Treatment For Calcaneus Fracture

treatment of calcaneus fracture

Treatment For Calcaneus Fracture

The calcaneus is a unique part of the skeleton; structurally, the calcaneus lacks the cortical structures of long bones and is composed of trabecular bone.

Traction trabeculae radiate from the inferior portion of the calcaneus and compression trabeculae converge to support the posterior and anterior articular facets.

Biomechanically this bone confers—together with the talus and through tight articular junctions to the talus and the cuboid, respectively—the contact energy of the foot to the ground allowing to walk, run, and jump.

Fractures of the calcaneus that account for 60% of the tarsal injuries are therefore of great clinical impact to the patients affected, and their treatment requires major efforts of the orthopedic trauma surgeon

Calcaneal anatomy

The calcaneus is the bone that is most frequently fractured in the tarsus, 75% of fractures are intra-articular and its treatment is still the subject of debate today.

We intend in this update to highlight the points of controversy, as well as clarify the consensus, especially in the treatment of intra-articular fractures, and describe the management of the main complications.

Treatment For Calcaneus Fracture by Diagnosis Clinical:

Heel pain and swelling, hindfoot deformity, and functional impotence for support. Ecchymosis on the arch of the foot.

Appearance of blisters that determine the time of surgical treatment (anti-edema measures and elevation of the limb are important in these fractures).

Occasionally, there is peroneal dislocation or subluxation, neurovascular compression of the posterior tibialis, or interposition of the tendon of the flexor hallucis longus between the fragments (leaving the first finger in a fixed flexed position).

Plain radiographs: one. Lateral foot and ankle x-ray: we measured the following angles:

Bohler’s angle: determined by the intersection between a line that runs from the posterior tuberosity of the calcaneus to the posterior calcaneal-talar articular facet, and another from this point to the anterior superior calcaneal end.

It is considered normal between 25°-40°. Its value is reduced in proportion to the level of elevation of the posterior tuberosity and / or subsidence of the thalamus, unequivocal signs of the presence of a fracture.

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Treatment For Calcaneus Fracture By Surgical treatment:

The basic goals of surgical treatment are as follows: one. Reinstate the Bohler angle. two. Recover the normal width and length of the calcaneus.

Anatomical reduction of the articular surfaces, especially of the subtalar joint. Four. Restore the biomechanics of the hindfoot and the gastrosoleo complex.

Treatment of extra-articular fractures Generally, they have a good prognosis and with a good response to orthopedic and functional treatment.

treatment of calcaneus fracture

1. Anterior process fracture:

If <25% calcaneocuboid involvement: conservative: plaster boot in discharge 4-6 weeks. If> 25% joint involvement: surgical.

Fragmentary exeresis: Rarely, only if symptomatic nonunion is evident

2. Posterior tuberosity fracture:

Displaced: open reduction and osteosynthesis with 1-2 cancellous screws

Inguinopedic cast in equine one month and 2 weeks in neutral

Without displacement or in the elderly: functional treatment

3. Mediolateral process fracture (tuberosity:

Displaced: bloodless reduction and molded cushion plaster. Change after 10 days. Active mobilization per month and progressive support from 2 months

Not displaced: physical and postural measurements, compression bandage. Early active mobilization

4. Body fracture (non-articular):

Displaced: reduction after skeletal traction, leaving the nail included

Not displaced: physical and postural measures; early mobilization

5. Fracture of the sostenculum tali:

Displaced: osteosynthesis

Not displaced: physical and postural measures; early mobilization

Charging start after 2 months Free fragment excision if not consolidated

Treatment of intra-articular fractures

Type I sanders or bad candidates for surgery:

Conservative treatment:

Better to do early mobilization.

Elevation, compression, ice and early immobilization without loading for 10-12 weeks.

Useful in undisplaced fractures, or patients who cannot be operated on (poor general condition, peripheral vascular disease, poor soft tissue condition, uncontrolled psychiatric conditions, severe smoking, comminuted fractures).

Sanders types ii and iii

Closed reduction and percutaneous fixation

Many techniques described (needles, Steinmann nails, fixators) but do not reduce the joint directly (so they generally do not tend to be used).

Exceptions: If articular surface displaced <2 mm.

The Essex-Lopresti type of tongue fracture: in this case the joint fragment is attached to the bone fragment, and by reducing this, we also reduce the joint.

Open reduction and internal fixation (ORIF):

The only way to reduce joint surface with guarantees. Gold standard: extended “L” lateral approach is the one of choice. Other approaches described (medial, combined).

Sanders type iv

Similar to types ii and iii, but if there is a lot of comminution:

ORIF + primary subtalar arthrodesis (discussed) or Omoto technique + conservative treatment and delayed arthrodesis.

Tongue fracture

Reduction with a Steinmann nail and insert it in plaster (classic Essex-Lopresti technique) or Tornetta technique (modification of the previous technique + fixation with 6.5mm cannulated screws).

Bloodless handling and reduction

We advocate the non-invasive reduction of all displaced intra-articular fractures, regardless of the final treatment selected; this maneuver will be most effective in the first 72 h.

Omoto technique: under truncal or spinal anesthesia, we performed the reduction maneuver with the patient in the prone position, with the knee flexed at 90°.

The surgeon stands at the feet of the patient, covers both lateral faces of the calcaneus with the palms of the hands, and clasps the fingers on the heel.

Compress with both hands, pulling at the zenith, while applying alternating varus-valgus movements. During the maneuver, crackles are palpable and heard, which subside the moment we have “achieved reduction.” The assistant holds the limb at thigh level for countertraction. After the manipulation, we place a plaster splint with the ankle at 90°.

Calcaneus Fracture icd 10

extended lateral L-shaped approach

It is our technique of choice and seems to be the “gold standard” 6,7 for most intra-articular fractures; it is a modification of the technique described by Palmer and Letournel, later popularized by Benirschke and Sangeorzan.

It consists of a lateral approach that creates a full-thickness bone-to-bone flap that encompasses the peroneal tendons, the sural nerve, and the vascularization of the flap itself.

It allows us a perfect visualization of the entire lateral wall of the calcaneus from the posterior tuberosity to the calcaneocuboid and subtalar joints, and by making a bone window in the lateral wall itself, or by “opening” the fracture itself, it allows us to perform a reduction Indirect medial wall and sustentculum.

A fundamental maneuver in this technique is the Westhues maneuver for repositioning the posterior tuberosity of the calcaneus: it consists of inserting a Schanz screw or Steinmann nail with a T-handle into the tuberosity itself and, subsequently, under direct scope, performing a downward force with the handle that allows us to ascend the tuberosity to its original height.

Caution should be exercised in the elderly population or patients with secondary osteoporosis, since this traction can be difficult due to the poor grip of the pin in the porotic bone.

It also allows us to correct the varus-valgus. The main concern with this approach is wound healing and complication rates of up to 25% have been reported (flap necrosis, haematoma formation, infection, dehiscence, peroneal injury, sural neuropathy, etc.) 9.

Minimally invasive treatment

These techniques pursue the objective of minimizing the soft tissue injury produced by the standard approach but, on the contrary, they are more technically demanding and the quality of reduction achieved may be more difficult to achieve and maintain intraoperatively. Medial and lateral approaches have been described.


Medial approach: designed because in most cases the reduction of the medial wall through the lateral approach is indirect.

It is especially recommended in case of simple 2-part intra-articular fracture or extra-articular fractures. The main problem is the potential lesion of the posterior tibial neurovascular bundle, which is why it has become obsolete6,7.

Approach to the sinus tarsi. Of growing interest in current literature. Recently, Kikuchi et al.10 described good results in relation to the use of this approach, with lower rates of wound infection and similar functional results (AOFAS) in relation to the extended lateral approaches.

The approach is made approximately 1cm distal and posterior to the fibula and extended to the base of the 4th metatarsal (2-5cm in length).

The calcaneus (os calcis) is the bone that makes up the heel of the foot. Although it has a fairly irregular geometry, in general we can liken it to a lying quadrangular prism.

It therefore has six faces. Of these, the superior articulates with the talus and the anterior with the cuboid.

It is a bone that is usually compared to a boiled egg, since it has a thin layer of cortical bone that surrounds an interior composed of cancellous bone.

The objective of this arrangement is to distribute the loads that are produced in contact with the ground. As we said before, the anterior face of the calcaneus articulates with the cuboid bone, being most of it covered by cartilage.

The upper face also has a high percentage of its surface covered by cartilage, since it is the area of contact with the talus.

The joint between the calcaneus and talus is known as the subtalar joint and, although its range of motion is not excessively wide, it does play an important role in stabilizing gait. Especially when walking on uneven terrain.

The posterior part of the bone is known as the calcaneal tuberosity and the Achilles tendon is inserted into it, transmitting the forces exerted by the calf to perform the plantar flexion movement (standing on tiptoe)

As calcaneal fractures often affect the normal anatomy of the area, there are a number of anatomical landmarks that are used to determine the relative “natural” position between the bones. Using them, surgeons can rebuild the normal anatomy of the area after a fracture. The most commonly used are the so-called Bohler and Gissane angles.

Bohler angle: formed by the intersection between two lines. The first goes from the upper part of the posterior tuberosity of the calcaneus to the posterior talo-calcaneal articular facet.

The second goes from the anterior superior end of the calcaneus to the facet itself.

It usually takes a value between 20º and 40º. Gissane’s crucial angle: also formed by the intersection between two lines. In this case they are the tangents to the ascending and descending slope of the proximal (superior) surface of the calcaneus. It is normally between 100º and 130º.

Calcaneus Bone Pain

Fractures of the calcaneus account for only 2% of all fractures, but for as much as 60% of all injuries affecting the tarsal skeleton.

Displaced intraarticular calcaneal fractures constitute serious injuries that are often associated with late complications, that is, posttraumatic arthrosis and pain, and major consequences for the professional and daily life of the patient affected.2–5 Many authors have contributed to the understanding of this fracture.

The combination of shear and compression forces produce two characteristic primary fracture lines. Shearing forces cause a fracture dividing the calcaneus into its medial and lateral portions.

This fracture line typically splits the posterior facet, and if the force continues, the fracture line can extend as far forward as the anterior process or the calcaneocuboidal joint, creating an anterolateral fragment.

In contrast, compression forces are responsible for the fracture line that separates anterior and posterior portions of the calcaneus.

Although it is recognized that trauma energy and the position of the foot at the time of injury are important factors in the pathogenesis and severity of calcaneal fractures, the possible role of ageand gender-related changes in calcaneal microarchitecture on intraarticular calcaneal fractures remains largely undefined.

This is indeed a surprise, as the calcaneus—even if its structure- and age-related structural changes have never been histomorphologically studied in detail—is used as a diagnostic reference site for osteoporosis using indirect measurements of bone mineral density by ultrasound and magnet-resonance tomography.

Osteoporosis is characterized by a low bone mass and an increased risk to fracture.20 It is caused by an imbalance between osteoblastic bone formation and osteoclastic bone resorption, a physiologically balanced process called remodeling, which normally maintains bone mass almost constant.

Osteoporosis is the most frequent remodeling disease and constitutes a major health concern in the aging western hemisphere.

If, however, the calcaneus is a skeletal element that is prone to display the characteristic changes of osteoporosis in its microarchitecture, as it is the distal radius, the proximal femur, and the spine, then one has to consider that calcaneal fractures can occur as osteoporotic fractures as it is the case for fractures of the hip and the distal radius.

Furthermore, as due to the demographic changes in the developed countries osteoporotic fractures will double within the next 25 years; this would mean that calcaneal fractures will get even more clinical relevance in aged patients.

Therefore, the aim of this study is

(1) to analyze the trabecular microarchitecture of the calcaneus; and

(2) to determine whether calcaneal bone structure is changing with age. The latter two questions are addressed by histomorphometric analysis of 60 age- and gender-correlated human calcanei that were harvested at autopsy and subjected to morphologic, radiographic, mCT, and histologic analysis.

Based on direct histomorphometric data this study shows that the calcaneus presents significant age-related changes in its microarchitecture and a bone loss that is specifically evident beneath the posterior facet of the talocalaneal joint, the most important region in respect to intraarticular calcaneal fractures.

Taken together, this study suggests, that beside biomechanical factors, that is, trauma energy and position of the foot during trauma, the calcaneal bone structure might be an independent risk factor for fractures of the calcaneus

There is consensus that biomechanic factors, especially the energy of the trauma leading to the injury and the position of the foot at that time, are major components in the pathogenesis of calcaneal fractures, and this is clinically confirmed by the observation that most calcaneal fractures occur in physically active males like industrial workers.

However, that a destruction of the microarchitecture can constitute a risk factor to fracture has been recently suggested for patients with calcaneal bone cysts34 and also by a report of two cases with insufficiency fracture of the body of the calcaneus in elderly women.

In this regard, and given the complex structure of the calcaneus, it is surprising that a possible role of the calcaneal microarchitecture—and its deterioration in ageing and osteoporosis—in relation to fracture has never been studied in detail. Based on the fact that the calcaneus is used as a reference site for diagnosis of osteoporosis.

It was tempting to speculate that an age and osteoporosis-associated bone loss occurs within the calcaneus, Indeed, the EPIC-Norfolk prospective population study revealed that quantitative calcaneum ultrasound (QUS) predicts total and hip fracture risk in men and women in a continuous relation,

whereas Dr. Gluer and co-worker were able to demonstrate in the OPUS study that QUS worked as well as central DXA for identification of women at risk for prevalent osteoporotic vertebral fractures.

Thus, both studies independently suggest that the calcaneus is a skeletal element that is prone to undergo osteoporotic changes.

However, results from QUS measurements are focussed on the posterior part of the calcaneus, which do not necessarily reflect the situation in the region adjacent to the posterior facet, the thalamic portion of the calcaneus, which might be more important in respect to calcaneal fractures.

Moreover, ultrasound and MRIs that are used for BMD measurements at the calcaneus are indirect methods that do not allow full appreciation of bony microstructure beyond bone mineral density.

Lin et al. were the first to correlate MRI measurements f the calcaneus with selected histomorphometric data of three calcaneal specimens, and suggested that measurement of bone volume is feasible by MRI.

This was recently corroborated by a report of Boutry and coworker, who compared the structural parameter as assessed by MRI to histomorphometric analysis of a bone biopsy that was obtained from the superior part of the calcaneus in a series of 24 specimens.

A detailed morphometric analysis of the calcaneus that also accounts for

(1) age-related changes,

(2) the different regions of the complete calcaneus, and

(3) especially the thalamic portion below the posterior facet that is of critical importance for calcaneal fractures has not yet been published.

In females, the major loss of bone mass is observed at the transition from group I (32.8%) to group II (20.0%), while in males this bone loss in the superior region occurs later at the transition from group II (28.8%) to group III (19.2%).

Qualitative and structural histomorphometric analysis of the complete calcaneus demonstrates that the bone loss in the thalamic portion of the calcaneus is due to the transition of plate-like trabecular elements into a rod-like structure.

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