. Acta Ortopédica Brasileira. 2016;24(2):90–3.
10. Berringer R. Avulsion fracture of the calcaneus.
Canadian Medical Association Journal. 2018;190(45).
11. Rowe CR. Fractures of the os calcis. JAMA.
1963;184(12):920.
12. Myerson Mark, Manoli Arthur. Compartment syndromes of
the foot after calcaneal fractures. Clinical Orthopaedics and Related Research.
1993;&NA;(290).
13. Popelka V.
Súčasné trendy v liečbe intraartikulárnych zlomenín pätovej kosti [Current
Concepts in the Treatment of Intra-Articular Calcaneal Fractures]. Acta Chir
Orthop Traumatol Cech. 2019;86(1):58-64. Slovak. PMID: 30843515.14.
14. Kinner B, Schieder S, Müller F, Pannek A, Roll C.
Calcaneocuboid joint involvement IN CALCANEAL FRACTURES. Journal of Trauma:
Injury, Infection & Critical Care. 2010;68(5):1192–9.
15. Park C-H, Gwak H-C, Kim J-H, Lee C-R, Kim D-H, Park
C-S. Peroneal tendon Subluxation and dislocation In CALCANEUS FRACTURES. The
Journal of Foot and Ankle Surgery. 2021;60(2):233–6.
16. Su J, Cao X. Can operations achieve good outcomes in
elderly patients with SANDERS II–III calcaneal fractures? Medicine.
2017;96(29).
17. Clare MP, Crawford WS. Managing complications of
CALCANEUS FRACTURES. Foot and Ankle Clinics. 2017;22(1):105–16.
18. Csizy M, Buckley R, Tough S, Leighton R, Smith J,
McCormack R, et al. Displaced Intra-articular CALCANEAL FRACTURES. Journal of
Orthopaedic Trauma. 2003;17(2):106–12.
19. Barla J, Buckley R, McCormack R, Pate G, Leighton R,
Petrie D, et al. Displaced intraarticular calcaneal fractures: Long-term
outcome in women. Foot & Ankle International. 2004;25(12):853–6.
20. Toussaint RJ, Lin D, Ehrlichman LK, Ellington JK,
Strasser N, Kwon JY. Peroneal tendon DISPLACEMENT Accompanying INTRA-ARTICULAR
CALCANEAL FRACTURES. Journal of Bone and Joint Surgery. 2014;96(4):310–5.
21. Badillo K, Pacheco JA, Padua SO, Gomez AA, Colon E,
Vidal JA. Multidetector CT evaluation Of CALCANEAL FRACTURES. RadioGraphics.
2011;31(1):81–92.
22. Buckley R. Displaced fracture of the calcaneus body
[Internet]. AO Foundation Surgery Reference. [cited 2021Sep29]. Available from:
https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/calcaneous/displaced-body-fractures/definition
23. Kato M, Warashina H, Kataoka A, Ando T, Mitamura S.
Calcaneal insufficiency fractures following ipsilateral total knee
arthroplasty. Injury. 2021;52(7):1978–84.
24. Park HJ, Cha SD, Kim HS, Chung ST, Park NH, Yoo JH,
et al. Reliability of MRI findings OF PERONEAL Tendinopathy in patients with
LATERAL CHRONIC Ankle Instability. Clinics in Orthopedic Surgery.
2010Nov5;2(4):237.
25. Weber JM, Vidt LG, Gehl RS, Montgomery T. Calcaneal
stress fractures. Clinics in Podiatric Medicine and Surgery. 2005;22(1):45–54.
26. Labronici P, Pires RE, Amorim L. Calcaneal stress
fractures in civilian patients. Journal of the Foot & Ankle.
2021;15(1):54–9.
27. Kiel J,
Kaiser K. Stress Reaction and Fractures. 2021 Aug 4. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 29939612.
28. Lawrence DA, Rolen MF, Morshed KA, Moukaddam H. MRI of
heel pain. American Journal of Roentgenology. 2013Apr18;200(4):845–55.
29. Ding L, He Z, Xiao H, Chai L, Xue F. Risk factors for
postoperative wound complications of calcaneal fractures following plate
fixation. Foot & Ankle International. 2013;34(9):1238–44.
30. Heier KA, Infante AF, Walling AK, Sanders RW. Open
fractures of THE Calcaneus: Soft-tissue Injury DETERMINES OUTCOME. The Journal
of Bone and Joint Surgery-American Volume. 2004;86(11):2569.
31. Guang-Rong Y, Xiao Y. Surgical management Of
Calcaneal Malunion. Journal of Orthopaedics, Trauma and Rehabilitation.
2013;17(1):2–8.
32. Davis D,
Seaman TJ, Newton EJ. Calcaneus Fractures. 2021 Aug 9. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID:
28613611.
33. Vilá-Rico J, Ojeda-Thies C, Mellado-Romero MÁ,
Sánchez-Morata EJ, Ramos-Pascua LR. Arthroscopic posterior subtalar arthrodesis
for salvage of posttraumatic arthritis following calcaneal fractures. Injury.
2018;49.
34. Mehta CR, An VV, Phan K, Sivakumar B, Kanawati AJ,
Suthersan M. Extensile lateral versus sinus Tarsi approach For displaced,
intra-articular Calcaneal Fractures: A meta-analysis. Journal of Orthopaedic
Surgery and Research. 2018;13(1).
35. Buckley R. Extended lateral approach to the calcaneus
[Internet]. AO Foundation Surgery Reference. [cited 2021Sep29]. Available from:
https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/calcaneous/approach/extended-lateral-approach-to-the-calcaneus
