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The Blackburn Foot and Ankle Hyperbook  
Evidence based education in foot and ankle surgery
  Calcaneal fractures

Epidemiology

Calcaneal fractures account for about 2% of all fractures and 60% of major tarsal injuries

Occur most commonly in middle adult life although have been reported at both extremes of age

Most are closed injuries; published series of open fractures (Furey et al 2003, Heier et al 2003, Lawrence et al 2003) come from large trauma units in which open fractures, often with polytrauma, made up 10-15% of all calcaneal fractures, but in most units the proportion will be lower.

Association with # lumbar spine (10-30%), pelvis, hip, tibia and ankle

Classification

Minor avulsion fractures can occur around the calcaneocuboid joint and the insertions of the Achilles tendon and plantar fascia

Fractures of the body are divided into those which are extra-articular () and those which are intra-articular, mainly into the subtalar joint.

Early classifications were based on plain radiography. The best known is that of Essex-Lopresti, who recognised peripheral and extra-articular injuries, and divided intra-articular injuries into:

  • tongue-type, in which the primary fracture line exited the bone posteriorly
  • joint-depression type, in which the primary fracture line exited the bone close to the subtalar joint

This classification was related to his percutaneous reduction technique (see below).

Modern classifications are based on CT imaging of the posterior subtalar articular facet. Crosby and Fitzgibbons (1993) divided 30 intra-articular fractures into undisplaced, displaced but non-comminuted, and comminuted, and showed that severity corelated with outcome and response to surgery.

The main CT classification is that of Sanders (). The main axis of classification is into

  • type-1 fractures, in which the articular fragments are displaced less than 2mm relative to one another
  • type-2 fractures, in which there are two articular fragments which are displaced at least 2mm relative to one another
  • type-3 fractures, in which there are three articular fragments which are displaced at least 2mm relative to one another
  • type-4 fractures, in which there are four or more articular fragments which are displaced at least 2mm relative to one another

The type-2 and 3 fractures are subdivided on the position of the articular fracture lines, producing types 2A, 2B and 2C, and types 3AB, 3AC and 3BC.

 

The Sanders classification of calcaneal fractures
The basis of the Sanders classification.The groups are denoted by the number of main fragments and the approximate main fracture lines as marked.
A two-part fracture with the main fracture line through the mid-part of the joint - type 2B
A three-part fracture with the main fracture lines lateral and central - type 3AB
A four-part fracture with fracture lines lateral, medial and central - type 4ABC

The main typings have been shown to influence prognosis and surgical complexity (Sanders ), and overall benefit from surgery (Buckley et al 2002). Furey (2003) studied interobserver variability using the Sanders classification and found moderate agreement with a weighted kappa value of 0.48 for the main classes and 0.56 including the subclasses. De Souza et al (2004) found 37/150 calcaneal fractures that could not be classified according to Sanders and described additional types and appropriate surgical strategies.

Pathomechanics of body fractures

Stress # occur in the osteoporotic and occasionally in athletes. Fracture of the os calcis after excision of a heel spur has been described. Fractures in toddlers with no history of injury have been reported, and do well without treatment.

Major body fractures are usually caused by a fall from a height (about 75% of most series) with RTA making up most of the rest.
The lateral process of the talus drives into angle of Gissane and splits the os calcis to produce primary fracture line (Fig 1). This runs from anterosuperomedial to posteroinferolateral. In 60-80% of body fractures this splits the posterior subtalar joint and may run into the calcaneocuboid joint also. Position of this fracture line depends on the hindfoot position at impact: the more valgus the hindfoot, the more lateral the fracture line.

Continuing descent of the talus and impaction against the medial fragment may split off one or more further joint fragments, and pushes the joint surface down.

On release of force, the talus recoils upwards, drawing the medial calcaneal fragment with it because of ligamentous attachment .

The peroneal tendons may become entrapped in the fracture site and may suffer partial rupture.

Clinical features

The foot is extremely swollen and painful. Myerson reports that 10% of patients with os calcis fractures develop compartment syndrome, although this has not been reproduced by other authors. Compartment syndrome occurs primarily in the quadratus plantae muscle (Andermahr et al 2001). Fracture blisters may develop. Nerve and vascular injuries are rare.

It is important not to miss associated injuries. The spine and entire lower limb must be carefully evaluated.

Investigation

Other significant injuries should be assessed as appropriate, including full ATLS primary and secondary surveys in seriously or multiply injured patients or where there has been a high energy injury.

Plain radiographs

The traditional plain radiographs are a lateral hindfoot view and an axial view of the calcaneum. Utukuri et al (2000) showed that the axial view contributes little to the diagnosis of fracture, and CT will be required if surgery is planned. Therefore, as it painful for the patient to obtain an axial view and it represents a radiation dosage, we do not routinely use this view in the emergency department. It is useful intra-operatively.

Fracture of the tuberosity Extra-articular body fracture Posterior avulsion fracture pulled off by the Achilles tendon

The lateral view not only allows the diagnosis of a body or peripheral fracture to be made with confidence in most cases, but with careful analysis will give useful information about damage and displacement of the subtalar joint. Indeed, Ebraheim (1996) has shown that the plain lateral view will give additional information on subtalar fragment displacement compared with CT in 25% of patients.

On the lateral view, the principal landmarks are:

  • the subtalar articular facet – multiple shadows indicate fragments and their displacement
  • the angle of Bohler – normal value 25-40 deg, may be reduced to a negative value in a highly-impacted fracture and this has prognostic and treatment-planning significance
  • the crucial angle of Gissane between the subtalar facet and the anterior surface – this angle needs to be reconstructed if surgery is performed
Bohler's angle
Gissane's crucial angle

Tomography

May be used if CT is unavailable but may fail to show joint incongruity adequately.

Broden’s views

AP views with leg internally rotated 30°. Films are taken with tube angled 10°, 20°, 30°, 40° toward head.Broden views show the joint surface well, but probably underestimate displacement compared with CT. They require expertise on the part of the radiographer. Although CT is preferable, they may be useful if this is not available, and are useful intra-operatively to assess reduction of the subtalar facet, and post-operatively to assess maintenance of reduction.

CT

CT should now be considered the gold standard for assessment of intra-articular os calcis fractures. It gives excellent images of subtalar joint surfaces, degree of displacement (Janzen et al 1992) and soft tissue injuries (Bradley and Davies 1992). It may not be so good for imaging the calcaneocuboid joint. Imaging of the subtalar joint is superior to plain films (Janzen et al 1992); no study that I can find has compared Broden views with CT. However, the plain lateral view will cantribute additional information in 25% of patients (Ebraheim 1996).

Both feet should be scanned, with image acquisition in both coronal and axial planes. The CT gantry is inclined to be at right angles to the subtalar joint surface. 3-D reconstructions may be performed, although their value is debatable.

Coronal CT of a type 2B fracture

MR

MR has been described in the assessment of calcaneal fractures. It gives excellent imaging of soft tissue injuries, especially to the peroneal tendons. However, CT usually gives superior imaging of bone and no study has shown that MR adds important information in the typical patient.

Management

Non-operative

Elevation and mobilisation only

Non-surgical treatment was promoted by Bohler, based on the principle of mobilisation of an injured part and the belief that prior reconstruction does not improve the result. The foot is elevated with ice packs. Passive and active mobilisation begin as soon as patient can tolerate them. The patient is mobilised NWB when swelling has sufficiently resolved. Weight bearing usually begins at 6-12 weeks.

This gives excellent results for most avulsion fractures (which don’t usually need restrictions on weightbearing), and satisfactory results in 55% of intra-articular fractures (Lance et al 1963). Some authors have used cast immobilisation, either initially or after a period of elevation and mobilisation, producing 56% satisfactory results(Rowe et al 1963)

Crosby and Fitzgibbons (1993) reviewed 30 intra-articular fractures treated by mobilisation, traction or closed reduction. All patients had CT before treatment and at follow-up.

  • 13 had undisplaced articular fragments, and all obtained good or excellent results
  • 10 had displacement of intra-articular fragments, but without comminution; two got good results, the rest were fair or poor
  • 7 had comminuted fractures; all had poor results, and all but one had had or awaited a subtalar arthrodesis.

Closed manipulation

Disimpaction can be performed with a large hammer if necessary (!) followed by manipulative reduction of the deformity. A Böhler clamp may be used to correct heel broadening and the foot is immobilised in cast for up to 10 weeks.

Rowe et al (1963) obtained 47% satisfactory results in intra-articular fractures with these methods. Hermann (1937) obtained 73% satisfactory results and Aitken (1963) 75%, although it is impossible to define their patient populations. These techniques are not normally used in current practice.

Surgery

Percutaneous reduction

Gissane described percutaneous elevation of depressed intra-articular fractures and this formed the basis of Essex-Lopresti’s classic 1951 paper. He elevated his tongue-type fractures with a percutaneous Gissane spike. Joint-depression fractures were reduced by a limited open approach before being fixed with a spike. Unfortunately he did not separate the fracture types in his results, which are shown in Fig 4.

There has been increased interest in percutaneous or limited open reduction techniques recently, often with arthroscopic assistance (Tornetta 2000, Gavlik et al 2002) or a ring fixator (Paley and Fischgrund, Talarico 2004). All have reported positive results, but the technique is demanding. Perhaps future trials of treatment should include percutaneous techniques as one comparator arm.

The soft tissue problems have led to other closed or limited open reduction techniques being tried. Baumgaertel and Goetzen (1993) reduced fractures initally with medial percutaneous pins followed by lateral internal fixation when swelling had resolved. Results are difficult to disentangle, but appear to be no worse than those with standard internal fixation, with fewer serious complications. carried out limited open reduction in conjunction with fixation and ligamentotaxis with an Ilizarov frame in 7 patients, obtaining 5 excellent and 2 good results.

Open reduction and internal fixation

Originally described by Lenormant and Wilmoth in 1932 and popularised by Palmer(1948). ORIF was intermittently popular throughout the 1950s and 60s but fell out of favour. Improvements in imaging, internal fixation technique, surgical approach and soft tissue management have contributed to a revival of popularity.

Does surgery improve the outcome?

There are four randomised controlled trials in intra-articular calcaneal fractures. Parmar et al (1988) used a minimal fixation technique with two lag screws to posterior the subtalar joint only, and found no difference in outcome between surgical and non-surgical groups. O’Farrell (1993) and Thordarson ( ) used open reduction and lateral plating in small trials of 24 and 26 patients. Both found small but significant improvements in the surgical groups: O’Farrell in heel size, return to work and walking distance, Thordarson in AOFAS hindfoot scores.

Buckley et al (2002) reported one of the largest trials undertaken in foot and ankle trauma. 424 patients were randomised to ORIF through an extended lateral incision using lag screws and lateral plating, or to functional non-surgical treatment. There were no significant difference between the groups in SF36 or visual analogue satisfaction scores. However, some groups did better than average:

  • women
  • age 20-29
  • Bohler angle >0deg
  • Sanders 2 fractures
  • patients in light work
  • patients not involved in Workers Compensation claims

Non-operatively treated patients were five times as likely to undergo subtalar fusion but the final results of this were not presented. A subsequent paper suggests that initial treatment did not affect the final outcome of subtalar fusion – in other words, failures of non-surgical treatment can be effectively salvaged.

It therefore appears that surgery is of limited, if any, value in the management of calcaneal fractures. Even the groups listed above were identified by post-hoc subgroup analysis, always a risky technique, and their suitability for surgery should be viewed as, at best, provisional pending further trials. The Buckley trial had some methodological flaws but was on the whole of good quality. Further trials would be worthwhile but should start from the Buckley trial. Given the increased interest in minimal-access techniques, these need to be included in future trials.

All the trials used a lateral approach with varied fixation techniques, but did not examine the effect of technique on outcome. Some information about technical aspects is available from case series.

ORIF of a calcaneal fracture through the lateral approach using lag screws to compress subtalar joint fragments and a lateral buttress plate to support the comminuted lateral wall

Medial or lateral approach?

Palmer used a lateral approach along the line of the peroneal tendon sheath. The sheath is opened and the tendons displaced anterior to the malleolus. The sural nerve may be retracted in either flap. This may cause problems with access, peroneal tendon adhesions or sural nerve injuries. Palmer reported 90% good results, but subsequent results have been variable (Rowe, Hazlett 1969, Letournel 1993).

Problems with wound healing, access and peroneal tendon adhesions have led modern surgeons to turn to an extended lateral incision (Eastwood et al) which runs down the lateral border of the tendo Achilles to the point of the heel, then directly forward to the calcaneocuboid joint or further. The flap is elevated subperiosteally and the peroneal tendon sheaths are not opened. The sural nerve is protected in the anterior flap. The lateral approaches have been preferred by most surgeons because it is felt that the key to stabilisation of the fracture is control of the lateral wall burst fracture.

McReynolds and Burdeaux emphasise reduction of the sustentacular fragment to the body, and believe that all necessary reduction can be done through the medial approach posterior to the neurovascular bundle, only reducing the lateral wall in a few comminuted fractures, those in which reduction of the joint could not be accomplished from the medial side, and calcaneo-cuboid joint fractures. Using this technique, McReynolds reported 78% good or excellent results in 108 fractures. Zwipp et al obtained only 50% good results with this approach, improving to 78% with a bilateral approach.

Most authors accept that a bilateral approach is sometimes necessary. Stephenson (1987) adopted this technique routinely and reported that 86% of fractures were congruently reduced and 77% got good results.

To graft or not to graft?

Palmer used iliac bone graft for stabilisation. Subsequent authors have used graft to supplement varying amounts of internal fixation. However, many authors do not graft, as the cancellous bone of the os calcis regenerates within 8 weeks (Stephenson 1987). Longino et al (2001) carried out a matched cohort study and found no difference in quality or maintenance of reduction in grafted or non-grafted patients.

Primary subtalar arthrodesis

Gallie (1943) suggested that the subtalar joint could not be reconstructed accurately enough to prevent arthritis developing and proposed primary posterior subtalar arthrodesis. Early series produced contradictory results. Sanders (1993) considers that severely comminuted fractures are probably best treated by primary arthrodesis after restoration of calcaneal height. Huefner et al (2001) reported six fractures treated in this way, five of whom got a good functional result.

Other operations

Excision of the os calcis

Leriche (1913) and Pridie (1946) advocated this operation. No recent study has described the results and I have been unable to get the original papers.

Soft tissue procedures

May be necessary either as primary intervention in open fractures or as part of a salvage procedure

Levin and Nunley (1993) review techniques available for different types of soft tissue problem.

Complications and treatment

Early

  • Massive tissue swelling and skin problems, requiring prolonged elevation, ice and Flotron therapy
  • Compartment syndrome May occur in up to 10% of patients. Myerson (1991) has described the technique of decompression.
  • Complications of surgery, particularly wound failure and deep infection. Major flap failure in the extende lateral approach often needs plastic surgical involvement to obtain healing. The best management is prevention by good patient selection.

Late

  • Malunion leading to:
    • Loss of heel height and increased heel width – can usually be accommodated in a shoe
    • Malleolar impingement
    • Peroneal tendon entrapment – may require a decompression or calcaneal osteotomy. Romash (1993) described a reconstructive osteotomy with bone grafting in seven patients. All were relieved of lateral impingement, six were pain-free and four had returned to work.
  • Entrapment neuropathies – usually medial calcaneal nerves or the nerve to quadratus plantae. May settle with local treatment or injections but occasionally require open neurolysis
  • Degenerative arthritis of subtalar or calcaneocuboid joint - subtalar pain with mild degenerative changes may respond to arthroscopic debridement (Elgafy and Ebraheim 1999). For patients with degenerative arthritis in the subtalar or calcaneocuboid joint, the best option is an arthrodesis. This may be carried out in situ or a tricortical bone block may be used to restore calcaneal height and treat secondary ankle impingment (Carr et al 1988, Trnka et al 2001, Rammelt et al 2004) . No randomised prospective studies have been done to compare these two techniques.
  • Heel pain – soft heel pads in the shoe may help and nerve injury or entrapment should be considered, but often soft tissue damage to the heel pad is difficult to treat and may be the main long-term disabling symptom
  • Gait abnormalitiy due to stiff subtalar joint
  • Deep infection may require further debridement and possible plastic involvement to obtain closure
  • Toe clawing due to unrecognised compartment syndrome
  • Complications of surgery

Recommended management

  • The patient should be carefully assessed for associated injuries
  • Resuscitation as necessary, treatment of other injuries and pain relief
  • Splintage in a backslab for pain relief and to prevent equinus
  • Open fractures should undergo thorough debridement and stabilisation as indicated; highly comminuted fractures may be best left unreduced
  • If the patient is female, under 30 years of age, in light work, and plain films show a Bohler angle >0deg, surgery should be considered. Where indications are equivocal a decision can be reached after discussion with the patient
  • Contra-indications to surgery include bilateral fractures, peripheral vascular disease, poorly controlled medical illness(especially diabetes), smoking and substance abuse
  • If surgery is not considered on clinical grounds, the foot should be elevated with ice and Flotron to reduce swelling. Ankle and subtalar exercises should be begun as soon as the patient can tolerate them
  • If surgery is considered on clinical grounds a CT should be obtained with coronal and axial images. CT should not be requested unless the patient is clinically suitable to consider surgery and wishes to consider this after counselling and reading the patient information sheet
  • If CT confirms a Sanders 2 fracture surgery may be offered after discussion with the patient and the use of the patient information sheet. The patient must be aware that the evidence in favour of surgery even in favourable cases is equivocal
  • Avulsions of the Achilles insertion are usually offered surgery.
  • Most extra-articular fractures are treated non-operatively
  • Sanders 3 and 4 fractures are not offered surgery and are treated with early mobilisation as above
  • Surgery is performed through an extended lateral incision, aiming to elevate and reduce the articular fragments, reduce the medial and lateral walls and stabilise with lag screws to the joint and a lateral plate. Patients are asked for consent for iliac crest bone grafting but this is not normally required
  • Post-operatively the normal treatment is elevation in a backslab with early nonweightbearing ankle and subtalar mobilisation
  • Both surgically and non-surgically treated patients normally do 6 weeks nonweightbearing and 6 weeks partial weightbearing
  • Further rehabilitation is as indicated under the control of the physiotherapist

References

Andermahr J et al. Compartment syndrome of the foot. Clin Anat 2001; 14:184-9

Berry GK et al. Open fractures of the calcaneus: a review of treatment and outcome. J Orthop Trauma 2004; 18:202-6

Buckley R et al. Operative compared withnonoperative treatment of displaced intra-articular calcaneal fractures: prospective, randomised, controlled multicenter trial. JBJS 2002; 84A:1733-44

De Souza LJ et al. Grouping of intraarticular calcaneal fractures relative to treatment options. CORR 2004; 420:261-7

Ebraheim NA et al. A p itfall of computed tomographic imaging in evaluation of calcaneal fractures. FAI 1996; 17:503-5

Elgafy H, Ebraheim NA. Subtalar arthroscopy for persistent subfibular pain after calcaneal fractures. FAI 1999; 20:422-7

Furey A et al. Os calcis fractures: analysis of interobserver variability in using Sanders’ classification. JFAS 2003; 42:21-3

Gavlik JM et al. Percutaneous, arthroscopically assisted osteosynthesis of calcaneal fractures. Arch Orthop Trauma Surg 2002; 122:424-8

Heier KA et al. Open fractures of the calcaneus: soft-tissue injury determines outcome. JBJS 2003;85A:2276-82

Lawrence SJ et al. Evaluation and treatment of open calcaneal fractures. Orthopedics 2003; 26:621-6

Longino D et al. Bone graft in the operative treatment of displaced intraarticular calcaneal fractures: is it helpful? J Orthop Trauma 2001; 15:280-6

Rammelt S et al. Foot function after subtalar distraction bone-block arthrodesis. JBJS 2004; 86B:659-68

Talarico LM et al. Management of displaced intraarticular calcaneal fractures by using external ring fixation, minimally invasive open reduction, and early weightbearing. JFAS 2004; 43:43-50

Tornetta P 3 rd. Percutaneous treatment of calcaneal fractures. CORR 2000; 375:91-6

Trnka H-J et al. Subtalar distraction bone block arthrodesis. JBJS 2001; 83B:849-54

Utukuri MM et al. The value of the axial view in assessing calcaneal fractures. Injury 2000; 31:325-6