James K DeOrio, MD Professor of Orthopedics, Director, Duke Foot and Ankle Fellowship, Duke University Medical Center, Duke University School of Medicine; Associate Professor, Mayo Clinic College of Medicine; Clinical Assistant Professor, F Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine if (document.MAX_used != ',') document.write ("&exclude=" + document.MAX_used); - typically results from fall from height (see mechanism) The poor correlation of these comprehensive classification systems with functional outcomes hindered their widespread acceptance. It can show the extent and extra- or intra-articular components of the fracture and hematoma along the sole of the foot (Mondor sign). Check for errors and try again. 13:75-89. Essex-Lopresti describedthe following twocalcaneus fracture subtypes Calcaneus malunion and nonunion. Bridgman SA, Dunn KM, McBride DJ, Richards PJ. -cannulated screw: inserted from latearal to medial into the sustentaculum tali; Foot (Edinb). 1. 1931. Unable to process the form. [QxMD MEDLINE Link]. 2020 Jun. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Type 2A Posterior beak fracture (no achilles involvement) - large threaded Steinman pin is placed through the posterior superior portion of the calcaneal tuberosity; Clipboard, Search History, and several other advanced features are temporarily unavailable. Because of distraction of fracture fragments, injury was treated with open reduction and internal fixation. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Zhong L, Xu Y, Wang Y, Liu Y, Huang Q. Rowe CR, Sakellarides H, Freeman P. Fractures of os calcis - a long-term follow-up study one hundred forty-six patients. Fractures of the calcaneum: the anterolateral fragment. - talus become dorsiflexed; - fracture classification: - this stabilizes the valgus reduction; Concomitant calcaneal fracture (s) with spine trauma indicate a greater chance of incomplete injury or intact neurology possibly due to dispersion of force vectors. Intra-articular fractures are often classified using the Sanders classificationsystem, which is one of the only systems that correlates well with patient outcome. Conferences [QxMD MEDLINE Link]. CALCANEAL FRACTURES Signs & Symptoms: Acute pain, edema about heel, pain w/ compression/palpation, pain w/ STJ motion, fx blisters on skin, plantar medial&lateral ecchymosis (mondur's sign) Bohler's Angle: Measures sagittal plane relationship of talus and calcaneus - compare to contralateral side. Type II or beak fractures are uncommon. The mechanism of injury in calcaneus fractures typically involves a high-energy axial load applied to the heel, which drives the talus downward onto the calcaneus. Schuberth et al performed a retrospective study of 24 cases of minimally invasive ORIF of intra-articular calcaneal fractures. eCollection 2020 Jul. Fractures of the Calcaneus: A Review with Emphasis on CT [QxMD MEDLINE Link]. Barei DP, Bellabarba C, Sangeorzan BJ, Benirschke SK. 2% of all fractures and 60% of all rearfoot trauma. 31:85. 1963. Treatment: Biomechanics Closed reduction and percutaneous Kirschner wire fixation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2-10 years. Skeletal Trauma: Basic Science, Management, and Reconstruction. 4. Fractures of the anterior process represent 10-15% of extra-articular injuries; these are the only type of calcaneus fractures that are more common in women than in men. 2020 Jul. [QxMD MEDLINE Link]. Calcaneus Fractures - Trauma - Orthobullets DeWall M, Henderson CE, McKinley TO, Phelps T, Dolan L, Marsh JL. J Foot Ankle Surg. Juliano P, Myerson MS. Fractures of the hindfoot. 2012 Sep;33(9):727-33. doi: 10.3113/FAI.2012.0727. Mansoor AhmedBohlers angle 1) most superior aspect of the posterior facet (posterior articular surface) to the highest point of the anterior process 2) superior portion of the calcaneal tuberosity to most superior aspect of posterior facetGissanes angle 1) along the lateral border of the posterior facet 2) along the anterior process of the calcaneus. Assessment and treatment of calcaneal fractures have made substantial progress over the last two decades. BMC Surg. Sanders CT classification of calcaneal fracture - Radiopaedia - early mobilization with protection from wt bearing is maintained until frx union occurs; Exudate-filled blisters Significant edema/hematoma Patient unable to bear weight Recent flashcard sets A1 S1 TP 1&2 anatomie - vertbres (droul 128-34. Calcaneus fractures. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Intra-articular fractures of the calcaneum. Eckstein et al reported long-term (20 y) follow-up of 22 patients who underwent surgical treatment of displaced calcaneal fractures. [4] : Both of these describe the primary fracture line. Comparing different types of calcaneal fractures, associated treatment options, and outcome data is currently hampered by the lack of consensus regarding fracture classification. Li S. Wound and Sural Nerve Complications of the Sinus Tarsi Approach for Calcaneus Fractures. [QxMD MEDLINE Link]. Clin Orthop Relat Res. 2021 Jun 1;479(6):1265-1272. doi: 10.1097/CORR.0000000000001634. Burdeaux BD Jr. Fractures of the calcaneus: open reduction and internal fixation from the medial side a 21-year prospective study. The results of this study did not lend support to the view that ORIFyields better outcomes than conservative therapy for these fractures. - all frx are initially treated by strict bed rest, elevation, until acute swelling has subsided; b) With displacement Long-term functional outcomes after operative treatment for intra-articular fractures of the calcaneus. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 'https://flow.aquaplatform.com/ajs.php':'http://flow.aquaplatform.com/ajs.php'); Selim A, Ponugoti N, Chandrashekar S. Systematic Review of Operative vs Nonoperative Treatment of Displaced Intraarticular Calcaneal Fractures. [QxMD MEDLINE Link]. Type 1B Sustentaculum tali fracture Abstract. Curr Rev Musculoskelet Med. Calcaneus fracture classification systems have evolved since Malgaine [ 10] first described them in 1843, before the advent of roentgenography. Acta Radiol. - threaded Steinman pin is inserted through the posterior calcaneus into the cuboid; Lee A. [QxMD MEDLINE Link]. J Orthop Trauma. Calcaneal Fracture : Wheeless' Textbook of Orthopaedics - Operative Versus Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures:A Prospective, Randomized, Controlled Multicenter Trial. Design The design was a prognostic study of a retrospective cohort with concurrent follow-up. [17, 18, 19] Each modality has at times enjoyed more attention and enthusiasm in the literature. document.write ("&loc=" + escape(window.location)); Calcaneus Fracture Imaging - Medscape Intra-articular fractures of the calcaneus: Present state of the art. Orthop. 2016 Mar. Thethree subtalar facets (anterior, middle, and posterior) must function as a unit, and any fracture that interrupts their alignment is, by definition, an intra-articular fracture. Case 8: calcaneal anterior process fracture, Case 9: extra-articular calcaneal fracture, Case 12: anterior calcaneal process fracture, see full revision history and disclosures, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, 1. At the time the article was created Matt Skalski had no recorded disclosures. Calcaneus Fracture - PodiaPaedia Mahmoud K, Mekhaimar M, Alhammoud A. For patient education resources, see theFirst Aid and Injuries Center, as well asBroken Foot,Understanding X-rays, andCast Care. [QxMD MEDLINE Link]. Skeletal Trauma. Fractures of the calcaneus. Eur J Transl Myol. The treatment of intra-articular calcaneus fractures with severe soft tissue damage with a hinged external fixator or internal stabilization: long-term results. 8600 Rockville Pike Core Radiology. - smoking patient who is unwilling to immediately quit smoking; At follow-up, only 12 of the 22 patients (55%) of the patients had very good or good clinical results; four had average results, and six had poor results. (3) 1. Type 3 Extra-articular fracture of body Wagstrom EA, Downes JM. Calcaneal fracture. Eversion, medial tuberosity is injured. 2) Centrolateral depression of joint Browner BD, Jupiter JB, Krettek C, Anderson PA, eds. - more common with severe comminuted fractures. A Prospective, Randomized, Controlled Multicenter Trial. ROWE (JAMA, 184:98-101, 1963)Type 11A - fracture of the plantar tuberosity due to inverted or everted foot1B - fracture of the sustentaculum tali due to twist on a supinated foot1C - fracture of the anterior tubercle due to plantarflexion on a supinated footType 22A - "beak fracture" without Achilles insertion involvement2B - avulsion fracture of Pharmacology 9:854210. Wound Management, Extensor digitorum brevis avulsion fracture, Suggest an edit or suggest some resources, We have not yet got to this page to finish it yet. - vasculopath: Intra-Articular Fractures of the Calcaneus. Axial loading of the foot following a fall from a height is the most common mechanism for severe calcaneal fractures. Fracture blisters: clinical and pathological aspects. Intra-articular fractures may be treated in a closed fashion but are more commonly treated with a combination of open reduction, ostectomy, osteotomy, internal fixation, and/or arthrodesis of the subtalar and calcaneocuboid joints. Calcaneal fractures are relatively uncommon, comprising 1 to 2 percent of all fractures, but important because they can lead to long-term disability. At the time the article was created The Radswiki had no recorded disclosures. [QxMD MEDLINE Link]. var m3_r = Math.floor(Math.random()*99999999999); [QxMD MEDLINE Link]. Rowe - prepodiatryclinic101.com Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8: The calcaneus is also a common site of stress fractures, occurring in the posterosuperior aspect. {"url":"/signup-modal-props.json?lang=us"}, Radswiki T, Vadera S, Niknejad M, et al. A Prospective, Randomized, Controlled Multicenter Trial, Long-Term Functional Outcomes After Operative Treatment for Intra-Articular Fractures of the Calcaneus, Orthopaedic Specialists of North Carolina. [QxMD MEDLINE Link]. With the advent of radiographic evaluation, several authors developed classification systems, including Bohler (in 1931), Essex-Lopresti (in 1951-2), Rowe et al (in 1963), and others. It is from this point that multiple secondary fracture lines may develop. Badillo K, Pacheco J, Padua S, Gomez A, Colon E, Vidal J. Multidetector CT Evaluation of Calcaneal Fractures. 5) From behind forward with dislocated STJ. between the posterior and middle facets; Types IV and V (60%) involve the subtalar joint. A prospective study. Sports Medicine Operative treatment in 120 displaced intraarticular calcaneal fractures. Teaching & Learning [QxMD MEDLINE Link]. Park YH, Cho HW, Choi JW, Choi GW, Kim HJ. A complete blood count (CBC), blood. Fractures of the os calcis. 1985;145(1):131-7. Am J Orthop Surg. - Treatment Options: Rowe Classification: Types I-III do not involve the subtalar joint. Foot and Ankle Disorders. 60-75% of injuries are intra-articular fractures, no significant increase in infection rates, peak incidence in women in seventh decade of life, violent contaction of the triceps surae with forced dorsiflexion, strong concentric contaction of the triceps surae with knee in full extension, intrinsic tightness of the gastrocnemius and achilles tendon, peripheral neuropathy leading to decreased pain sensation and proprioception resulting in recurrent microtrauma, increased physical activity in the setting of relative energy deficiency, primary fracture line results from oblique shear and leads to the following, includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments, dictate whether there is joint depression or tongue-type fracture, strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus, more common in osteopenic/osteoporotic bone, inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament, superolateral fragment contains the articular facets, superior articular surface contains three facets that articulate with the talus, the flexor hallucis longus tendon is medial to the posterior facet and inferior to the medial facet and can be injured with errant drills/screws that are too long, between the middle and posterior facets lies the, projects medially and supports the neck of talus, connects the dorsal aspect of the anterior process to the cuboid and navicular, calcaneal tuberosity (Achilles tendon avulsion), the primary fracture line runs obliquely through the posterior facet forming two fragments, the secondary fracture line runs in one of two planes, the axial plane beneath the facet exiting posteriorly in, when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly, behind the posterior facet in joint depression fractures, based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet, One fracture line in the posterior facet (, Two fracture lines in the posterior facet (, based on fracture morphology of the calcaneus tuberosity, tenting, ecchymosis, or lack of skin blanching with tuberosity fractures, neccessitates urgent sugical reduction and fixation to avoid posterior heel skin necrosis, must be debrided and epithelialized prior to surgical intervention, lack of heel cord continuity in avulsion fractures, lack of posterior heel skin blanching with tenting fractures, assess for compartment syndrome secondary to swelling, presence of Langer's lines and skin wrinkles suggests skin is appropriate for surgical intervention, decreased ankle plantarflexion strength with avulsion fractures, assess for neuologic compromise due to swelling, severe peripheral vascular disease may preclude surgical treatment due to poor wound healing potential, useful for evaluation of intraoperative reduction of posterior facet, with ankle in neutral dorsiflexion and ~45 degrees internal rotation, take x-rays at 40, 30, 20, and 10 degrees cephalad from neutral, visualizes tuberosity fragment widening, shortening, and varus positioning, place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees, demonstrates lateral wall extrusion causing fibular impingement, indicates partial separation of facet from sustentaculum, angle between line from highest point of anterior process to highest point of posterior facet + line tangential to superior edge of tuberosity, represents collapse of the posterior facet, angle between line along lateral margin of posterior facet + line anterior to beak of calcaneus, demonstrates posterior and middle facet displacement, demonstrates calcaneocuboid joint involvement, used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis, cast immobilization with nonweightbearing for 10 to 12 weeks, anterior process fracture involving <25% of calcaneocuboid joint, comorbidities that preclude good surgical outcome (smoker, diabetes, PVD), avoids the high wound complications seen with these fractures, minimally displaced tuberosity fractures (<1 cm of displacement) without threatened soft-tissue envelope in elderly patients with reduced function or physical capacity, begin early range of motion exercises once swelling allows, early reduction prevents skin sloughing and need for subsequent flap coverage, ideal in patients with sever peripheral vascular disease or severe soft-tissue compromise, lag screws from posterior superior tuberosity directed inferior and distal, require urgent reduction and fixation to avoid skin necrosis (disastrous consequence), open reduction allows for sufficient debridement of contaminated tissue, inability to participate in closed treatment, large extra-articular > 2 mm displacement, posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity, anterior process fracture with >25% involvement of calcaneocuboid joint, wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days, no benefit to early surgery due to significant soft tissue swelling, displaced tuberosity fractures with posterior skin compromise should be addressed urgently, number of intra-articular fragments and the, surgical treatment decreases the risk of post-traumatic arthritis, age > 50 (similar outcomes with surgical and nonsurgical treatment), initial Bhler's angle <0 (these injuries do poorly regardless of treatment), lower Bhler angles suggest greater energy absorbed, open fractures (significant soft tissue injury and engery absorbed), bilateral calcaneal fractures (significant gait problems following bilateral injuries), factors associated with most likely need for a secondary subtalar fusion, male worker's compensation patient who participates in heavy labor work with an initial Bhler angle less than 0 degrees, standard short-leg cast for calcaneal stress fractures, standard short-leg cast applied with mild equinus, windowed over posterior heel to allow for frequent skin checks, requires close follow-up to determine if pull of gastrocnemius-soleus dispaces fracture, weekly cast changes are necessary due to high incidence of skin complications, high incidence of vascular insufficiency and diabetes in this population, ideal for poor soft tissue coverage or patients with peripheral vascular disease, Steinmann pin placed into the fracture site anteromedially-to-posterolateral to leverage fragments into place, additional K-wires and Steinmann pins are placed from posterior-to-anterior and lateral-to-medial to secure remaining bone fragments, calcaneal transfixin pin can be used to distract fracture, percutaneus tamps and elevators can be used to raise the articular surface, pins are cut flush with the skin and removed 8-10 weeks post-op, can be combined with distracting external fixator, pins placed in calcaneal tuberosity, cuboid, and distal tibia, restor calcaneal height, width, and alignment, can be combined with percutaneous cannulated screws, extensile lateral L-shaped incision is most popular, vertical portion inbetween posterio fibula and achilles tendon, horizontal portion in line with 5th metatarsal base, a more inferior incision protects the sural nerve, provides access to the calcaneocuboid and subtalar joints, full-thickness skin, soft tissue, and periosteal flaps are developed, lateral calcaneal branch of peroneal artery, superior flap contains the calcaneofibular ligaments and peroneal tendon sheath, sural nerve and peroneal tendons are retracted superiorly, fracture opened and medial wall reduced going medial to lateral, reduction confirmed indirectly via fluoroscopy, tuberosity reduction is done under direct visualization, manual traction, Schanz pins, and minidistractors, height and length of tuberosity is recreated, definitive fixation with plates and screws, restore Bhler's angle and calcaneal height, minimally invasive incision that minimizes soft tissue dissesction, reduces wound complications associated with extensile lateral incision, allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall, same incision can be utilized for secondary subtalar arthrodesis or peroneal tendon debridement, patient placed in lateral decubitus position, incision made in line with the tip of the fibula and the base of the 4th metatarsal, extensor digitorum brevis retracted cephalad to expose sinus tarsi and posterior facet, Schanz pin inserted percutaneously in posteroinferior tuberosity going from lateral to medial, provides distraction and aids with reduction, fibrous debris and fat removed from sinus tarsi, small elevator or lamina spreader placed under posterior facet fragment to aid in reduction, K-wires inserted for provisional fixation aimed towards the sustentaculum, two screw are placed lateral-to-medial to engage sustentaculum and support facet, one large fully threaded screw from posterior-to-anterior to support axial length of calcaneus, low-profile plate is applied underneath a well developed soft tissue envelope with screws engaging anterolateral and tuberosity fragments, nonweight bearing for 6-8 weeks post-op with ankle range-of-motion exercises beginning 2 weeks post-op, manipulate the heel to increase the calcaneal varus deformity, manipulate the heel to correct the varus deformity with a valgus reduction, stabilize the reduction with percutaneous K-wires or open fixation as described above, arthroscopic-assisted reduction and internal fixation, improved visualization of articular surface and carilage lesions, increased swelling from fluid extravasation, can be combined with sinus tarsi approach, patient positioned in lateral decubitus position, fluoroscopy unit positioned posterior and oblique to patient, anterolateral and posterolateral portals are used to visualize posterior facet, loose bodies and cartilage fragments are removed with a shaver, Freer elevator is introduced into one of the portal sites and used to elevate the posterior facet, Schanz pin to control tuberosity fragment, cannulated screws from the posterior aspect of the calcaneal tuberosity to the anterior aspect of the calcaneus, lateral-to-medial screws placed in sustentaculum, buttress screw from the posterior aspect of the calcaneal tuberosity to the subchondral bone of the posterior facet, posterior approach for calcaneal tuberosity fractures, fracture fragment is mobilized and debrided, plantar flexion of foot aids with reduction, presence of gastrocnemius tightness may preclude reduction, Strayer procedure may be performed to aid in reduction, figure-of-8 tension-band wire passed around ends of K-wires or cannulated screws, Krackow sutures passing through bone tunnels, restricted weight bearing for 6 weeks followed by progression of weight bearing an additional 6 weeks, performed in highly comminuted Sanders IV intraarticular fractures, high rate of secondary fusion after ORIF with these injuries, avoids added treatment costs and decreases time off from work, can be performed through an extensile lateral or sinus tarsi approach, fracture reduction is perfromed in a similar fashion as ORIF, articular cartilage of the subtalar joint denuded to bleeding subchondral bone, cannulated compression screws are placed from the posterio calcaneal tuberosity to the talar dome, lateral fixation plate applied to hold reduction, increased risk in smokers, diabetics, and open injuries, may consider nonoperative treatment in these patients, tongue type fractures at high risk (>20%) for posterior skin necrosis, should be splinted in 30 degrees of planarflexion to relieve soft tissue tension, keep all hardware away from the corner of the incision, delayed wound healing is the most common complication, can be addressed with ankle bracing (gauntlet type), NSAIDs, injections, and physical therapy, may require bone block subtalar arthrodesis to address loss of calcaneal height, important when there are symptoms of anterior ankle impingement, Lateral impingement with peroneal irritation, at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment), loss of height, widening, and lateral impingement, distraction bone block subtalar arthrodesis, incongruous subtalar joint/post-traumatic DJD, results from posterior talar collapse into the posterior calcaneus, Lateral exostosis with no subtalar arthritis, Lateral exostosis with subtalar arthritis, Lateral exostosis, subtalar arthritis, and varus malunion, increased due to mechanism (fall from height), smoking, and early surgery, lateral soft tissue trauma increases the rate of complication, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries.
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