Calcaneous Fracture 825.0

 

synonyms: os calcis fracture, calcaneous fracture

Calcaneus Fracture ICD-9

  • 825.0(closed)
  • 825.1(open)

Calcaneus Fracture Etiology / Epidemiology / Natural History

  • 60% of tarsal fractures
  • 80-90% male industrial workers, high economic cost
  • May be totally incapacitating for 3 yrs and partially impaired for 5 yrs
  • Generaly high energy axial load: fall from height, MVC.

Calcaneus Fracture Anatomy

  • Transmits body weight to ground, strong lever arm for calf muscles
  • Main weight beaing surface is the posterior facet
  • Primary fx line in an axial-loading fx occurs from superior-lateral to inferior medial separating calcaneous into sustentacular and tuberosity fragments.
  • Sustentaculum tali remains in its anatomic position due to supporting ligamentous structures and provides key to reconstruction of the calcaneus.
  • Anterior process: a saddle-shaped projection of bone at the superior aspect of the calcaneal body. Its inferior surface articulates with the cuboid. The bifurcate ligament inserts on the anterior process and connects the cuboid and navicular bones. Serves as the origin of part of the extensor digitorum brevis.
  • Peripheral structures of the calcaneus include the sustentaculum tali, the peroneal tubercle, and the medial and lateral calcaneal tubercles.
  • Tibial nerve crossses the calcaneous below the sustentaculum tali medially and may be injured with displaced fractures causing incomplete loss of sensation on the plantar surface of the foot.

Calcaneus Fracture Clinical Evaluation

  • Usually high-energy, fall from height or MVA.
  • Evaluate soft tissues, common severe soft tissue disruption, fracture blisters, full-thickness skin necrosis.
  • Evaluate for Open fracture.
  • Evaluate for compartment syndrome.
  • Document smoking history, diabetes, PVD (increased risk of wound complications).
  • Document plantar foot sensation (risk of tibial nerve injury with incomplete loss of sensation on the plantar surface of the foot.)
  • Evaluate entive musculoskeletal system, head, chest, abdomin due to high incidence of concomittant injuries.

Calcaneus Fracture Xray / Diagnositc Tests

  • A/P, Lateral, and Mortise Ankle and A/P, Oblique, Lateralfoot xrays indicated. A/P foot may show extension into calcaneocuboid joint.
  • Harris view(axial view): demonstrates degree of lateral migration of the tuberosity.
  • Broden's view-demonstrates articular surface of posterior facet-pt supine, cassette under leg/ankle, foot in neutral flexion with leg internally rotated 30-40, beam centered over lateral malleolus; xrays taken at 40, 30, 20, 10 degrees toward head of patient.  Shows posterior facet as it moves from posterior to anterior. (Bruden Acta Radiol 31:85;1949). Generally get CT instead.
  • Bohlers angle(on lateral xray) usually between 20°-40°; formed by lines drawn from the highest point of the anterior process of the calcaneous to the highest point of the posterior facet and a line drawn tangential to the superior edge of the tuberosity.  Decrease indicates posterior facet has collapsed.
  • Gissane's Angle(on lateral xray) seen directly inferior to the lateral process of the talus, formed by lines along lateral border of posterior facet and anteriorly to the beak of the calcaneous. Usually between 95° and 105°.
  • CT is usually indicated especially in intraarticular fx.  Semicoronal images show articular surface of posterior facet, sustentaculum, shape of heel, peroneal and FHL tendons.  Axial images show calcaneocuboid joint, anteroinferior posterior facet and sustentaculum. Only the surface of the bone is illustrated with 3-D reconstructions.  Sagittal reconstructions are rarely of value.  The semicoronal plane should be perpendicular to the posterior facet of the calcaneus, not parallel to it. (Crosby LA, JBJS 1990;72A:852).
  • Lumbar spine films generally indicated to evaluate for associated injuries.

Calcaneus Fracture Classification / Treatment

  • ATLSresuscitation. These can be high enegery injuries, assessment should begin with the A,B,C's.
  • Sanders JOT 6:2 1992 CT classification (coronal view)
    -Type 1=nondisplaced posterior facet
    -Type 2=single fracture line: If displaced consider percutaneous reduction and screw fixation with 2.5mm screws
    -Type 3=two-degree fx line with 3 posterior facet fragments
    -Type 4=3 fx lines with 4+ fragments:
  • Treatment = ORIF / Subtalar fusion/ Nonoperative
  • Non-operative Treatment:
    -Indications: physiologic age >50, workers compensation, stenous labor occupation, Saunders type-I fx, non-displaced or <4mm displaced, severe PVD, IDDM, medical problems, open fx, soft-tissue compromise, prolonged edema(>6wks) (Bajammal S, JOT 2005;19:360).
    -Ice, NWB x 3months, early ROM, fx boot to prevent equinus constracture, elastic compression stocking to minimize edema. (Allmacher DH, JOT 2006;20:464).
  • Peroneal tendinitis and stenosis are commonly seen after non-op management due to lateral subfibular impingement.
  • ORIF
    -Indications: females, patients not involved with workers compensation, physiologic age <50y/o, patients with higher initial Bohler angle, pateitns with occupations not involving stenous labor, simple intra-articular fracture patterns.(Bajammal S, JOT 2005;19:360).
    -Usually delayed 7-14 days for soft tissue edema to resolve.  Initially treatment with Jones dressing, posterior mold, elevation, ice.  Good results with foot pump have been recorded.  When skin-wrinkling is seen and no pitting edema is evident surgery is safe.
  • Tongue-type fracture
    -Posterior facet remains in continuity with the superior aspect fo the calcaneal tuberosity
    Treatment = CRPP (Essex-Lopresti technique)
  • Primary subtalar arthrodesis with open reduction indicated for severe articular injury in a laborer.  (Huefner Foot Ankle Int 22:9;2001), (Coughlin Foot Ankle Int 21:896;2000).
  • Late reconstruction can be performed with subtalar bone block fusion (Carr JB, Foot ankle 9:81;1988).
  • Anterior process fracture of the calcaneus. Anterior process is the attachment site for the bifurcate ligament and is a potential cause of persistent lateral ankle pain after an inversion ankle injury.  Appropriate surgical treatment for a nonunion of an anterior process fracture of the calcaneus is excision of the nonunited fragment.  (Degan TJ, JBJS 1982;64A:519).
  • Patient Guides: AAOS,

Calcaneus Fracture Associated Injuries / Differential Diagnosis

  • Spine fx's(10%), routine xrays of lumbar spine should be taken in calcaneous fx patients
  • Compartment syndrome-long-term sequelae of foot compartment syndrome are clawfoot deformity with permanent loss of function, contracture, weakness, and sensory disturbance.
  • Anterior process Calcaneous fracture
  • Peroneal tendon dislocation
  • Ankle instability: ankle ligament rupture

Calcaneus Fracture Complications

  • Wound breakdown 10-20%, increased in smokers, diabetics, peripheral vascular disease
  • Compartment syndrome 10%
  • Heel deformity/malunion
  • Peroneal tendon impingement / instability / tendinosis: generally occurs with non-operative management because the displaced lateral wall causes impingement and binding of the peroneal tendons
  • Subtalar arthritis
  • Malunion-best treated with lateral wall exostectomy, peroneal tenolysis, +/- subtalar arthrodesis, +/- calcaneal osteotomy depending on type (Clare MP, JBJS 2005;87A:963-73). (Clare MP, Lee WE 3rd, Sanders RW. Intermediate to long-term results of a treatment protocol for calcaneal fracture malunions. J Bone Joint Surg Am. 2005 May;87(5):963-73). (Carr JB, Hansen ST, Benirschke SK. Subtalar distraction bone block fusion for late complications of os calcis fractures. Foot Ankle. 1988 Oct;9(2):81-6).
  • Heel pad pain
  • Heel exostoses
  • CRPS
  • Infection / Osteomyelitis
  • Calcaneocuboid arthritis

Calcaneus Fracture Follow-up Care

  • Bulky jones dressing with posterior splint post-operative. Must keep foot elevated for first 36-72 hours to decrease incidence of wound healing problems.
  • 7-10 day f/u:calcaneous xrays, SLC, NWB. Consider cam-walker with gentle ROM exercises.
  • 4 wk follow-up: calcaneous xrays, compression stocking, cam-walker boot, gentle ankle/subtalar ROM exercises, NWB. Sub-talar motion = figure-of-eight motion, drawing alphabet with the great toe.
  • 3 months f/u: calcaneous xrays, 25% WB, progress to full WB over 1-2 weeks. Start PT for ROM, gait training.
  • 6 months f/u: calcaneous xrays, evaluate function outcome, ROM.
  • 1 year f/u: calcaneous xrays, evaluate function outcome, ROM.

Calcaneus Fracture Review References

  • Benirschke SK, AAOS OKO
  • CORR 290
  • Macey LR, JAAOS 1994;2:36
  • Chandler JT, Bonar SK, Anderson RB, Davis WH: Results of in situ subtalar arthrodesis for late sequelae of calcaneus fractures. Foot Ankle Int 1999;20:18-24. Chan SC,
  • Alexander IJ: Subtalar arthrodesis with interposition tricortical iliac crest graft for late pain and deformity after calcaneus fracture.  Foot Ankle Int 1997;18:613-615.
  • Amendola A, Lammens P: Subtalar arthrodesis using interposition iliac crest bone graft after calcaneal fracture.  Foot Ankle Int 1996;17:608-614.
  • Myerson MS, Quill GE Jr: Late complications of fractures of the calcaneus.  J Bone Joint Surg 1993;75A:331-341.
  • Sanggeorzan BJ: salvage procedures for calcaneus fractures, in Springfield D (ed): ICL 46. Rosemont, IL, AAOS, 1997, pp339-346.
  • Rockwood and Green's Fractures in Adults 6th ed, 2006
  • Sangeorzan BJ, in Masters Techniques in Orthopaedic Surgery: The Foot and Ankle, 2002.
  • Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000 Feb;82(2):225-50.
  • Sanders RW, Clare MP. Fractures of the calcaneous. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Vol 2. 8th ed. Philadelphia, PA: Mosby; 2007:2017-2074

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