Calcaneus (Os Calcis) Fractures

Mechanism

  • Calcaneus initially fractures into two main fragments
  • fracture line runs plantarmedial to dorsolateral
  • results in two main fragments
    • anteromedial(sustentacular fragment)
      • rarely comminuted
      • variable size
      • remains attached to the talus by the strong deltoid & interosseous talocalcanean ligaments
    • dorsolateral (tuberosity fragment)
      • Comminution of this fragment is common
      • displaces superiorly & laterally
      • resulting in incongruity of the posterior facet & widening & shortening of the heel

Classifications

Essex-Lopresti

  • according to the direction of the “secondary fracture line”
  • Tongue fracture
    • secondary fracture line
      • runs straight back to the posterior border of the tuberosity from the crucial angle (of Gissane)
    • This produces one large posterior, superior & lateral fragment
    • It can be displaced, “like a see-saw, down at the front & up at the back”
    • displaced key fragment can be maneuvered using the long lever
    • fragment may be flexed by the continuing pull of the Achilles tendon
  • Joint depression fracture
    • secondary fracture line
      • runs across the body just behind the joint, & deviates dorsally to exit the bone just posterior to the articular facet, creating a fragment separate to the tuberosity – the thalamic portion
        • which contains the major portion of the posterior articular facet of the calcaneus
    • This also acts in a see-saw fashion, down at the front & up at the back
    • More common than the tongue fracture
    • displaced fragment buried in the bone can only be reduced by an open approach

Sanders>Sanders CT based Classification

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  • based on coronal & axial CT scans
    • widest undersurface of the posterior facet of the talus is divided into 3 by two lines, A & B
    • A third line, C, corresponds to the medial edge of the posterior facet of the talus, & separates the posterior facet from the sustentaculum
    • These lines result in a total of four potential pieces
    • order A, B, C, D is from lateral to medial because the lateral fragments are easiest to reduce from a lateral approach
    • Type Description
    I~All non-displaced articular fractures, irrespective of the number of fracture lines
    II~two part fractures of the posterior facet, similar in appearance to a split fracture of the tibial plateau
    ~Three types, IIA, IIB & IIC exist, based on the location of the primary fracture line
    III~three part fractures that feature a centrally depressed fragment, similar to a die punch type distal radial fracture
    ~Types include IIIAB, IIIAC & IIIBC
    IV~highly comminuted
    ~often more than four articular fragments exist
    Sanders CT Based Classification of Calcaneal Fractures

    Investi>Investigations

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  • AP, lateral & axial calcaneal
  • Broden’s view
    • X-ray view to demonstrate the posterior facet of the subtalar joint
    • foot is in neutral flexion
    • leg is internally rotated 30°
    • beam is centred over the lateral malleolus
    • Four views are taken with the beam angled 40, 30, 20 & 10° respectively toward the head
    • 10 degree view shows the posterior part of the facet
    • 40 degree view the anterior part of the facet.

    • CT Scan

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  • patient is positioned in the supine position with the knees & hips flexed
  • feet are kept together with the planter surface resting on the table
  • Both feet are routinely scanned for comparison
  • Sagittal & coronal section are required, through the posterior subtalar joint

    • TreatmentTreatment

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  • If nonoperative treatment is selected, ankle & subtalar ROM exercises are crucial to maintain adequate subtalar motion.

    • Operative t>Operative treatment

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  • Options
    • ORIF
    • Percutaneous Fixation
    • Primary Arthrodesis
  • Principles
    • Essex-Lopresti
      • Tongue type
        • principle is to insert a Gissane spike (nowadays a Schanz pin) into the long axis of the displaced fragment
        • use this to lever the tongue in its correct alignment with the taloid component of the posterior joint
      • Joint depression
        • fracture is openly reduced by a lateral incision & after reduction is held with a Gissane spike
    • ORIF
    • Primary Arthrodesis
      • option for extremely comminuted (Sanders IV) fractures

    • Complicatio>Complications

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  • Compartment syndrome in 10%
  • Difficulty in shoe wearing due to heel widening
  • Peroneal impingement
  • Subtalar arthritis
  • Tarsal tunnel syndrome
  • Wound problems
    • higher in smokers, diabetics & patients with peripheral vascular disease
  • Nonunion
    • is almost unknown, due to the excellent blood supply to the bone