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Musculoskeletal System ORGAN SYSTEMS

Calcaneal fracture

Introduction

  • Calcaneal fractures account for 50-60% of all fractured tarsal bones
  • Tarsal fractures account for 2% of all fractures

Aetiology

Trauma:

Commonly occur during high energy events leading to axial loading of the bone but can occur with any injury to the foot and ankle.
Trauma mechanism. | Leite, C., Macedo, R. S., Saito, G. H., Sakaki, M. H., Kojima, K. E., & Fernandes, T. D. (2018). Epidemiological study on calcaneus fractures in a tertiary hospital. Revista brasileira de ortopedia, 53(4), 472–476. https://doi.org/10.1016/j.rboe.2018.05.014

Associated fractures:

Associated fractures. | Leite, C., Macedo, R. S., Saito, G. H., Sakaki, M. H., Kojima, K. E., & Fernandes, T. D. (2018). Epidemiological study on calcaneus fractures in a tertiary hospital. Revista brasileira de ortopedia, 53(4), 472–476. https://doi.org/10.1016/j.rboe.2018.05.014

Classification

Intraarticular fractures (75% cases):

Talus acts as a hammer/wedge compressing the calcaneus at the angle of Gissane causing the fracture.

Adult man in a working age represents the typical patient representing about 75% of all cases

Extraarticular fractures (25% cases)

Avulsion injuries of either calcaneal tuberosity from the Achilles tendon, the anterior process from the bifurcate ligament, or the sustentaculum tali. Fractures that do not involve the posterior facet of the subtalar and represent 25% of heel fractures

In children aged 8 to 14 years, the 60% of the fractures are extra-articular; while in children younger than 7 years, more than 90% of calcaneal fractures are extra-articular

  • Type A: Fracture involving the anterior process of the calcaneus
  • Type B: Fracture involving the midcalcaneus or body, including lateral process, sustentaculum tali or trochlear process.
  • Type C: Fracture involving the posterior calcaneus, including medial tubercle and posterior tuberosity

Clinical features

  • Diffuse pain, edema, and ecchymosis at the affected fracture site.
  • Unable to bear weight
  • Plantar ecchymosis extending through the plantar arch of the foot
  • Associated disability of the Achilles tendon

Diagnosis

Plain radiograph:

AP, lateral, and oblique plain films of the foot and ankle is needed. A Harris View may be obtained which demonstrates the calcaneus in an axial orientation.
  • ↓ Bohler’s Angle: Angle between two lines drawn on plain film: First line between highest point on tuberosity and highest point of posterior facet and second line the highest point on the anterior process and the highest point on the posterior facet.
    • The normal angle is between 20-40°
  • ↑ Critical Angle of Gissane: Angle between two lines drawn on plain film: First line along anterior downward slope of the calcaneus and second along superior upward slope
    • Normal angle is 130-145°
  • Bohler’s angle | Razik, A., Harris, M., & Trompeter, A. (2018). Calcaneal fractures: Where are we now?. Strategies in trauma and limb reconstruction, 13(1), 1–11. https://doi.org/10.1007/s11751-017-0297-3
  • Critical angle of Gissane | Razik, A., Harris, M., & Trompeter, A. (2018). Calcaneal fractures: Where are we now?. Strategies in trauma and limb reconstruction, 13(1), 1–11. https://doi.org/10.1007/s11751-017-0297-3

Essex-Lopresti classification:

Based on plain radiographs
  • Joint depression type: Single verticle fracture line through the angle of Gissane separating the anterior and posterior portions of the calcaneus.
  • Tongue type: Verticle fracture line as a depression type with another horizontal fracture line running posteriorly, creating a superior posterior fragment. The tuberosity fragment may then rotate superiorly.

Noncontrast computed tomography (NCCT):

Gold standard for traumatic calcaneal injuries used for preoperative planning, classification of fracture severity, and in instances where the index of suspicion for a calcaneal fracture is high despite negative initial plain radiographs (2 to 3-mm cuts are recommended).
  • Mondor’s sign: Hematoma identified on CT that extends along the sole and is considered pathognomic for calcaneal fracture.
CT images with MPR in sagittal (A) para-axial (B) and para-coronal planes (C), show multiple intra-articular fracture (white arrows) | Galluzzo, M., Greco, F., Pietragalla, M., De Renzis, A., Carbone, M., Zappia, M., Maggialetti, N., D’andrea, A., Caracchini, G., & Miele, V. (2018). Calcaneal fractures: radiological and CT evaluation and classification systems. Acta bio-medica : Atenei Parmensis, 89(1-S), 138–150. https://doi.org/10.23750/abm.v89i1-S.7017

Sanders classification:

Based on reconstituted CT findings, used for classifying intra-articular calcaneal fractures
  • Type I fractures: 1 nondisplaced or minimally displaced bony fragment 
  • Type II fractures: 2 bony fragments involving the posterior facet. Subdivided into types A, B, and C depending on the medial or lateral location of the fracture line.
  • Type III fractures: 3 bony fragments including an additional depressed middle fragment. Subdivided into types AB, AC, and BC, depending on the position and location of the fracture lines.
  • Type IV fractures: 4 comminuted bony fragments.
Sanders classification—type I–type IV; based on coronal CT imaging | Razik, A., Harris, M., & Trompeter, A. (2018). Calcaneal fractures: Where are we now?. Strategies in trauma and limb reconstruction, 13(1), 1–11. https://doi.org/10.1007/s11751-017-0297-3

Management

Treatment is based on the characteristics of the fracture and associated injuries, as well as on the local soft tissue conditions.

Conservative management:

Indicated for extra-articular injuries or in those with small intra-articular involvement, with little or no deviation

Surgical management:

Indicated in severe joint involvement, significant deviation, and compound lesions

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