1. OTA Resident Course April 2014
Calcaneus Fractures
OTA Resident Course
April 2014

2. Disclosures
Elsevier

3. Anatomy Posterior Facet Middle Facet Sustentaculum Anterior Process
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4. Epidemiology 2% of all fractures Mechanism Axial load MVA
80-90% occur in men years old
20% of individuals are incapacitated for 3-5 years

5. Epidemiology Rule of 10’s 25% associated with other limb injuries
10% with associated spine injuries
10% Open injuries
10% Bilateral
25% associated with other limb injuries
Articular surface involved 75% of time

6. Radiographic evaluation
Bohler’s angle (20-40 degrees)
Angle of Gissane ( degrees)

7. Radiographs Radiographs Harris view Sustentaculum Lateral wall
Hindfoot varus/valgus
10 degrees of valgus

8. Radiographs Broden View
Provides visualization of the posterior facet articular surface

9. Radiographs Deformities Flattening of pitch/height
Loss of Bohlers angle
Articular incongruity
Horizontal talus
Hindfoot widening, varus positioning

10. Computed Tomography
Provides detailed imaging of the articular involvement

11. Fracture Patterns Extra-articular Intra-articular
25-33% of calcaneus fractures
Twisting injury or direct impact (not compressive)
Involve anterior process, sustentaculum, body, or posterior tuberosity
Intra-articular
Involve Posterior Facet
Essex-Lopresti Classification
Sanders Classification

12. Anterior Process Fracture
Regularly involves calcaneocuboid joint
Often missed initially
Caused by inversion and plantar flexion
Fixation if large fragment (>1cm) or late removal

13. Sustentacular Fracture
Direct impact on an inverted foot
Medial swelling, ecchymosis
ORIF if >2mm displaced
Closed treatment if minimally or non-displaced

14. Extra-articular body fractures
Do not involve posterior facet
Can advance weight-bearing more rapidly than articular injuries
Progressive weight bearing in a cast/boot

15. Posterior Tuberosity Fracture
Avulsion injury
Frequently occurs in osteoporotic bone due to a forceful contraction of the gastrocsoleus complex
More common in older and diabetic population
Non-displaced = nonoperative
Displaced = ORIF/percutaneous
Beware of soft tissues!

16. Classification Essex-Lopresti Sanders Joint depression vs. tongue-type
Does not correlate with prognosis
Based upon plain radiographs
Sanders
Evaluates posterior facet step-off
More prognostic/determine treatment
Based upon CT

17. Classification
Sanders
CT scan semi- coronal image plane

18. Classification
Type IIB
Type IIIAC
Type IV

19. Classification
Intra-articular tongue
Fracture-dislocations

20. Operative Indications
Why fix these?
>2mm displacement results in abnormal loading
Shortening impacts lateral column support
Hindfoot malalignment prevents unlocking of the subtalar complex
Height loss can result in anterior ankle impingement

21. Operative Goals Restore anatomy Restore function Avoid malunion
Avoid complications

22. Calcaneal Malunion Sub-fibular impingement Varus Alignment
Horizontal talus/Anterior ankle impingement

23. Operative Treatment Percutaneous techniques
Open fractures (high grade)
Poor skin quality or comorbidities

24. Operative Treatment
ORIF
Sander’s Type II & III injuries

25. Operative Treatment ORIF with primary arthrodesis
Sander’s Type IV (and select III) injuries
Poor soft tissues or non-reconstructable articular injury
(Restore calcaneal pitch and height)

26. Operative Treatment Tongue Type
Posterior facet attached to posterior tuberosity
May be performed percutaneously

27. Operative Treatment Lateral positioning Radiolucent table Fluoroscopy
Broden
Harris view (Axial)
Contralateral

28. Operative Treatment Incision Exposure
Full thickness soft tissue flap centrally
Beware of sural nerve proximally/distally
Protect peroneal tendons
Exposure
Hands-free retraction
5.0 mm Shanz pin in tuberosity

29. Operative Treatment Sequential reduction
Anatomically fix the posterior facet
Restore height (Bohler’s) and angle of Gissane
Restore normal valgus/neutral alignment
Anterior Process

30. Operative Treatment Temporarily fix everything with K-wires
Stabilize posterior facet with lag screws
Lag screws for anterior process if needed
Plate application
Void management
Drain

31. Postoperative protocol
Immobilize and elevate
Fracture brace
Ankle/subtalar ROM
Progressive weight-bearing at 8-12 weeks
Wound will dictate advance of motion

32. Complications Subtalar arthrosis Subtalar stiffness
Increased with nonoperative treatment
6x more likely to undergo arthrodesis
Subtalar stiffness
Compartment syndrome (10%)
Wound healing (2-10%)
Smokers
Diabetics
Open fractures
7-12% infection
5% osteomyelitis
5% amputation
Delay in treatment
Recommend immobilize until wound heals

33. Outcomes Some subtalar stiffness can be expected
Good results can be achieved after selective operative fixation of displaced, intra-articular, fractures in younger patients, female patients, and with anatomical reduction
Poorer results expected with increasing comminution, articular incongruity, flattened Bohler’s angle, and Workman’s Compensation related injuries
Avoidance of complications is paramount for favorable outcomes

34. Thank You