Keywords

Anatomy

  • Calcaneus acts as a lever to increase the power of the gastrocnemius soleus complex.

  • Insertion site of the Achilles tendon (posterior tuberosity).

  • Articular facets:

    • Anterior facet – carries the facet of the calcaneocuboid joint.

    • Posterior facet – largest, major weight-bearing surface.

    • Flexor hallucis longus tendon runs just inferior to this facet and can be injured with screws/drills that are too long.

    • Anterior portion is perpendicular to the calcaneus long axis.

  • Middle facet – anteromedial on sustentaculum tali

  • Superior facet – contains three facets that articulate with the talus

  • Sustentaculum tali

    • Projects medially and supports the talar neck, extension of the medial wall of the body

    • FHL passes beneath it

    • Contains the anteromedial facet, which remains constant in injury settings due to ligamentous attachments

  • Sinus tarsi

    • Between the middle and posterior facets

Presentation

  • Calcaneus is most commonly fractured tarsal bone

  • Severe pain, may have deformity, open fracture

Mechanism

  • Usually traumatic loading is primary mechanism

  • May also have shear component which contributes to secondary fracture lines

Physical Exam

  • Pain, diffuse tenderness to palpation of heel, accompanied by swelling

  • May have a varus deformity of the heel, appear shortened and wide as compared to contralateral limb

Demographics

  • More common in males

  • Must rule out associated injuries like vertebral fractures (10%) and contralateral calcaneus fracture (10%)

Fracture Types

Intra-articular

  • Up to 75% of fractures, result from axial loading

  • Classification

    • Essex Lopresti: primary fracture line runs obliquely through the posterior facet creating two fracture fragments; the secondary fracture line runs either behind the posterior facet (joint depression fractures) or beneath the posterior facet exiting posteriorly (tongue-type fracture).

    • Sanders classification: coronal CT cut at the widest portion of the posterior facet used to classify fracture based on number of articular fragments seen (types i–iv).

Extra-articular

  • Result from twisting forces on the hindfoot

  • Posterior tuberosity avulsion fractures

    • Account for 1–3% of all calcaneus fractures.

    • Due to insertion of the Achilles tendon.

    • Fractures with significant displacement can threaten the skin posteriorly and require urgent reduction to prevent skin necrosis.

  • Anterior process fractures

    • Avulsion secondary to bifurcate ligament

Imaging

Radiographs

  • AP, lateral, oblique of foot

  • Visualize decreased Bohler’s angle (normal 20–40°), increased angle of Gissane (normal 130–145°), varus tuberosity, shortening of calcaneus (Fig. 83.1)

Fig. 83.1
figure 1

Normal lateral radiograph of the foot showing (a) Bohler’s angle and (b) crucial angle of Gissane (Image from Core Knowledge in Orthopedics: Trauma)

Full size image

  • AP ankle

    • Fibular impingement can be caused by lateral wall extrusion.

  • Broden: posterior facet visualized

    • Ankle maintained in neutral dorsiflexion and X-ray beam moved to 10°, 20°, 30°, and 40° of internal rotation

  • Harris: tuberosity visualized and assessed for shortening, widening, and varus position

    • Foot in maximal dorsiflexion with the X-ray beam at 45°

CT Scan

  • Has become gold standard for imaging calcaneus fractures

  • Sagittal view: shows tuberosity displacement

  • Axial view: shows calcaneocuboid joint involvement

  • Semicoronal view: shows posterior and middle facet displacement, used for Sander’s classification (Fig. 83.2)

Fig. 83.2
figure 2

Semicoronal view of the calcaneus on a CT scan used for the Sander’s classification (Image from Core Knowledge in Orthopedics: Trauma)

Full size image

  • 3D reconstructions can aide in operative planning and understanding fracture patterns better.

MRI Scan

  • Not routinely used unless diagnosis is unclear (stress fracture)

Treatment

Nonoperative

  • Cast immobilization and non-weight bearing for at least 10–12 weeks

    • Indications: nondisplaced fractures, extra-articular fractures <1 cm with intact Achilles tendon, anterior process fractures <25% of calcaneocuboid joint, patients unable to undergo surgery due to medical comorbidities

Operative

  • Closed reduction and percutaneous pinning

    • Indications: large extra-articular fractures, minimally displaced tongue-type fractures, mild shortening

  • Open reduction internal fixation (ORIF)

    • Indications: displaced tongue-type fractures, large extra-articular fragments with detachment of the Achilles tendon. Anterior process fractures involving >25% of the joint, flattening of Bohler’s angle, varus malalignment of tuberosity, posterior facet displacement >2 mm

    • Goals to restore calcaneal height, correct varus, and stabilize fracture

    • Wait up to 2 weeks for swelling to resolve prior to surgery (positive wrinkle sign)

    • Extensile lateral or medial approach most commonly utilized

      • Full-thickness skin flaps must be raised to maintain soft tissue integrity.

      • No-touch skin technique with the use of K-wires helps preserve the soft tissue envelope and prevent extra tissue damage from handling.

  • Sinus tarsi approach

    • Best utilized in fracture patterns where anatomic reduction can be achieved through a small incision, such as Sanders type II fractures

    • Can be used in other types of calcaneus fractures, but achieving a congruent articular surface can be difficult through the small incision

  • Primary subtalar arthrodesis

    • Combined with ORIF to restore height, Sanders type IV

Postoperative Rehabilitation

  • Bulky U-splint initially after surgery

  • Non-weight bearing for at least 10–12 weeks

  • Can start subtalar range of motion exercises once incision healed after 2–3 weeks

Complications

  • Wound complications (up to 25%)

    • Increased in smokers, diabetic patient, open fractures

  • Posttraumatic subtalar arthritis

  • Compartment syndrome (may result in claw toes)

  • Lateral impingement with peroneal tendon irritation

  • FHL damage

  • Malunion

Outcomes

  • Overall poor with 40% complication rate