Calcaneus Fractures


Article Author:
David Davis


Article Editor:
Edward Newton


Editors In Chief:
David Wood
Andrew Wilt
Mary Cataletto


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
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Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
3/13/2019 4:10:50 PM

Introduction

Calcaneus fractures are rare but potentially debilitating injuries. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. The hindfoot articulates with the tibia and fibula creating the ankle joint. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal/plantar flexion. Calcaneal anatomy is demonstrated in Figure 1. Historically a burst fracture of the calcaneus was coined a "Lovers Fracture" as the injury would occur as a suitor would jump off a lovers balcony to avoid detection. [1][2][3]

Etiology

Calcaneal fractures most commonly occur during high energy events leading to axial loading of the bone but can occur with any injury to the foot and ankle. [4][5] Falls from height and automobile accidents are the predominant mechanisms of injury, although jumping onto hard surfaces, blunt or penetrating trauma and twisting/shearing events may also cause injury. Most of the injuries cause the bone to flatten, widen, and shorten. Stress fractures may occur with over use or repetitive use, such as running.

Epidemiology

The epidemiology of tarsal fractures is as follows:

  • Tarsal fractures account for 2% of all fractures.
  • Calcaneal fractures account for 50-60% of all fractured tarsal bones.
  • Less than 10% present as open fractures.
  • Traditionally, there is a male predominance of injuries due to the industrial nature of the accidents. Recent studies suggest regional variation in male/female predominance due to disparities in the types of regional accident occurrence.
  • Most patients with calcaneus fractures are young, with the 20-39 age group the most common.
  • Comorbidities such as diabetes and osteoporosis may increase the risk of all types of fractures.
  • Calcaneal fractures are rare in children. 

Pathophysiology

Falls from height directly translates energy into the calcaneus on impact as the heel strikes a surface crushing the calcaneus against the talus. The talus acting as a wedge causes depression and widening of the calcaneal body. [6][7]Similarly, a foot depressed against an accelerator, brake or floor board translates a large amount of force through the calcaneus during high-speed automobile accidents. Fracture patterns are similar in either mechanism. Gunshot wounds and other ballistic injuries cause a more diffuse nonpredictable fracture pattern but remain uncommon. Avulsion fractures require a large amount of twisting or shearing force due to the strength of the ligamentous and tendinous attachments to the calcaneus. The tibial artery and nerve run along the medial aspect of the calcaneal body and are thought to be shielded by the sustenaculum tali thus neurovascular injuries are uncommon with calcaneal fractures.

History and Physical

A traumatic event will almost invariably precede the presentation of calcaneal injury.

  • Patients will present with diffuse pain, edema, and ecchymosis at the affected fracture site.
  • The patient is not likely able to bear weight.
  • Plantar ecchymosis extending through the plantar arch of the foot should raise suspicion significantly.
  • There may be associated disability of the Achilles tendon, also raising the suspicion of a calcaneus injury.

Evaluation

Evaluation of a potential calcaneus fracture should include the following:

  • Complete neurovascular examination as well as evaluation of all lower extremity tendon function. Loss of ipsilateral dorsalis pedis or posterior tibial pulse compared to contralateral limb should raise suspicion of arterial injury and prompt further investigation with angiography or Doppler scanning.
  • Initial bony evaluation with 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.
  • Noncontrast computed tomography remains the gold standard for traumatic calcaneal injuries. CT scan is 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.
  • Mondors Sign is a hematoma identified on CT that extends along the sole and is considered pathognomic for calcaneal fracture.
  • Stress fractures such as those seen in runners would be best evaluated with a bone scan or MRI. 
  • Bohler's Angle may be depressed on plain radiographs. Defined as the angle between two lines drawn on plain film. The first line is between highest point on the tuberosity and the highest point of posterior facet and the second is the highest point on the anterior process and the highest point on the posterior facet. Normal angle is between 20-40 degrees.  
  • The Critical Angle of Gissane may be increased. Defined as the angle between two lines drawn on plain film. The first along the anterior downward slope of the calcaneus and the second along the superior upward slope. A normal angle is 130-145 degrees.  
  • Normal Bohlers and Gissane angles do not rule out a fracture.
  • Abnormalities of either of these findings should prompt a CT scan for further classification and evaluation of the fracture.

Calcaneal fractures can be classified into two general categories.[8][9]

  • Extraarticular fractures account for 25 % of calcaneal fractures. These typically are avulsion injuries of either the calcaneal tuberosity from the Achilles tendon, the anterior process from the bifurcate ligament, or the sustenaculum tali.
  • Intraarticular Fractures account for the remaining 75%. The talus acts as a hammer or wedge compressing the calcaneus at the angle of Gissane causing the fracture.

There are two main classification systems of extraarticular fractures.

Essex-Lopresti:

  • Joint depression type with a single verticle fracture line through the angle of Gissane separating the anterior and posterior portions of the calcaneus.
  • Tongue type which has the same verticle fracture line as a depression type with another horizontal fracture line running posteriorly, creating a superior posterior fragment. 

Sanders Classification: Based on reconstituted CT findings.

  • 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.

Treatment / Management

Emergent treatment includes:

  • Aggressive wound care and antibiotics as needed for contaminated wounds.
  • Analgesics.
  • ICE and elevation.
  • Immobilization with splinting.
  • All patients who are candidates for outpatient treatment are nonweight bearing at discharge.

Open fractures require more urgent surgical treatment and wound care. 

Closed fracture reduction can be delayed.

  • All surgical treatment is aimed at restoration of heel height and width (i.e., reconstructing the anatomy to reapproximate Bohler and Gissane angles), repair and realignment of the subtalar joint, and returning the mechanical axis of the hindfoot to functionality. 
  • Most extraarticular fractures are treated conservatively with 10-12 weeks of casting.  
  • Calcaneal tuberosity avulsion, displaced sustenaculum tali, and large substantial calcaneal body fractures may require operative management.  
  • Some intraarticular injuries may be treated in a closed fashion depending upon severity. Many are treated with either open surgical reduction and internal fixation, percutaneous pinning, or sometimes arthrodesis.
  • Nondisplaced Sanders type I fractures may be treated in a conservative, closed fashion. 

Pearls and Other Issues

Due to the severe nature and the force required to sustain calcaneal fractures concomitant injuries must be considered.[10][11] Studies have shown greater than 70% of patients with calcaneus fractures have additional injuries.

  • A thorough evaluation of the entire spine should be performed anytime a calcaneal fracture is identified especially when a fall is a mechanism. The force from impacting the ground translates through the lower extremity and upward sometimes causing spinal compression fractures
  • Compartment syndrome of the foot is a rare but severely debilitating complication of calcaneal fractures and can occur in up to 10% of the injuries. A high index of suspicion is needed in considering patients presenting with increased pain either after treatment or during the initial evaluation.
  • Osteomyelitis, postoperative wound infection, malunion and subtalar arthritis are all potential complications of calcaneal fractures and repair.

Enhancing Healthcare Team Outcomes

Calcaneus fractures have enormous morbidity and are often associated with many other injuries. Thus, the condition is best managed by a multidisciplinary team that includes a trauma surgeon, emergency department physician, orthopedic nurses, orthopedic surgeon, internist, physiotherapist, and a surgeon. All open wounds need immediate surgery. After surgery complications are common and may include compartment syndrome, osteomyelitis, wound infection malunion and subtalar arthritis. Non displaced fractures are managed conservatively. 

Overall the outlook for patients with calcaneus fractures is guarded. Those with an isolated fracture do recover with time but those with a concomitant injury to the pelvis, spine, neck or head often require prolonged rehabilitation and still have residual physical deficits.

Complete recovery from a calcaneus fracture may take months or even years. [12][13](Level V)

 

 


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    Contributed by David R Davis MD
Attributed To: Contributed by David R Davis MD

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Calcaneus Fractures - Questions

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What bone is injured in a lover's fracture?



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Which of the following which is most likely to cause a calcaneal fracture?



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In a patient with a calcaneal fracture, what other body system commonly has fractures?



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Mondor sign is pathognomonic for which disorder?



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Which of the following structures does not course along the medial wall of the calcaneus?



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Which of the following is true regarding Bohler angle in the assessment of a foot and ankle x-ray?



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An individual suffered a Saunders classification Type IIA calcaneus fracture. What are the fracture characteristics?



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A 35-year-old is working on a roof when he suddenly slips and falls off and lands on his feet. The patient never hit his head and did not lose consciousness. He is brought to the emergency department two hours after falling and present with pain in his heels and inability to bear weight. What should be included in his work up?



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Calcaneus Fractures - References

References

Adams MR,Koury KL,Mistry JB,Braaksma W,Hwang JS,Firoozabadi R, Plantar Medial Avulsion Fragment Associated With Tongue-Type Calcaneus Fractures. Foot     [PubMed]
Bibbo C,Siddiqui N,Fink J,Powers J,Ehrlich DA,Kovach SJ, Wound Coverage Options for Soft Tissue Defects Following Calcaneal Fracture Management (Operative/Surgical). Clinics in podiatric medicine and surgery. 2019 Apr;     [PubMed]
Cottom JM,Douthett SM,McConnell KK, Intraoperative Reduction Techniques for Surgical Management of Displaced Intra-Articular Calcaneal Fractures. Clinics in podiatric medicine and surgery. 2019 Apr;     [PubMed]
Hordyk PJ,Fuerbringer BA,Roukis TS, Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures. Clinics in podiatric medicine and surgery. 2019 Apr;     [PubMed]
Schepers T, Sinus Tarsi Approach with Screws-Only Fixation for Displaced Intra-Articular Calcaneal Fractures. Clinics in podiatric medicine and surgery. 2019 Apr;     [PubMed]
Herrera-Pérez M,Oller-Boix A,Valderrabano V,González-Casamayor S,Gutiérrez-Morales MJ,Guerra-Ferraz A,País-Brito JL, [Calcaneal fractures: controversies and consensus]. Acta ortopedica mexicana. 2018 May-Jun;     [PubMed]
Diacon AL,Kimmel LA,Hau RC,Gabbe BJ,Edwards ER, Outcomes of midfoot and hindfoot fractures in multitrauma patients. Injury. 2019 Feb;     [PubMed]
Jiménez-Almonte JH,King JD,Luo TD,Aneja A,Moghadamian E, Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. Clinical orthopaedics and related research. 2019 Feb;     [PubMed]
Shih JT,Kuo CL,Yeh TT,Shen HC,Pan RY,Wu CC, Modified Essex-Lopresti procedure with percutaneous calcaneoplasty for comminuted intra-articular calcaneal fractures: a retrospective case analysis. BMC musculoskeletal disorders. 2018 Mar 9;     [PubMed]
Spierings KE,Min M,Nooijen LE,Swords MP,Schepers T, Managing the open calcaneal fracture: A systematic review. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons. 2018 Nov 5;     [PubMed]
Zhang Z,Wang Z,Zhang Y,Qiu X,Chen Y, Risk factors for increased postoperative drainage of calcaneal fractures after open reduction and internal fixation: An observational study. Medicine. 2018 Aug;     [PubMed]
Albin SR,Koppenhaver SL,Marcus R,Dibble L,Cornwall M,Fritz JM, Short-Term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial. The Journal of orthopaedic and sports physical therapy. 2019 Feb 13;     [PubMed]
Toro G,Langella F,Gison M,Toro G,Moretti A,Toro A,Iolascon G, Stentoplasty of calcaneal fractures: Surgical technique and early outcomes. Injury. 2019 Feb 2;     [PubMed]

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