Incidence

• calcaneal # = 60% of tarsal bone #’s & 2% of all #’s
• no method of RX that yields consistently good results

Anatomy

• has a thin cortical shell except at the posterior tuberosity
• within the shell is cancellous bone

3 Articular facets

• on the anterior 1/2 of the calcaneus
• posterior - on the body
• middle & anterior - on sustentaculum tali
• these facets articulate with the talus & form the subtalar joint

Tuberosity

• most hind part of the calcaneus
• TA inserts here

Anterior process

• articulates with cuboid

Bohler’s (or tuber) angle

• seen on the lateral X ray
• normally 25 - 40° & must be compared with the other side

Crucial angle of Gissane

• the wedged shaped lateral process of the talus points into
• measure 135°(± 10°)

Classification

Essex - Lopresti

• extra-articulars
• 25% of calcaneal
• don’t involve subtalar joint
• tuberosity, sustentaculum tali, anterior process or body

• Inta-articular
• 75%
• undisplaced
• displaced
• tongue type
• joint (central) depression type
• comminuted

Mechanism of injury

Extra - articular

• twisting forces mainly
• # of the tuberosity - usually avulsion type injuries
• direct blows can cause any type

Intra - articular

• usually d/t fall from a height
• bilateral in 5-10%

Associated injuries

• 10% dorsal or lumbar spine compression
• 30% other injuries of the lower limb

Clinical

• deformity, swelling
• loss of N contour
• widened & shortened calcaneus
• may have severe ST injury, compartment sy.
• bruise onto the arch of the foot
• pain
• associated injuries
• Th-L spine
• lower limb

X Ray investigations

• AP, lateral & axial views
• films of the ankle joint, lower limb. pelvis & spine are mandatory

AP view

• calcaneo-cuboid joint
• subluxation of the talonavicular joint

Lateral view shows

• tuber angle - 20-40° - compare sides
• congruity of the post. facet & sub-talar joint

Axial view

• widening
• the medial wall, lateral wall & medial facet-sustentacular complex

Isherwood

• 3 oblique views to demonstrate subtalar joint incongruity
• lateral oblique - ant facet & ant calcaneal process
• medial oblique axial projection - middle & post. facets
• lateral oblique axial projection - posterior facet

CT scan

• intra - articular’s best evaluated
• coronal sections show
• size & no. of fragments
• amount of joint incongruity
• amount of fragment displacement
• essential for pre - operative planning

Extra - articular's

#s of the anterior process

2 Types

• Avulsion
• More common - bifurcate ligament attaches here
• Inversion
• Compression
• due to forceful abduction of the foot

NB! don't confuse a # with a calcaneus secondarium on X ray

• conservative
• ORIF if large displaced articular fragment
• If symptomatic non-union - excision

Fracture of the tuberosity

2 Types: (older classifications)

• beak - superior part of the tuberosity
• avulsion - inferior part
• avulsion is probably the mechanism in both types
• occurs in older people
• usual mechanism a stepping off a small height
• determined by the amount of displacement

Undisplaced

• immobization in 5-10° equinus for 6 weeks
• PWB & serial X rays to confirm reduction

Displaced

• ORIF to restore TA to length - screw, cerclage wiring
• NWB in BK POP for 6 to 8 weeks in 5-10° of equinus

Fractures of the sustentaculum tali

• twisting injuries
• rare
• pain & swelling on the medial aspect of the foot - worse on inverting the foot
• painful non-union - excision

Fracture of the body

• usually d/t a fall from a height
• tuber angle can be affected without subtalar joint involvement

2 types of # displacement may warrant more aggressive treatment:

• significant widening of the heel -> medial - lateral compression- BK POP 6 weeks
• decrease in the tuber angle - ? shorten the TA with a << in push off strength

• traction with a transverse Steinman’s pin
• once reduction is achieved -> incorporate pin in POP for 4 weeks

Summary of management of extra-articular fractures

• most will need only
• compression dressing
• bed rest & leg elevation to decrease swelling
• physio & exercises of the ankle & sub-talar joint
• significant widening - manual compression to << late peroneal tendon irritation
• NWB for 6 to 8 weeks
• reliable: crutches & encouraged to do an exercise program
• unreliable: protected in a BK POP NWB

Prognosis

• good result usually
• union always occurs
• with early mobilization joint stiffness is minimal

Intra - articular

• Intra - articular
• Rowe, McLaughlin
• closed reduction & fixation
• aim is to restore the subtalar joint Bohler’s angle
• normal heel width

Essex- Lopresti: axial percutaneous pin for tongue type #’s (Gissane spike)

• ORIF with or without bone grafting

Apply especially to the joint depression type
Essex-Lopresti’s method: lateral approach, fragment elevation & reduction & fixation with a pin through the tuberosity, no bone graft
Palmer’s method: lateral approach with dislocation of the peroneal tendons, BG McReynolds’ method: medial approach with reduction the medial fragments & fixation with a staple - lateral fragments can be reduced through the # line on the medial side

Primary arthrodesis

Treatment

• after conservative RX - recovery slow & unsatisfactory d/t
• disruption of the subtalar joint
• alteration in hindfoot mechanics (rowe 1963, nade & monahan 1972, slatis 1979)
• ideal RX = anatomic reduction, stable fixation & early joint mobilization
• pre-requisite for successful surgical management -> knowledge of the # anatomy

X Ray investigations

• lateral axial, oblique & AP films
• coronal CT scans

Plain X Rays

• descriptions of primary & secondary # lines
• primary # line
• crosses the posterior facet of the subtalar joint & separates:
• smaller medial sustentacular fragment - rarely comminuted & remains attached to the talus by the deltoid ligament
• a large infero-lateral fragment
• this creates a 2 part fracture
• secondary # line
• starts at the crucial angle & divides the infero - lateral fragment into
• a. lateral joint fragment
• b. a body fragment
• this creates a 3 part #

Essex - Lopresti classification

• divides the 3 part # into 2 groups
• according to the position of the secondary # line on the lateral X ray
• a. tongue type
• # line runs posteriorly along the body
• exits laterally below the TA
• b. joint depression #
• line runs down the lateral side immediately behind the posterior facet of the subtalar joint
• more common
• flattening Bohler’s angle occurs in both groups

CT scans

• reveals more details of the #
• classified into four main types
• The inverted Y type, the commonest, represents a primary fracture into the joint and a secondary fracture of the lateral fragment
• The large fragment type results from the primary fracture passing far laterally, leaving only a small part of the posterior facet on the lateral fragment
• The longitudinal split type comprises a primary fracture splitting the facet without secondary fracture or depression
• The fracture may be too comminuted for classification

Eastwood

• depression of the lateral joint fragment is rare & simple elevation of this fragment can’t fully reduce #
• reduction of the medial wall is NB
• broadening of the heel is d/to displacement of the # fragments at the medial wall
• reduction will therefore narrow the heel & decrease fibula impingement

Pre-op

• leg elevation, intermittent compression, backslab & ankle & foot movement

Technique

• an extended lateral approach
• to avoid sural nerve injury & problems of soft tissue healing
• reduce articular surfaces
• correct varus
• restore calcaneal width, length & height
• care of soft tissues
• may need OT & bone graft

Post op.

• drain
• B/K cast (bi-valve), elevation
• NWB 8-12/52

Indications for surgery

• significant derangement of the sub - talar joint
• broadening of the heel with displacement & compromise of the peroneal tendons
• rotation of the body fragment which likely to upset hind foot mechanics
• a fixable #

Contra - Indications

• excessive comminution of the sustentacular fragment - main one
• juvenile DM & ipsilateral sciatic or tibial nerve disruption - relative CI
• age, fitness, neuro-vascular status

Complications

• post traumatic OA - major complication
• wound necrosis & dehiscence
• infection
• loss of reduction
• malunion
• neurovascular injury
• nerve entrapment - branches of the post tibial & sural nerve
• peroneal tendinitis
• plantar bone spur - due to loss of heel fat pad

Arthrodesis

• Pennal & Yadav
• if anatomic reduction of the posterior subtalar joint is not possible by open reduction -> then subtalar fusion is indicated
• Thompson
• triple arthrodesis should be done because there is often unrecognised damage to the T-N joint & C-C joint
• Campbell
• if after 2 years the patient is incapacitated & having significant pain with activity then triple arthrodesis is the best salvage procedure