BMC Surg. AJR Am J Roentgenol. - may need to be supplemented by orthotic support with a custom-molded insole, rocker-bottom shoe, or ankle-foot orthosis; [QxMD MEDLINE Link]. 2009 Mar-Apr. 9th ed. Orthop Clin North Am. - tongue fracture Calcaneus fractures. J Bone Joint Surg Am. Effectiveness of MIS technique as a treatment modality for open intra-articular calcaneal fractures: A prospective evaluation with matched closed fractures treated by conventional technique. Front Surg. Reference article, Radiopaedia.org (Accessed on 01 May 2023) https://doi.org/10.53347/rID-27025, View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, Sander's classification of calcaneal fracture, Calcaneal fractures (Sanders classification system), Sander's CT classification of calcaneal fracture. 12 (1):125-35. Type I (20%) the fracture line may be through the tuberosity, the sustentaculum tali, or the anterior process of the calcaneus. Os calcis fractures can be broadly classified into intra-articular and extra-articular types. This classification is based on the number of intraarticular fracture lines and their location on semicoronal CT images. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Note loss of Bhler angle. A systematic search for articles dealing with calcaneal fracture was performed, and the prevalence of use of each classification system determined. Calcaneus injuries represent 2% of all fractures seen in adults. Diagnosis is made radiographically with foot radiographs with CT scan often being required for surgical planning. Wound healing complications in closed and open calcaneal fractures. Diabetes [QxMD MEDLINE Link]. 30 (3):e88-92. The results of this study did not lend support to the view that ORIFyields better outcomes than conservative therapy for these fractures. (2013) ISBN: 9781107679689 -, 9. LINDSAY WR, DEWAR FP. official website and that any information you provide is encrypted J Foot Ankle Surg. [QxMD MEDLINE Link]. 1984 May. Type 2B Posterior beak fracture (achilles involvement) ; Tongue type which has the same vertical fracture line as a depression type with another horizontal fracture line running posteriorly, creating . 39 (4):443-449. 15 (1):167. - threaded Steinman pin is inserted through the posterior calcaneus into the cuboid; Essex-Lopresti describedthe following twocalcaneus fracture subtypes Intra-articular fractures of the calcaneum treated operatively or conservatively. Disability associated with calcaneal fractures is significant, often resulting in permanent disability. [12, 13, 14], Despite improvements in imaging, as well as a better understanding of the patterns of injury in complex fractures of the calcaneus, opinions on the management of such injuries continue to differ. 7 (5):417-27. 2020 Jul. 28 (2):7352. - displaces superiorly & laterally resulting in incongruity of posterior facet and widening & shortening of heel; Fracture blisters: clinical and pathological aspects. Yu S & Yu J. Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis. - further axial loading may fracture tuberosity fragment creating a supero-lateral fragment of posterior facet; 2010 Aug. 41 (8):804-9. Severely comminuted intra-articular fractures may be treated with a combination of open reduction and internal fixation (ORIF) and arthrodesis of the subtalar joint. The OTA classification related statistically significant with the MFS (p = 0.006), AOFAS score (p = 0.013), FOA (p = 0.019), Rowe (p = 0.0027), and MFA score (p = 0.03). Rowe Classification: Type 1A Medial tuberosity fracture Type 1B Sustentaculum tali fracture Type 1C Anterior process fracture Type 2A Posterior beak fracture (no achilles involvement) Type 2B Posterior beak fracture (achilles involvement) Type 3 Extra-articular fracture of body Type 4 Intra-articular fracture of body without collapse/depression - Sub-Talar Joint Magnetic resonance imaging evaluation of calcaneal fat pads in patients with os calcis fractures. The site is secure. CT is the modality of choice to evaluate calcaneal fracture. Foot Ankle Int. Chen et al investigated a combination of minimally invasive dual incision and internal fixation with mini plates as an alternative to ORIF in 20 patients with Sanders type III intra-articular calcaneal fractures and a posterior subtalar articular displacement greater than 2 mm. - displaced supero-lateral fragment can impinge upon peroneal tendons; You are being redirected to
Scott Nicklebur, MD Assistant Professor of Emergency Medicine, Texas A&M Health Science Center College of Medicine Neurology - anteromedial (sustentacular) frag is rarely comminuted but varies in size; [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedic Surgery, University of Texas Medical Branch School of Medicine [QxMD MEDLINE Link]. Foot Ankle Int. - Open Fractures of the Calcaneus: Soft-Tissue Injury Determines Outcome. Bosch: of 25 frxs, 12 patients reported little or no pain, 7 patients had moderate pain, and 2 patients had severe pain; All fractures healed well or very well. Displaced intra-articular calcaneal fractures treated in a minimally invasive fashion: longitudinal approach versus sinus tarsi approach. J Orthop Trauma. Careers. - historical treatment has included closed reduction (Bohler) w/ distraction and medial lateral compression; Eversion, medial tuberosity is injured. The resultant primary fracture line extends from the lateral aspect of the angle of Gissane in a posteromedial direction, initiating an oblique, primary fracture line. 2018 Apr 24. Materials and methods: 2) Centrolateral depression of joint 60-75% of injuries are intra-articular fractures, no significant increase in infection rates, peak incidence in women in seventh decade of life, violent contaction of the triceps surae with forced dorsiflexion, strong concentric contaction of the triceps surae with knee in full extension, intrinsic tightness of the gastrocnemius and achilles tendon, peripheral neuropathy leading to decreased pain sensation and proprioception resulting in recurrent microtrauma, increased physical activity in the setting of relative energy deficiency, primary fracture line results from oblique shear and leads to the following, includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments, dictate whether there is joint depression or tongue-type fracture, strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus, more common in osteopenic/osteoporotic bone, inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament, superolateral fragment contains the articular facets, superior articular surface contains three facets that articulate with the talus, the flexor hallucis longus tendon is medial to the posterior facet and inferior to the medial facet and can be injured with errant drills/screws that are too long, between the middle and posterior facets lies the, projects medially and supports the neck of talus, connects the dorsal aspect of the anterior process to the cuboid and navicular, calcaneal tuberosity (Achilles tendon avulsion), the primary fracture line runs obliquely through the posterior facet forming two fragments, the secondary fracture line runs in one of two planes, the axial plane beneath the facet exiting posteriorly in, when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly, behind the posterior facet in joint depression fractures, based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet, One fracture line in the posterior facet (, Two fracture lines in the posterior facet (, based on fracture morphology of the calcaneus tuberosity, tenting, ecchymosis, or lack of skin blanching with tuberosity fractures, neccessitates urgent sugical reduction and fixation to avoid posterior heel skin necrosis, must be debrided and epithelialized prior to surgical intervention, lack of heel cord continuity in avulsion fractures, lack of posterior heel skin blanching with tenting fractures, assess for compartment syndrome secondary to swelling, presence of Langer's lines and skin wrinkles suggests skin is appropriate for surgical intervention, decreased ankle plantarflexion strength with avulsion fractures, assess for neuologic compromise due to swelling, severe peripheral vascular disease may preclude surgical treatment due to poor wound healing potential, useful for evaluation of intraoperative reduction of posterior facet, with ankle in neutral dorsiflexion and ~45 degrees internal rotation, take x-rays at 40, 30, 20, and 10 degrees cephalad from neutral, visualizes tuberosity fragment widening, shortening, and varus positioning, place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees, demonstrates lateral wall extrusion causing fibular impingement, indicates partial separation of facet from sustentaculum, angle between line from highest point of anterior process to highest point of posterior facet + line tangential to superior edge of tuberosity, represents collapse of the posterior facet, angle between line along lateral margin of posterior facet + line anterior to beak of calcaneus, demonstrates posterior and middle facet displacement, demonstrates calcaneocuboid joint involvement, used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis, cast immobilization with nonweightbearing for 10 to 12 weeks, anterior process fracture involving <25% of calcaneocuboid joint, comorbidities that preclude good surgical outcome (smoker, diabetes, PVD), avoids the high wound complications seen with these fractures, minimally displaced tuberosity fractures (<1 cm of displacement) without threatened soft-tissue envelope in elderly patients with reduced function or physical capacity, begin early range of motion exercises once swelling allows, early reduction prevents skin sloughing and need for subsequent flap coverage, ideal in patients with sever peripheral vascular disease or severe soft-tissue compromise, lag screws from posterior superior tuberosity directed inferior and distal, require urgent reduction and fixation to avoid skin necrosis (disastrous consequence), open reduction allows for sufficient debridement of contaminated tissue, inability to participate in closed treatment, large extra-articular > 2 mm displacement, posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity, anterior process fracture with >25% involvement of calcaneocuboid joint, wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days, no benefit to early surgery due to significant soft tissue swelling, displaced tuberosity fractures with posterior skin compromise should be addressed urgently, number of intra-articular fragments and the, surgical treatment decreases the risk of post-traumatic arthritis, age > 50 (similar outcomes with surgical and nonsurgical treatment), initial Bhler's angle <0 (these injuries do poorly regardless of treatment), lower Bhler angles suggest greater energy absorbed, open fractures (significant soft tissue injury and engery absorbed), bilateral calcaneal fractures (significant gait problems following bilateral injuries), factors associated with most likely need for a secondary subtalar fusion, male worker's compensation patient who participates in heavy labor work with an initial Bhler angle less than 0 degrees, standard short-leg cast for calcaneal stress fractures, 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, 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 transfixin pin can be used to distract fracture, percutaneus 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 distracting external fixator, pins placed in calcaneal tuberosity, cuboid, and distal tibia, restor calcaneal height, width, and alignment, can be combined with percutaneous cannulated screws, extensile lateral L-shaped incision is most popular, vertical portion inbetween posterio fibula and achilles tendon, horizontal portion in line with 5th metatarsal base, a more inferior incision protects the sural nerve, provides access to the calcaneocuboid and subtalar joints, full-thickness skin, soft tissue, and periosteal flaps are developed, lateral calcaneal branch of peroneal artery, superior flap contains the calcaneofibular ligaments and peroneal tendon sheath, sural nerve and peroneal tendons are retracted superiorly, 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, height and length of tuberosity is recreated, definitive fixation with plates and screws, restore Bhler's angle and calcaneal height, 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, same incision can be utilized for secondary subtalar arthrodesis or peroneal tendon debridement, patient placed in lateral decubitus position, incision made in line with the tip of the fibula and the base of the 4th metatarsal, extensor digitorum brevis retracted cephalad to expose sinus tarsi and posterior facet, 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 screw 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, low-profile plate is applied underneath a well developed soft tissue envelope with screws engaging anterolateral and tuberosity fragments, nonweight 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, 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, improved visualization of articular surface and carilage lesions, increased swelling from fluid extravasation, can be combined with sinus tarsi approach, patient positioned in lateral decubitus position, fluoroscopy unit positioned posterior and oblique to patient, anterolateral and posterolateral portals are used to visualize posterior facet, 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, Schanz pin to control tuberosity fragment, cannulated screws from the posterior aspect of the calcaneal tuberosity to the anterior aspect of the calcaneus, lateral-to-medial screws placed in sustentaculum, buttress screw from the posterior aspect of the calcaneal tuberosity to the subchondral bone of the posterior facet, posterior approach for calcaneal tuberosity fractures, 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 reduction, figure-of-8 tension-band wire passed around ends of K-wires or cannulated screws, Krackow sutures passing through bone tunnels, restricted weight bearing for 6 weeks followed by progression of weight bearing an additional 6 weeks, performed in highly comminuted Sanders IV intraarticular fractures, high rate of secondary fusion after ORIF with these injuries, avoids added treatment costs and decreases time off from work, can be performed through an extensile lateral or sinus tarsi approach, fracture reduction is perfromed in a similar fashion as ORIF, articular cartilage of the subtalar joint denuded to bleeding subchondral bone, cannulated compression screws are placed from the posterio calcaneal tuberosity to the talar dome, lateral fixation plate applied to hold reduction, increased risk in smokers, diabetics, and open injuries, may consider nonoperative treatment in these patients, tongue type fractures at high risk (>20%) for posterior skin necrosis, should be splinted in 30 degrees of planarflexion to relieve soft tissue tension, keep all hardware away from the corner of the incision, delayed wound healing is the most common complication, can be addressed with ankle bracing (gauntlet type), NSAIDs, injections, and physical therapy, may require bone block subtalar arthrodesis to address loss of calcaneal height, important when there are symptoms of anterior ankle impingement, Lateral impingement with peroneal irritation, at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment), loss of height, widening, and lateral impingement, distraction bone block subtalar arthrodesis, incongruous subtalar joint/post-traumatic DJD, results from posterior talar collapse into the posterior calcaneus, Lateral exostosis with no subtalar arthritis, Lateral exostosis with subtalar arthritis, Lateral exostosis, subtalar arthritis, and varus malunion, increased due to mechanism (fall from height), smoking, and early surgery, lateral soft tissue trauma increases the rate of complication, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. 87-95. The discomfort associated with a fracture of the calcaneus may be so distracting to the patient that other significant injuries are ignored. [QxMD MEDLINE Link]. Nondisplaced intra-articular fractures are generally treated in a closed fashion. Badillo K, Pacheco J, Padua S, Gomez A, Colon E, Vidal J. Multidetector CT Evaluation of Calcaneal Fractures. The .gov means its official. [QxMD MEDLINE Link]. 'https://flow.aquaplatform.com/ajs.php':'http://flow.aquaplatform.com/ajs.php'); 1) Beak type Grn W, Molund M, Nilsen F, Stdle AH. - most crucial measurement is degree of continuity of posterior facet, which is best determined by CT scan; - spinal compression frx; [CDATA[ - smoking patient who is unwilling to immediately quit smoking; - Intraarticular calcaneal fractures. Calcaneus Fractures - Trauma - Orthobullets ORTHO BULLETS Free CME Join nowLogin Select a Community MB 1Preclinical Medical Students MB 2/3Clinical Medical Students ORTHOOrthopaedic Surgery About Bullet Health Please confirm topic selection Are you sure you want to trigger topic in your Anconeus AI algorithm? Type 1A Medial tuberosity fracture Radiographics. Cochrane Database Syst Rev. Intra-articular fractures of the calcaneus: Present state of the art. Fractures of the calcaneus often result in collapse of the normal height of the heel bone. Rowe Classification: Types I-III do not involve the subtalar joint. Foot Ankle Int. 3) Vertical Significant varus or valgus alignment. 8600 Rockville Pike Clin Orthop Relat Res. var m3_r = Math.floor(Math.random()*99999999999); As Essex-Lopresti correctly noted 70 years ago, intra-articular fractures of the calcaneus result in morbidity figures substantially higher than those of extra-articular fractures. 6 (2):216-22. Intra-articular fractures are often classified using the Sanders classificationsystem, which is one of the only systems that correlates well with patient outcome. [QxMD MEDLINE Link]. Most commonly occurs as a result of a fall from a height the direct axial loading of the calcaneus by the talus may be associated with spinal fracture. J Orthop Trauma. Data Trace is the publisher of
Surgery for calcaneus fractures should be delayed, ideally for 10-14 days, in the presence of significant edema or fracture blister formation. - intra-articular - thalamic fragment: depressed portion of the posterior facet; - misc characteristics:
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