IntraArticular Fractures of the Calcaneus

Courtesy: Prof Dane Wukich MD, CHarles Gregory Distinguished Chair in Orthopaedic Surgery, UT SouthWestern, Dallas, Texas

Historical perspective
• Norris (1839) and Malgaigne (1843) described calcaneal fractures
• Lorenz Bohler (1935) described the mechanism of injury and classified them

Epidemiology
• 50-60% of all tarsal bone fractures
• <10% are open injuries
• Mainly in young adults (20-39 years of age)

Mechanism of injury
• High energy injury usually by fall from height or motor vehicle accidents

Classification

Essex- Lopresti classification

• x-ray based classification system
• 2 main types- joint depression type & tongue type

Sander’s classification

• CT scan based classification
• Most widely used and has prognostic value
• Guide the treatment

Look at the level of widest portion of posterior facet of talus in coronal section

Type 1 – undisplaced (non-surgical management is preferred)
Type 2 – two fragments (surgical fixation)
Type 3 – three fragments (surgical fixation)
Type 4 – four fragments (consider primary fusion with reduction)
A – lateral 1/3 rd.
B – middle 2/3 rd.
C – medial 1/3 rd.

Initial treatment

• Pain relief
• Control oedema (ice, elevation, compression and splinting)
• Urgent irrigation and debridement along with wound management in open injuries
Important radiographic parameters

• Bohler’s angle- normally 200 to 400
• Shenton’s line- normal gradual curve on the medial side
• The constant fragment – helps in restoring the anatomy

Note: look for wrinkle sign before proceeding to surgery

Goals of surgery

• Regain length
• Correct varus
• Reduce the joint
• Restore height

Lateral extensile approach

• Primary approach for many years
• Allows adequate visualization
• Allows manipulation to restore alignment
• Creating full thickness flap

Risk factors for wound complications
– Diabetes
– Smoking
– Open fractures

Minimally invasive techniques

• Sinus tarsi approach
• Percutaneous techniques
• External fixation

Sinus tarsi approach
– Increasing in popularity
– Lesser wound complications
– Technically challenging
– Lateral position
– Half pin used as a joystick

Conclusion

• Calcaneal fracture is a life altering event
• Goal is to improve function and avoid complications
• Know which patient needs surgery
• Secondary reconstruction to correct malunions are highly challenging