Presentation

• Usually axial-loading, high-energy, fall from height; 5-10% are bilateral
• Lower energy in females >60y
• Calcaneum ‘explodes’ within tight soft tissue envelope, causing:
  • Severe pain
  • Swelling, blistering – open fractures in 15%
  • Shortening / widening of heel
  • compartment syndrome in up to 10% (causes toe clawing in the long-term)
• Tongue and beak fractures can lead to rapid, full thickness necrosis of posterior skin; needs urgent surgical management
• Often poor hosts: smokers +/- substance abuse, poor compliance

 

Imaging

• X-rays
  • AP + lateral view: assess Bohler and Gissane angles
  • axial view: width, subfibular impingement, varus / valgus
  • Broden’s views for subtalar congruity (intra-op)
• CT scan essential for
  • assessing joint incongruity
  • surgical planning
  • fracture classification (incl Sanders)

 

Classification

Extra-articular (25%)

• avulsion injury of:
  • anterior process by bifurcate ligament
  • sustentaculum tali
  • calcaneal tuberosity (Achilles avulsion)

Intra-articular (75%)

• Essex-Lopresti classification
  • Primary fracture line runs obliquely through the posterior facet forming two fragments
  • Secondary fracture line runs in one of two planes:
    • axial plane exiting posteriorly in tongue-type fractures
    • behind the post facet in joint-depression fractures
• Sanders classification
  • Based on the number of articular fragments seen on a coronal CT image through the widest part of the posterior facet
  • Helpful for understanding fracture patterns, planning treatment, and predicting outcome

 

 

Treatment

Operative versus non-operative management

• A Cochrane review and 3 large RCTs (Buckley et al 2002, Agren et al 2013 and UK heel 2014) did not find statistical support for superiority of surgical management over non-operative management of DIACFs. There are many shortcomings of these studies, the main problem being selection bias.
• Buckley showed that surgical management was superior, after removing patients on worker’s compensation. Surgical outcomes were also found to be superior in younger patients and females.
• Csizy et al, after further analysis of Buckley’s paper, found non-op management likely to result in subtalar fusion 6 times more than the surgical group.
• Agren’s paper found surgical management reduced risk of post traumatic arthritis by 41%.

Non-operative

• Minimally or un-displaced fractures
• High risk patients (elderly, vasculopaths, diabetes)
• Low functional demand
• Poor compliance

Soft tissue management must always be a priority:

• NWB backslab or cast for 2 weeks to allow soft tissues to settle
• NWB in moon boot for next 4 weeks – can remove for hygiene and ankle exercises
• WB as tolerated thereafter
• Counsel for risk of post-traumatic arthritis

Operative

Surgical aims:

• restore height, length, width and alignment
• anatomic joint reduction (STJ and CCJ)
• stable internal fixation

Long-term aims to reduce the impact of the following:

• Joint depression → subtalar arthritis
• Lateral wall blowout → heel widening, difficulty with shoe wear, sub-fibular impingement, peroneal tethering / dislocation
• Loss of talar declination → anterior impingement Þ reduction of ankle dorsiflexion
• Residual hindfoot varus → lateral border overload

Strong indications for surgery

• Open fractures
• Severe soft tissue compromise from bony fragments
• Displaced tongue-type fracture
• Severe varus or valgus
• Fibular impingement / incarceration within lateral wall

Approaches

• Extensile lateral approach most commonly used (up to 25% wound complication rate)
• Sinus tarsi approach
• Limited approaches, e.g. short longitudinal incision over posterior tuberosity
• 3-point distraction technique with percutaneous joint surface elevation and fixation
• Percutaneous fixation +/- subtalar arthroscopy
• Posterior extension of the sinus tarsi approach for fracture dislocation patterns with direct compression fractures of lateral malleolus
• Medial approaches – sustentacular fractures and medial plantar tuberosity fractures

Traditional method of ORIF is to reduce the fracture fragments to the “constant” fragment (sustentaculum), but caution if the sustentaculum is fractured or displaced.

Most studies involving the extended lateral approach showed good AOFAS scores but high rates of wound healing problems and infections.

Cohort studies of minimally invasive surgery show good to excellent AOFAS scores and much lower complication rates (5%).

Studies comparing extensile and minimally invasive approaches did not show statistical difference in outcomes but complication rates were much lower in the minimally invasive groups (e.g. 3-4% compared to 20% in the extensile group).

 

 

Special situations

Open fractures

• follow BOAST recommendations for open fractures
• usually inside out injury by sharp medial fragment
• most common wound grade is Gustilo Anderson type III
• most common pattern is Sanders III
• complication rates, including deep infection and amputation, increase with injury severity
• seek early plastic surgery opinion

A systematic review recommended reduction of the fracture at the time of debridement to reduce pressure on the soft tissues. K wires +/- percutaneous screws can be used. If very comminuted and unstable, an external fixator can be used.

Poor soft tissues

• manage with similar care as open fractures – temporising fixation with percutaneous techniques supplemented with external fixator
• consider staged fixation can be done

Type IV Sanders fractures

• Buckley found equivalent clinical outcomes with standard ORIF and primary ORIF with arthrodesis
• ORIF + arthrodesis is much more challenging than ORIF alone

 

Complications

• wound dehiscence
• superficial / deep infection, osteomyelitis
• pin tract infection
• peroneal tenosynovitis, stenosis, dislocation
• post-traumatic arthritis
• calcaneal malunion
• heel pad pain
• heel exostoses
• nerve injury / entrapment
• need for metalwork removal
• subtalar fusion is more common following non-operative management
• in-situ fusions have poorer outcomes compared to corrective fusions when done for malunited fractures

 

References

Rammelt S, Swords MP. Calcaneal fractures – Which approach for which fracture? Orthop Clin North Am 2021;52:433-450.

Gougoulias N, McBride D, Maffulli N. Outcomes of management of displaced intra-articular calcaneal fractures. The Surgeon 2021;19:E222-E229.

Spierings KE et al. Managing the open calcaneal fracture: A systematic review. Foot Ankle Surg 2019;25:707-713.

Gotha HE, Zide JR. Current controversies in management of calcaneus fractures. Orthop Clin North Am 2017;48:91-103

Hsu AR, Anderson RB, Cohen BE. Advances in surgical management of intra-articular calcaneus fractures. J Am Acad Orthop Surg 2015;23:399-407.

Buckley R et al. Open reduction and internal fixation compared with ORIF and primary subtalar arthrodesis for treatment of Sanders type IV calcaneal fractures: a randomized multicenter trial. J Orthop Trauma. 2014 Oct;28(10):577-83.

Griffin D et al. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. BMJ 2014;349:4483.

Buckley R et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002 Oct;84(10):1733-44.