At a glance......
- 1 Pathophysiology
- 2 Types of Calcaneus Fractures
- 2.0.1 There are two main classification systems of extraarticular fractures.
- 3 Causes of Calcaneus Fractures
- 4 Symptoms of Calcaneus Fractures
- 5 Diagnosis of Calcaneus Fractures
- 6 Treatment of Calcaneus Fractures
- 6.1 Medication
- 6.2 Surgical Treatment
- 6.3 Considerations on Reduction and Fixation
- 7 Physical Therapy Management
- 8 Complications
- 9 Postoperative and Rehabilitation Care
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Treatment of Calcaneus Fractures/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. Historically a burst fracture of the calcaneus was coined a”Lovers Fracture” as the injury would occur as a suitor would jump off a lover’s balcony to avoid detection. [rx][rx][rx]
Calcaneus fractures often result in a varus deformity with heel widening, loss of calcaneal height, and subtalar joint incongruency. ORIF can be used to address deformities, restoring the anatomic morphology of the calcaneus, and thereby the biomechanics and function of the hindfoot. Restoring heel width prevents chronic peroneal tendonitis secondary to impingement from lateral wall blowout of the calcaneus, and restoring the length and alignment of the Achilles tendon maintains plantarflexion strength [rx, rx, rx]. ORIF also provides the opportunity for anatomic reduction and rigid internal fixation of the subtalar joint. Normal subtalar motion is integral for the foot to adapt on uneven surfaces with inversion and eversion [rx, rx, rx].
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.
Falls from a height directly translate 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 the widening of the calcaneal body. [rx][rx]Similarly, a foot depressed against an accelerator, brake or floorboard 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 sustentaculum tali thus neurovascular injuries are uncommon with calcaneal fractures.
Types of Calcaneus Fractures
There are two main classification systems of extraarticular fractures.
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. The tuberosity fragment may then rotate superiorly.
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.
The Sanders classification system is the most commonly used system for categorizing intra-articular fractures. There are 4 types:
- Type I fractures are non-displaced fractures (displacement < 2 mm).
- Type II fractures consist of a single intra-articular fracture that divides the calcaneus into 2 pieces.
- Type IIA: fracture occurs on lateral aspect of calcaneus.
- Type IIB: fracture occurs on central aspect of calcaneus.
- Type IIC: fracture occurs on medial aspect of calcaneus.
- Type III fractures consist of two intra-articular fractures that divide the calcaneus into 3 articular pieces.
- Type IIIAB: two fracture lines are present, one lateral and one central.
- Type IIIAC: two fracture lines are present, one lateral and one medial.
- Type IIIBC: two fracture lines are present, one central and one medial.
- Type IV fractures consist of fractures with more than three intra-articular fractures.
Extra-articular fractures include all fractures that do not involve the posterior facet of the subtalar joint.
- Type A involve the anterior calcaneus
- Type B involve the middle calcaneus. This includes the sustentaculum tali, trochlear process and lateral process.
- Type C involve the posterior calcaneus, the posterior tuberosity and medial tubercle included.
Causes of Calcaneus Fractures
- 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 overuse or repetitive use, such as running.
- Trips and falls – Losing your balance may lead to trips and falls, which can place excessive weight on your ankle. This might happen if you walk on an uneven surface, wear ill-fitting shoes, or walk around without proper lighting.
- Heavy impact – The force of a jump or fall can result in a broken and causes of fracture. It can happen even if you jump from a low height.
- Missteps – You can break your ankle if you put your foot down awkwardly. Your ankle might twist or roll to the side as you put weight on it.
Sports – High-impact sports involve intense movements that place stress on the joints, including the calcenious fructure. Examples of high-impact sports include soccer, football, and basketball.
- Car collisions – The sudden, heavy impact of a car accident can cause broken ankles. Often, these injuries need surgical repair. The crushing injuries common in car accidents may cause breaks that require surgical repair.
- Falls – Tripping, and falling can break bones in your ankles, as can landing on your feet after jumping down from just a slight height.
- Missteps – Sometimes just putting your foot down wrong can result in a twisting injury that can cause a broken bone.
- If only the ligaments give way and tear, you have sprained the ankle.
- If a bone gives way and breaks, you have an ankle fracture.
- Fractures can occur with simultaneous tears of the ligaments. You can do this in several ways:
- Rolling the ankle in or out
- Twisting the ankle side to side
- Flexing or extending the joint
- Applying severe force to the joint by coming straight down on it as in jumping from a high level
Symptoms of Calcaneus Fractures
Calcaneal fractures produce different signs and symptoms, depending on whether they are traumatic or stress fractures. The signs and symptoms of traumatic fractures may include:
- Sudden pain in the heel and inability to bear weight on that foot
- Swelling in the heel area
- Bruising of the heel and ankle
- Generalized pain in the heel area that usually develops slowly (over several days to weeks)
- Swelling in the heel area
- Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
- Significant swelling, which may occur along the length of the leg or may be more localized.
- Blisters may occur over the fracture site. These should be promptly treated by a foot and ankle surgeon.
- Bruising that develops soon after the injury.
- Inability to walk; however, it is possible to walk with less severe breaks, so never rely on walking as a test of whether or not a bone has been fractured.
- Change in the appearance of the ankle—it will look different from the other ankle.
- Bone protruding through the skin—a sign that immediate care is needed. Fractures that pierce the skin require immediate attention because they can lead to severe infection and prolonged recovery.
Diagnosis of Calcaneus 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.
Skin quality around the heel must be evaluated for tenting and/or threatened skin. This is especially important in the setting of Tongue-type calcaneus fractures.
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 dorsal 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. [rx]
Mondor’s 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 the 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. The 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.
- Stress test – Depending on the type of ankle fracture, the doctor may put pressure on the ankle and take a special x-ray, called a stress test. This x-ray is done to see if certain ankle fractures require surgery.
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 sustentaculum 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.
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 (2 to 3-mm cuts are recommended).
X-rays – This test is the most common and widely available diagnostic imaging technique. X-rays create images of dense structures, such as bone. An x-ray can show if your calcaneus is broken and whether the bones are displaced.
Computed tomography (CT) scans – Because of the complex anatomy of the calcaneus, a CT scan is routinely ordered after a fracture has been diagnosed on x-ray. A CT scan will produce a more detailed, cross-sectional image of your foot and can provide your doctor with valuable information about the severity of your fracture. This information will help your doctor recommend the best plan for treatment.
Treatment of Calcaneus Fractures
Initial treatment includes
- Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in the front part of your leg closer to the base of your leg. You’ll innately know that something is seriously wrong because you won’t be able to lift your arm up above the heart level. Cleaning and treating any wounds on the skin of the injured hand.
Aggressive wound care – as needed for contaminated wounds. Clear with disinfectant material [rx]
ICE and elevation – It help for prevention swelling, edema
Splinting – Bulky Jones type splints are commonly applied.
Weight-bearing by others person or cratch – All patients who are candidates for outpatient treatment are non-weight bearing at discharge.
- Rest, compression, and elevation (RICE) – Rest (staying off the injured foot) is needed to allow the fracture to heal. Ice reduces swelling and pain; apply a bag of ice covered with a thin towel to the affected area. Compression (wrapping the foot in an elastic bandage or wearing a compression stocking) and elevation (keeping the foot even with or slightly above the heart level) also reduce the swelling.
- Immobilization – Sometimes the foot is placed in a cast or cast boot to keep the fractured bone from moving. Crutches may be needed to avoid weight-bearing. For traumatic fractures, treatment often involves surgery to reconstruct the joint, or in severe cases, to fuse the joint. The surgeon will choose the best surgical approach for the patient.
- Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your ankle fracture look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and phalanges movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
- Taping the hand – as a type of soft splint, with the pinky and ring finger, taped together to help in healing correction of the dislocated bone, which may be done with anesthesia.
- Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones of all types, including. Therefore, focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
- Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
- Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
- Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
- Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.
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 (true extra-articular fractures only account for roughly 20% of all calcaneal fractures)
Calcaneal tuberosity avulsion displaced sustentaculum 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.
The following medications may be considered doctor to relieve acute and immediate pain
- Antibiotic – Cefuroxime or Azithromycin, or Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
- Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
- Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To healing the nerve inflammation and clotted blood in the joints.
- Muscle Relaxants – These medications provide relief from associated muscle spasms.
- Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
- Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and Ketorolac, Aceclofenac, naproxen
- Calcium & vitamin D3 – to improve bone health and healing fracture.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
- Dietary supplement -to remove general weakness & improved health
When surgical management is recommended it is with the goal to restore calcaneal morphology and to restore articular congruency. The decision to move forward with surgery must be based on fully informed consent of the abundant risks and expected benefits of surgery and must involve the patient in shared decision making as the operative intervention for calcaneal fractures is fraught with complications.
Surgical treatment must be delayed until the so-called, “wrinkle sign,” returns. This will usually occur five to ten days following the injury. Furthermore, all serous and hemorrhagic blisters must be epithelialized. [rx] Sanders et all describe that the soft tissue swelling may take up to 21 days to resolve and that surgery should not proceed until this has occurred. [rx]
Surgical intervention is typically recommended for the following indications: [rx]
Displaced tongue type Fractures
Joint depression with articular comminution or anterior process involvement
Bohler’s angle of <5 degrees on initial presentation
Anterior process fractures with >25% of the calcaneocuboid articulation involved
Calcaneal body fractures with significant varus or valgus malalignment, lateral impingement, loss of calcaneal height, or significant translation of the posterior tuberosity.
Cast immobilization with non-weightbearing for 6 weeks
- techniques:standard short-leg cast for calcaneal stress fractures non weight bearing cast well-padded heel
Cast immobilization with non weightbearing for 10-12 weeks
- techniques:standard short-leg cast applied with mild equinus windowed over posterior heel to allow for frequent skin checks requires close follow-up to determine if pull of gastrocnemius-soleus dispaces fracture weekly cast changes are necessary due to high incidence of skin complications high incidence of vascular insufficiency and diabetes in this population
Closed reduction and percutaneous pinning
- ideal for poor soft tissue coverage or patients with peripheral vascular disease
- Steinmann pin placed into the fracture site anteromedially-to-posterolateral to leverage fragments into place additional K-wires and Steinmann pins are placed from posterior-to-anterior and lateral-to-medial to secure remaining bone fragments
- calcaneal transfixing pin can be used to distract fracture
- percutaneous tamps and elevators can be used to raise the articular surface
- pins are cut flush with the skin and removed 8-10 weeks post-op
- can be combined with a distracting external fixator
- pins placed in calcaneal tuberosity, cuboid, and distal tibia
- restore calcaneal height, width, and alignment
- can be combined with percutaneous cannulated screw
Extensile lateral or medial approach
- full-thickness skin, soft tissue, and periosteal flaps are developed
- flap supplied by lateral calcaneal branch of peroneal artery
- superior flap contains the calcaneofibular ligaments and peroneal tendon sheath
- sural nerve and peroneal tendons are retracted superiorly
- lateral calcaneal wall visualized
- fracture opened and medial wall reduced going medial to lateral reduction confirmed indirectly via fluoroscopy
- tuberosity reduction is done under direct visualization
- manual traction, Schanz pins, and minidistractors
- pin in tuberosity aids with the reduction
- height and length of tuberosity is recreated
- quality of reduction affects outcomes
- manual traction, Schanz pins, and minidistractors
- provisional fixtaion was K-wires
- definitive fixation with plates and screws
Extensile lateral L-shaped incision is the most popular
- vertical portion between posterio fibula and achilles tendon
- the horizontal portion in line with 5th metatarsal base
- a more inferior incision protects the sural nerve
- high rate of wound complications
- provides access to the calcaneocuboid and subtalar joints
- bone grafting provided no added benefit
- restore congruity of subtalar joint
- restore Böhler’s angle and calcaneal height
- restore width
- correct varus malalignment
Sinus tarsi approach
- minimally invasive incision that minimizes soft tissue dissesction
- reduces wound complications associated with extensile lateral incision
- allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall
- lower incidence of sural nerve neuralgia
- same incision can be utilized for secondary subtalar arthrodesis or peroneal tendon debridement
- decreased surgical time
- patient placed in lateral decubitus position incision made in line with the tip of the fibula and the base of the 4th metatarsal
2-4 cm in length
- extensor digitorum brevis retracted cephalad to expose sinus tarsi and posterior facet
- peroneal tendons retracted posteriorly
- Schanz pin inserted percutaneously in posteroinferior tuberosity going from lateral to medial
- provides distraction and aids with reduction
- fibrous debris and fat removed from sinus tarsi
- small elevator or lamina spreader placed under posterior facet fragment to aid in reduction
- K-wires inserted for provisional fixation aimed towards the sustentaculum
- two screws are placed lateral-to-medial to engage sustentaculum and support facet
- one large fully threaded screw from posterior-to-anterior to support axial length of calcaneus
- the low-profile plate is applied underneath a well developed soft tissue envelope with screws engaging anterolateral and tuberosity fragments
- non weight bearing for 6-8 weeks post-op with ankle range-of-motion exercises beginning 2 weeks post-op
- manipulate the heel to increase the calcaneal varus deformity
- plantarflex the forefoot
- manipulate the heel to correct the varus deformity with a valgus reduction
Stabilize the reduction with percutaneous K-wires or open fixation as described above arthroscopic-assisted reduction and internal fixation
- increased set-up increased swelling from fluid extravasation technically challenging
- can be combined with sinus tarsi approach
- fluoroscopy unit positioned posterior and oblique to patient
- allows for axial hindfoot views anterolateral and posterolateral portals are used to visualize posterior facet 2.4 mm 0° arthroscope
- patient positioned in the lateral decubitus position
- an interosseous ligament is preserved
- hematoma is irrigated
- loose bodies and cartilage fragments are removed with a shaver
- Freer elevator is introduced into one of the portal sites and used to elevate the posterior facet reduction can be visualized directly
- Schanz pin to control tuberosity fragment
- cannulated screws from the posterior aspect of the calcaneal tuberosity to the anterior aspect of the calcaneus
- restores and stabilizes length
- lateral-to-medial screws placed in sustentaculum
- buttress screw from the posterior aspect of the calcaneal tuberosity to the subchondral bone of the posterior facetposterior approach for calcaneal tuberosity fractures
- patient positioned prone on table
- posterior midline incision
- fracture fragment is mobilized and debrided
- plantar flexion of foot aids with reduction
- presence of gastrocnemius tightness may preclude reduction
- Strayer procedure may be performed to aid in the reduction
- presence of gastrocnemius tightness may preclude reduction
- provisional fixation with K-wires
- final fixation with either lag screws tension-band constructs figure-of-8 tension-band wire passed around ends of K-wires or cannulated screws suture fixation Krackow sutures passing through bone tunnels
- restricted weight-bearing for 6 weeks followed by a progression of weight bearing an additional 6 weeks
- decreased soft-tissue dissection
- preservation of local blood supply
- removal of loose bone fragments
- improved visualization of the articular surface and cartilage lesions
Extensile lateral approach
Complex fractures with severe displacement and multiple intraarticular fracture lines at the subtalar joint can be effectively treated through an extensile lateral approach.rx This approach allows good visualization of the comminuted lateral wall, the fractured posterior facet, the sinus tarsi, and the anterior process including the calcaneocuboid joint. However, it requires careful soft-tissue handling with an elevation of a full-thickness fasciocutaneous flap form the lateral calcaneal wall, gentle mobilization of the peroneal tendons within their sheet, respecting the course of the sural nerve and the lateral calcaneal artery,[rx] preservation of the unique glabrous skin at the heel and the abductor digiti quinti muscle to avoid soft-tissue complications.
Sinus tarsi approach
The direct lateral approach to the subthalamic portion of the lateral calcaneal wall runs parallel to the peroneal tendons in a slightly curved manner close to the subtalar joint.72 This approach requires less soft-tissue dissection as compared to the extensile lateral approach. However, it cuts directly through the angiosome of the lateral calcaneal artery and may lead to scarring of the peroneal tendons and the sural nerve.
Oblique lateral approach over the sinus tarsi, slightly above the angle of Gissane (“sinus tarsi approach”) has gained increasing popularity for less invasive reduction and fixation of calcaneal fractures.,[rx] These small approaches may also be helpful if an attempted percutaneous reduction proves impossible and direct access to the joint is required.[rx] With this approach, the peroneal tendons are gently mobilized plantarly within their sheets and the subtalar joint can be visualized directly from above. Manipulation and reduction of the main fragments is carried out percutaneously, but the joint fragments can be manipulated directly through the approach. Definite fixation is achieved with percutaneous screws or bolts,[rx,rx] an intramedullary nail with locking screws,[rx,rx] or a small plate that is sled in through the approach and tunnelled beneath the peroneal tendons.
Minimally-invasive fixation of calcaneal fractures significantly reduces the risk of soft-tissue complications.[rx,rx]Many authors consider percutaneous reduction and screw fixation in cases of extraarticular and simple intraarticular fractures with the posterior facet being displaced as a whole as in Sanders Type IIC fractures.[rx,rx] These techniques can be extended to intraarticular fractures with only 1 displaced fracture line across the subtalar joint (i.e., Sanders Types IIA and IIB) with proper control of the articular reduction with subtalar arthroscopy or three-dimensional (3D) fluoroscopy.[rx,rx] However, performing percutaneous reduction and fixation irrespective of the type of fracture and without adequate control of reduction carries the risk of inadequate reduction and loss of fixation.
For fracture–dislocations of the calcaneum with direct compression of the fibular tip by the tuberosity fragment and subsequent dislocation of the peroneal tendons, an extension of the direct lateral approach (dislocation approach) allows access to the displaced tuberosity and lateral joint fragment from above.[rx] It starts over the lateral malleolus, thus allowing fixation of an accompanying fibular fracture and reattachment of the peroneal retinacle after fracture reduction and rerouting of the tendons. Reduction and fixation of the main fragments is usually straightforward with compression screws inserted from laterally into the sustentaculum tali.[rx,rx]
A small medial approach directly over the sustentaculum tali is used in cases of isolated fractures of the sustentaculum tali or in addition to the extended lateral approach with the fragmentation of the medial joint facet in more complex fracture patterns. The incision of about 3 cm lies horizontally over the palpable sustentaculum. The nearby posterior tibial and flexor digitorum longus tendons are held away with vessel loops and the posterior tibial neurovascular bundle is usually not exposed. The medial joint facet is reduced under direct vision and the sustentaculum is generally fixed with 3.5 mm compression screws.[rx]
Considerations on Reduction and Fixation
Control of reduction
Given the importance of anatomic reduction as extensively discussed above, adequate control of reduction is essential regardless of the choice of approaches. Precise intra-operative control of the reduction of the subtalar joint can be achieved after initial K-wire fixation either by open subtalar arthroscopy[rx] or intraoperative 3D fluoroscopy. If an intraarticular step-off is found, the K-wires are removed and joint reduction can be corrected immediately thus preventing painful postoperative conditions or the need for further surgery. In clinical series, relevant irregularities or screw malpositioning within the subtalar joint could be detected in >20% of cases that had been judged as being anatomically reduced with conventional fluoroscopy.[rx,rx,rx]
Internal fixation and defect filling
For internal fixation, various calcaneal plates have been designed. Most authors use a single lateral plate that displays the anatomical features of the calcaneum, providing support to the tuberosity, the thalamic portion with the posterior joint facet and the anterior process. Most current plate designs are polyaxially locked plate designs.[rx,rx] If an interlocking plate is used, 1 or 2 conventional screws should be placed first to bring the plate close to the bone thus increasing stability by friction and avoiding soft-tissue impingement from plate protrusion.[rx] The need of filling subthalamic impaction defects with bone grafting or synthetic bone substitutes is controversial and its use not substantiated by clinical evidence.[rx]
Primary fusion of comminuted fractures
Several authors advocate primary subtalar fusion in the cases of highly comminuted fractures (Sanders type IV) that are associated with less favorable functional results. In such cases, ORIF of the calcaneum is followed by removal of all remaining cartilage and fusion with autologous bone graft and 1 or 2 6.5 mm–8.0 mm cancellous bone lag screws.[rx] In a recent RCT on Sanders type IV fractures, primary fusion was not superior to ORIF and only 1 of 17 patients randomly allocated to ORIF went on to a secondary fusion.[rx] The rates of secondary subtalar fusion for symptomatic posttraumatic arthritis range between 0% and 14%. with most authors reporting rates between 2 and 6%.[rx] It may therefore be reasonable to perform ORIF on patients with Sanders type IV fractures and perform secondary arthrodesis only if painful subtalar arthritis develops.[rx] In situ fusion of a well reduced and solidly healed calcaneal fracture is easier to achieve and associated with less complications and better clinical outcome than corrective arthrodesis for malunited calcaneal fractures that have been treated conservatively at first presentation.[rx,rx]
Physical Therapy Management
After the surgery, active range of motion exercises may be practiced with small amounts of movement for all joints of the foot and ankle. These exercises are used to maintain and regain the ankle joint movement. When needed for the involved lower extremity, the patient may continue with elevation, icing and compression. During the therapy, the patient will progress to gradual weight-bearing. Patients may find this very difficult and painful. The physiotherapist conducts joint mobilization to all hypermobile joints.
During the treatment, progressive resisted strengthening of the gastrocnemius muscles is done by weighted exercises, toe-walking, ascending and descending stairs and plyometric exercises. When the fracture is healed, the physiotherapist will progress the weight-bearing in more stressful situations. This therapy consists of gait instruction and balance practice on different surfaces.
These are some outcome measures that can be used to measure the functional abilities of the patient to see the prognosis which can be used during the rehabilitation period.
- Lower Extremity Functional Scale (LEFS)
- Foot and Ankle Ability Measure (FAAM)
Initial stability is essential for open reduction internal fixation of intraarticular calcaneal fractures.
Preoperative revalidation consist of:
• Immediate elevation of the affected foot to reduce swelling.
• Compression such as foot pump, intermittent compression devices, or compression wraps as tolerable.
• Instructions for using wheelchair, bed transfers, or crutch walking.
Both the progression of nonoperative and postoperative management of calcaneal fractures include traditional immobilization and early motion rehabilitation protocols. In fact, the traditional immobilization protocols of nonoperative and postoperative management are similar, and are thereby combined in the progression below.  Phases II and III of traditional and early motion rehabilitation protocols after nonoperative or postoperative care are comparable as well and are described together below.
Phase I: Weeks 1-4
- Control oedema and pain
- Prevent extension of fracture or loss of surgical stabilization
- Minimize loss of function and cardiovascular endurance
- Cast with the ankle in neutral and sometimes slight eversion,
- Toe curl and active ankle joint (dorsiflexion and plantarflexion)-encourage to do from the first post-operative day.
- After 2-4 days, instruct in non-weight bearing ambulation utilizing crutches or walker-crutch walking training
- Instruct in wheelchair use with an appropriate sitting schedule to limit time involved extremity spends in dependent-gravity position
- Instruct in comprehensive exercise and cardiovascular program utilizing upper extremities and uninvolved lower extremity
- Strengthening adjacent joint musculature ( hip and knee)
Phase II: Weeks 5-8
- Control remaining or residual oedema and pain
- Prevent re-injury or complication of fracture by progressing weight-bearing safely
- Prevent contracture and regain motion at ankle/foot joints
- Minimize loss of function and cardiovascular endurance
- Continued elevation, icing, and compression as needed for involved lower extremity.
- After 6-8 weeks, instruct in partial-weight bearing ambulation utilizing crutches or walker
- Initiate vigorous exercise and range of motion to regain and maintain motion at all joints: tibiotalar, subtalar, midtarsal, and toe joints, including active range of motion in large amounts of movement and progressive isometric or resisted exercises
- Progress and monitor comprehensive upper extremity and cardiovascular program
Phase III: Weeks 9-12
- Progress weight-bearing status
- Normal gait on all surfaces
- Restore full range of motion
- Restore full strength
- Allow return to previous work status
- After 9-12 weeks, instruct in normal full-weight bearing ambulation with the appropriate assistive device as needed
- Progress and monitor the subtalar joint’s ability to adapt for ambulation on all surfaces, including graded and uneven surfaces
- Joint mobilization to all hypomobile joints including: tibiotalar, subtalar, midtarsal, and to toe joints
- Soft tissue mobilization to hypomobile tissues of the gastrocnemius complex, plantar fascia, or other appropriate tissues
- Progressive resisted strengthening of gastrocnemius complex through the use of pulleys, weighted exercise, toe-walking ambulation, ascending/descending stairs, skipping or other plyometric exercise, pool exercises, and other climbing activities
- Work hardening program or activities to allow return to work between 13- 52 weeks.
Implant removal 1 year after plate fixation is only advocated in cases of protruding hardware or massive arthrofibrosis with limited range of motion, mostly after plate fixation through extensile approaches. Implant removal is combined with intraarticular arthrolysis and debridement employing subtalar arthroscopy
Due to the severe nature and the force required to sustain calcaneal fractures concomitant injuries must be considered.[rx][rx] 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.
Infections and wound breakdown – are the most common and devastating complications of the extensile lateral approach. Wound complications and infections can be as high as 37% and 20% respectively with operative intervention. [rx]
Subtalar osteoarthritis – may result from surgical or nonsurgical treatment with an increasing number of patients with non-operatively treated displaced intra-articular calcaneus fractures requiring late subtalar fusion as a result of subtalar arthritis. [rx] Another study found that non-operative measures were up to 6 times more likely to lead to a late subtalar fusion due to symptomatic subtalar arthritis. [rx]This is considered post-traumatic arthritis. Loss of subtalar motion is very common as well.
Sural nerve injury – may result in up to 15% of cases treated operatively (more often with the extensile lateral approach). The risk is reduced with a more inferiorly based L-incision. [rx]
Chronic pain – is also a common complication, in many cases owing to post-traumatic subtalar arthritis, malalignment or stiffness resulting from the injury.
- Wound Healing Problems – Although seen with any surgical procedure, wound healing complications are particularly concerning following calcaneal fracture surgery. The area around the outside of the heel has relatively thin skin and limited soft-tissue coverage. This can make wound healing problems more likely following calcaneal fracture surgery, and potentially more severe if they do develop. Wound healing problems are increased significantly for smokers and diabetics.
- Infection – Infections can create a major problem if they occur following a calcaneal fracture. As a result of the limited soft-tissue covering the outside of the heel, a superficial wound infection can quickly spread down to the underlying bone. If an infection develops, your surgeon may recommend the use of oral or intravenous antibiotics. A repeat trip to the operating room may be required.
- Subtalar Arthritis – Painful subtalar arthritis and stiffness of the hindfoot is common following calcaneal fractures. This occurs as a result of the damage to the cartilage at the time of the initial injury.
- Painful Hardware – Pain may be associated with the screws and plates used to align and secure the broken bone fragments. This occurs in about 10-20% of patients who have had surgical stabilization of a calcaneus fracture. Your doctor will help you determine if hardware removal is required.
Peroneal tendon instability – may result from displaced, intra-articular calcaneus fractures. [rx] This may result from direct damage to the tendons themselves as a result of the injury or fracture fragments that may impinge on the tendons. Up to a 40% displacement of the peroneal tendons has been appreciated on CT scans of calcaneus fractures. [rx]. Furthermore, with significant height loss, calcaneal widening and hindfoot varus subfibular impingement may result from soft tissue or osseous abnormalities. Subfibular impingement may result in lateral heel pain, particularly with eversion of the hindfoot. Techniques have been described to perform percutaneous calcaneal osteotomy and peroneal tendon decompression to try to alleviate subfibular impingement after calcaneal malunion. [rx]
Postoperative and Rehabilitation Care
Immediately post-operatively – the patient’s foot and ankle should be placed into an extremely well-padded posterior splint.
Drains are typically removed– on postoperative day 2 or even earlier based on surgeon preference.
The patient should be adequately educated – on the need to elevate the extremity for the first several weeks after surgery to reduce swelling and the subsequent risk of wound complications.
The splint – may be removed as early as 2-5 days based on some recommendations or left in place for 2 weeks in some cases, but after removing the splint the patient should begin his or her range of motion exercises for the subtalar joint and ankle joint as soon as possible.
Weight-bearing – is often delayed 8-12 weeks (or more depending on the degree of comminution and progression of healing on radiographs).
Routine serial radiographs – should be obtained to ensure the progression of healing.
- Early motion. Many doctors encourage motion of the foot and ankle early in the recovery period. For example, you may be instructed to begin moving the affected area as soon as your pain allows. If you have had surgery, you may be instructed to begin moving the affected area as soon as the wound heals to your doctor’s satisfaction.
- Physical therapy. Specific exercises can help improve the range of motion in your foot and ankle and strengthen supporting muscles. Although they are often painful at the beginning and progress may be difficult, exercises are required in order for you to resume normal activities.
- Weight-bearing. When you begin walking, you may need to use crutches, a cane, or a walker and/or wear a special boot. It is very important to follow your doctor’s instructions for walking on your foot. If you put weight on your foot too soon, the bone pieces may move out of place and you might require surgery. If you have had surgery, the screws might loosen or break and the bone may collapse. This may not occur the first time you walk on it but, if the bone is not healed and you continue to bear weight, the metal will eventually break.