Fractures of the superior tuberosity beak or avulsion fractures represent 10% of extra-articular injuries. - Operative Versus Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures:A Prospective, Randomized, Controlled Multicenter Trial. - nondisplaced frx w/ mild or moderate decrease in Bohler's < are initially treated by early mobilization, avoidance of wt bearing for 6 weeks; 2002 Oct. 23 (10):906-16. Chap 29. [QxMD MEDLINE Link]. 2005;25(5):1215-26. 2007 Mar. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. Disclaimer. Medscape Education. - this pushes up depressed parts ofsubtalar joint; Inversion, lateral tuberosity. Please enable it to take advantage of the complete set of features! Conferences Calcaneal Fracture : Wheeless' Textbook of Orthopaedics Cotton commented in 1916 that "the man who breaks his heel bone is done so far as his industrial future is concerned." Extensive intraarticular fractures of the foot. Wheeless' Textbook of Orthopaedics. - technique: - anteriorly frx may exit laterally, usually at angle of Gissane, but it can also involve the calcaneocuboid joint; J Bone Joint Surg Am. - threaded Steinman pin is inserted through the posterior calcaneus into the cuboid; Foot Ankle Int. document.write ('&cb=' + m3_r); document.write ("'><\/scr"+"ipt>"); 1) avulsion due to pull of bifurcate ligament or EDB muscle, supination 2) compressive, pronated Rowe 2a Beak fracture, land on heel with knee extended and foot dorsiflexedRowe 2b avulsion of the entire insertion of the Achilles, older patients with DM and osteoporosis Rowe 3a simple body fracture, STJ not fractured or depressed Rowe 3b comminuted body fracture, STJ not fractured or depressedIf the posterior facet is not involved, usually closed reduction with cast immobilization for six weeks is good.Rowe 4a simple body fracture, STJ fracture, but not depressedRowe 4b comminuted body fracture, STJ fracture, but not depressedRowe 5a comminuted body fracture, STJ fracture, and STJ depressionRowe 5b comminuted body fracture, STJ fracture, STJ depression, CC joint fracture 2002 Oct. 84 (10):1733-44. Type III (20%) are oblique fractures. Calcaneal Fractures | Causes and treatment options Open injuries that have been reported have occurred in only 2% of cases. - Essex Lopresti: [QxMD MEDLINE Link]. Intra-articular fractures of the calcaneum treated operatively or conservatively. - thalamic fragment: depressed portion of the posterior facet; - misc characteristics: Badillo K, Pacheco J, Padua S, Gomez A, Colon E, Vidal J. Multidetector CT Evaluation of Calcaneal Fractures. Clipboard, Search History, and several other advanced features are temporarily unavailable. ADVERTISEMENT: Supporters see fewer/no ads. - typically results from fall from height (see mechanism) Patient Assessment and Examination Biomechanics Design The design was a prognostic study of a retrospective cohort with concurrent follow-up. - Discussion: - smoking patient who is unwilling to immediately quit smoking; Amani A, Shakeri V, Kamali A. Twelve observers classified 30 intra-articular calcaneal fractures . Brunner A, Heeren N, Albrecht F, Hahn M, Ulmar B, Babst R. Foot Ankle Int. Radiographic evaluation of calcaneal fractures: to measure - Springer Ten percent of calcaneus fractures are bilateral. Cohort study on the percutaneous treatment of displaced intra-articular fractures of the calcaneus. Materials and methods: For 152 patients (189 calcaneal fractures; average followup, 9.9 years), all fractures were classified in accordance with the Essex-Lopresti, OTA, Regazzoni, and Sanders classifications and matched with the following scores: AOFAS score, CNHF, FOA, MFS, Rowe, MFA, SF-36, and VAS. [QxMD MEDLINE Link]. The medical approach for calcaneal fractures. Compare minimally displaced calcaneal tuberosity fracture on patient's left side with comminuted intra-articular (Sanders type III) fracture on right. 2018;57(3):572-8. 6 (2):216-22. Comparison of calcaneus joint internal and external fractures in open surgery and minimal invasive methods in patients. 9th ed. Indian J Orthop. document.write ("&loc=" + escape(window.location)); [QxMD MEDLINE Link]. - large threaded Steinman pin is placed through the posterior superior portion of the calcaneal tuberosity; The site is secure. Treatment: Injury. [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. Complications (eg, malunion or screw positioning deviation) occurred in six patients and delayed wound healing in one. Exudate-filled blisters Significant edema/hematoma Patient unable to bear weight Recent flashcard sets A1 S1 TP 1&2 anatomie - vertbres (droul Reference article, Radiopaedia.org (Accessed on 01 May 2023) https://doi.org/10.53347/rID-12879, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":12879,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/calcaneal-fracture/questions/2122?lang=us"}. Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic AssociationDisclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker. - most crucial measurement is degree of continuity of posterior facet, which is best determined by CT scan; fracture, Rowe Classification: Scott Nicklebur, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of PhysiciansDisclosure: Nothing to disclose. The most common method for classifying these fractures is the Rowe classification scheme, with five types. J Foot Ankle Surg. Degan TJ, Morrey BF, Braun DP. The subtalar joint is involved 75% of the time. Rowe Calcaneal Fracture - Radiology and Biomechanics 7,462 views Sep 13, 2014 Mansoor Ahmed Show more 114 Dislike Share ahMEDacademy 3.54K subscribers Myerson classification - LisFranc. Calcaneus fractures - OrthopaedicsOne Articles - OrthopaedicsOne Computed tomographic assessment of soft tissue abnormalities following calcaneal fractures. 2006 May. Open Fractures of the Calcaneus: Soft-Tissue Injury Determines Outcome. - Complications of Treatment, Current Concepts Review. 8600 Rockville Pike Foot Ankle Orthop. 1931. Broden B. Roentgen examination of the subtaloid joint in fractures of the calcaneus. 2% of all fractures and 60% of all rearfoot trauma. - Rowe: types 1-5 (types 4-5 intra-articular) 1963. A so-called "lover's Fracture" is an intra-articular fracture produced by an axial loading force typically produced by a leap from a height with person landing on heels (also called a "Don Juan" fracture) Why is it called a "Lover's fracture?". Cochrane Database Syst Rev. Foot Orthotics Classifications in Brief: Sanders Classification of Intraart - LWW If very symptomatic, use a SLC with initial NWB period until pain subsides. Vol 2: Chap 67. Skeletal Trauma. Intra-articular Calcaneus Fractures: Current Concepts Review. - joint depression calcaneal fracture. Unable to process the form. Data Trace is the publisher of Schuberth JM, Cobb MD, Talarico RH. Zwipp H, Paa L, ilka L, Amlang M, Rammelt S, Pompach M. Introduction of a New Locking Nail for Treatment of Intraarticular Calcaneal Fractures. Become a Gold Supporter and see no third-party ads. Application of medial column classification in treatment of intra-articular calcaneal fractures. Professional Organisations [QxMD MEDLINE Link]. Calcaneus fractures. - historical treatment has included closed reduction (Bohler) w/ distraction and medial lateral compression; Results of closed treatment. Malunited calcaneal fracture: the role and technique of - Springer A critical analysis of results and prognostic factors. Bethesda, MD 20894, Web Policies - technique: At follow-up, only 12 of the 22 patients (55%) of the patients had very good or good clinical results; four had average results, and six had poor results. J Bone Joint Surg Am. [21] Whereas the minimally invasive approach resulted in a lower postoperative complication rate for Sanders type II and III injuries, functional outcomes were similar. Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Philadelphia: Elsevier Saunders; 2014. Epub 2013 Oct 28. [QxMD MEDLINE Link]. A complete blood count (CBC), blood. 3. An official website of the United States government. [QxMD MEDLINE Link]. Rowe Calcaneal Fracture - Radiology and Biomechanics - YouTube Intra-articular fractures constitute 70% of all calcaneus fractures in adults. Ideally, the CT scans are formatted in two planes: the semicoronal or oblique coronal plane, which is perpendicular to the posterior facet . 9:854210. A prospective study. Bridgman SA, Dunn KM, McBride DJ, Richards PJ. - this stabilizes the valgus reduction; Results of fractures of the os calcis. Telephone: 410.494.4994, Displacement of the Sustentacular Fragment in Intra-Articular Calcaneal Fractures, The management of soft-tissue problems associated with calcaneal fractures, Compartment syndrome of the foot after intraarticular calcaneal fracture. Check for errors and try again. Sustentaculum tali fractures are rarely seen as isolated injuries. A systematic search for articles dealing with calcaneal fracture was performed, and the prevalence of use of each classification system determined. Calcaneus Fractures Clinical Presentation - Medscape - Intra-articular fractures of the calcaneum treated operatively or conservatively. - tongue fracture Philadelphia: Elsevier; 2020. Is Bone Mineral Density Testing Underused in Prostate Cancer Care? Mann's Surgery of the Foot and Ankle. The French surgeon described two types of fracture mechanisms: an avulsion injury resulting from muscular pull and a crushing injury. Grn W, Molund M, Nilsen F, Stdle AH. 1949. [24] At 1 year, group 1 had a mean Maryland Foot Score (MFS) of 79 and an American Orthopaedic Foot and Ankle Society (AOFAS) score of 77.37, whereas group 2 had an MFS of 84.4 and and AOFAS score of 86.1. 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. Mondors sign bruising from malleoli to sole of foot common in calcaneus fractures. [QxMD MEDLINE Link]. 1) Tongue type with displacement 2018 Apr. Calcaneus fractures are most commonly seen in young men. A frustrating factor that perpetuates this disagreement is the subset of calcaneus fractures with poor long-term outcomes, regardless of management. [Full Text]. Concomitant spine and calcaneum fractures: a possible indication of 2015;205(5):1061-7. 2) Avulsion of medial border 7 (5):417-27. - distraction helps restore calcaneal width and height - no attempt is made to reconstruction the articular surface; Patients A total of 33 patients with a unilateral calcaneal fracture and a minimum follow-up of 13 months participated. [QxMD MEDLINE Link]. Initial management compression and elevation to reduce swelling; Compartment syndrome is early complication needs immediate fasciotomy, Long term sequelae: a) Without displacement For 152 patients (189 calcaneal fractures; average followup, 9.9 years), all fractures were classified in accordance with the Essex-Lopresti, OTA, Regazzoni, and Sanders classifications and matched with the following scores: AOFAS score, CNHF, FOA, MFS, Rowe, MFA, SF-36, and VAS. Zhonghua Wai Ke Za Zhi. J Foot Ankle Surg. The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures . Aditya Daftary et.al. There were no wound infections. 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. Calcaneal fractures are the most common tarsal fracture and can occur in a variety of settings. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Calcaneal Fracture Classifications - Everything You Need To Know - Dr. Nabil Ebraheim - YouTube Dr. Ebraheim's educational animated video describes the classifications of calcaneal. Galluzzo M, Greco F, Pietragalla M et al. For patient education resources, see theFirst Aid and Injuries Center, as well asBroken Foot,Understanding X-rays, andCast Care. 2007 Aug. 120 (2):459-66; discussion 467-9. Minimally invasive arthroscopic-assisted reduction with percutaneous fixation in the management of intra-articular calcaneal fractures: a review of 24 cases. This classification is based on the number of intraarticular fracture lines and their location on semicoronal CT images. [4] : Both of these describe the primary fracture line. 1998;27(1):1-6. Eur J Transl Myol. - Sander's Classification: 2000. 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.