Fractures of The Calcaneus

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TREATMENT OF COMPLEX FRACTURES

FRACTURES OF THE CALCANEUS David P. Barei, MD, FRCS(C), Carlo Bellabarba, MD, Bruce J. Sangeorzan, MD, and Stephen K. Benirschke, MD

Fractures of the calcaneus account for approximately 60% of tarsal injuries and usually are the result of a fall from a height. Of those injured, 80% to 90% are men in their prime working years.21, 40, 73, 93, 94, 101 Other injuries to the appendicular and axial skeleton occur frequently and should be sought. Despite the relative prevalence of this injury, definitive management is controversial. Historically the closed treatment of these injuries had been unsatisfactory, leading Cotton and Wilson23 to write in 1916, “the man who breaks his heel bone is done.” Conn22 reiterated this pessimistic view, reporting “calcaneus fractures are serious and disabling injuries in which the end results continue to be incredibly bad.” Later, Bankart5 similarly reported his experience: “the results of crush fractures of the os calcis are rotten.” Because the bony architecture is complex and the soft tissue envelope tenuous, open reduction is challenging and fraught with potential morbidity. Historically, open treatment failed to show improved outcome over non-operative care and in some circumstances resulted in a worse outcome.31, 32, 47, 52, 58, 71, 73, 82, 94, 105 Modern techniques allow a better appreciation of the complex fracture and bony anatomy. Open reduction with rigid internal fixation is the standard for displaced intra-articular fractures in other weight-bearing joints. Unfortunately, the results of contemporary open treatment have not been as satisfactory in the calcaneus as in other intra-articular fractures. Current

techniques of radiographic imaging, fixation methods, rehabilitation, and outcome assessments suggest that an improved result can be achieved.72, 80, 98, 102 ANATOMY The calcaneus is a three-dimensionally complex bone with five clinically significant aspects of the bony anatomy (Fig. 1) (1) The superior surface has three articular facets supported by a complex corticocancellous bony structure. The large posterior facet and the smaller middle and anterior facets function as a single articulation with the talus and together compose the inferior portion of the subtalar joint. Changes in the relationships among the facets affect subtalar joint mechanics and are analogous to an intra-articular fracture even when the fracture line does not traverse a cartilage surface. A shallow oblique groove that represents the floor of the tarsal canal separates the posterior facet from the anterior and middle facets. Laterally the tarsal canal opens into a recessed area anterior to the posterior facet known as the sinus tarsi. The relationship among the articular surfaces defies simple description. (2) The middle and anterior facets frequently are contiguous and, although smaller than the posterior facet, bear more weight per unit area.103 The dense bone of the sustentaculum tali supports the lesser facets and provides an optimal site for rigid screw fixation. (3) The medial wall is sharply sloped

From the Department of Orthopaedic Surgery, University of Washington, Harborview Medical Center, Seattle, Washington

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Figure 1. See legend on opposite page

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and is in close proximity to the medial neurovascular structures and flexor group of tendons. It is less surgically accessible and more vulnerable to neurovascular injury. (4) The lateral wall of the calcaneus is relatively flat and is covered primarily by skin and subcutaneous tissue; this allows easier surgical access and facilitates placement of fixation devices. The lateral aspect of the calcaneus is subject to soft tissue complications. (5) Distally the anterior portion of the calcaneus articulates with the cuboid creating a mobile joint. Secondary fracture lines that involve this distal facet occur frequently and when displaced result in articular incongruity. The calcaneus functions as a major vertical support, or foundation, during weightbearing activities and as a fulcrum allowing effective function of the calf musculature. In the intact calcaneus, the superior facets act together to allow an oblique rotation of the hindfoot that accounts for most of the inversion and eversion of the foot.103 Simplistically, subtalar inversion locks the midtarsal joints, allowing the foot to function as a rigid platform for push-off. Conversely, subtalar eversion creates relative motion at the midtarsal joints allowing the foot to absorb energy during heel-strike. An effective gait is achieved by maintenance of lateral column length and heel height coupled with smooth, adequate subtalar joint motion. Given this intricate relationship, a truly anatomic fracture reduction is difficult. FRACTURE ANATOMY Calcaneal fractures typically result from axial loading mechanisms. On impact, the talus continues the downward descent into the relatively stationary calcaneus. The inferior midcoronal portion of the talus, including the lateral process, acts as a fulcrum, or wedge, fracturing the calcaneus. The ultimate fracture pattern depends on numerous variables, in-

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cluding the lateral position of the calcaneus beneath the talus,85 the changing position of the foot at impact, the quality of bone, and the direction and magnitude of the resultant force. Despite the infinite potential configurations, certain consistent fracture patterns have been observed (Fig. 2).17 Although its position varies, a primary fracture line or separation fracture is common to most intra-articular fractures of the calcaneus.6, 8, 17, 19 This primary fracture line begins in the sinus tarsi near the lateral wall and propagates obliquely across the posterior facet to the medial wall. The anterolateral exit point is at the angle of Gissane but may extend anteriorly as far as the calcaneocuboid joint.14,28 The posteromedial exit point is posterior to the sustentaculum. The primary fracture line divides the calcaneus into posterolateral and anteromedial fragments. The posterolateral segment consists of the tuberosity and lateral wall with a variable portion of the posterior facet. The anteromedial segment comprises the remaining posterior facet and the sustentacular fragment with the middle and anterior facets. The posterolateral tuberosity fragment typically is driven anteriorly and laterally along the primary fracture line, assuming a position beneath the fibula. The anteromedial sustentacular fragment may rotate downward away from the talus, particularly in highenergy injuries, and locks into the posterior facet fragment.64 Disimpaction of the tuberosity allows the sustentacular fragment to rotate back to its native position secondary to its strong soft tissue attachments. Additional secondary fracture lines invariably occur. These include a medial fracture extension that divides the middle facet from the posterior facet and an anterior fracture extension that divides the anterior process, producing a common anterolateral fragment.18, 53 Secondary fracture lines in the body of the calcaneus further affect the posterior facet fragment. The morphology of the lateral posterior facet fragment depends on the exit point

Figure 1. A, Lateral view of the normal talocalcaneal relationship. B, Lateral view of the calcaneus with the talus removed. The posterior facet (PF), middle facet (MF), and distal articular facet (CC) are demonstrated. The distal articular facet is the calcaneal portion of the calcaneocuboid joint. C and D, The superior aspect of the calcaneus demonstrates the posterior facet ( gray arrow ) and the confluent anterior and middle facets ( black arrow ). These facets constitute the inferior portion of the subtalar joint and articulate with corresponding areas on the inferior surface of the talus. E, This posterior view of the calcaneus demonstrates the relationship of the posterior facet ( white arrow ) to the sustentaculum tali ( black arrow ) and the sloping medial wall. F, Relationship of the posterior facet (PF), middle facet (MF), and distal facet (CC) to each other and to the tuberosity as viewed from the distal aspect of the calcaneus.

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Figure 2. A, Primary ( black arrow ) and secondary anterior ( gray arrows ) fracture lines, viewed from the superior aspect of the calcaneus. Note the creation of the posterolateral and anteromedial fragments by the primary fracture line. B, This axial CT image demonstrates the primary fracture line ( white arrow ). The tuberosity segment is displaced laterally and distally along the primary fracture line, thus shortening and widening the heel. A portion of the posterior facet (PF) remains attached to the sustentaculum tali (ST). C and D, The direction of the primary fracture line on the lateral view is typically vertical. When a secondary posterior fracture line is transversely oriented and exits the tuberosity on its posterior surface, a separate “tongue” fragment is created. This fragment is composed of a portion of the posterior facet and the tuberosity. Understanding this relationship facilitates reduction of the posterior facet in “tongue-type” fracture patterns. E and F, When the secondary fracture line exits on the superior aspect of the tuberosity, a “joint depression” fragment is created. Typically, this fragment is depressed and rotated into the body of the calcaneus. Unlike the “tongue-type” fracture, manipulation of the tuberosity does not reduce the posterior facet in a “joint depression” fracture. Illustration continued on opposite page

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Figure 2 (Continued ).

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of this fracture line relative to the calcaneal body and tuberosity. Two common patterns have been identified. A fracture line that travels in a transverse plane and exits the calcaneal tuberosity on the upper posterior surface results in a tongue-type fragment. The relationship of the lateral posterior facet and the superior aspect of the tuberosity remains intact. Joint depression fractures are those in which the secondary fracture line separates the lateral posterior facet from the body and tuberosity of the calcaneus. This fragment is rotated or depressed into the body. The relationship between the depressed fragment and the tuberosity is altered. Continued impaction of the lateral edge of the talus into the calcaneus results in additional comminution of the posterior facet, creating extreme lateral posterior facet fractures and multiple chondral and osteochondral fracture fragments. Comminution and impaction of the posterior facet drives the lateral wall fragments further laterally and exacerbates subfibular impingement. Conceptually the primary fracture line is a reproducible part of a stellate fracture pattern centered in the sinus tarsi. The final defor-

mity reflects the predictable displacements of the major fracture fragments relative to each other. The calcaneal length and height are diminished. The heel is widened secondary to the displacement of the posterolateral tuberosity fragment and the associated lateral wall blowout. The posterior facet is incongruent and potentially multifragmented. The relationship of the 3 superior facets necessarily is altered. Anterior process fractures may result in calcaneocuboid incongruity, which, if extensive, jeopardizes distal screw purchase (Fig. 3). Loss of Bohler’s angle results in a more horizontal attitude of the talus and affects tibiotalar and talonavicular mechanics. Loss of normal talonavicular and calcaneocuboid interaction affects midtarsal mobility. CLASSIFICATION Several fracture classifications have been proposed, none of which is accepted universally or has shown reproducible prognostic potential.20, 24, 26, 50, 84 The major, more recent classification systems are based on 3 fracture characteristics: displacement, the presence of

Figure 3. A and B, Severe anterior process comminution ( black arrow ) may preclude satisfactory screw purchase. Distal facet comminution and anterolateral fragments can also be seen. In these situations, fixation may be extended to the intact cuboid.

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posterior facet involvement, and the severity of posterior facet involvement. Only computed tomography (CT) can assess this last feature accurately. Descriptive classifications use basic fracture terminology, such as nondisplaced or displaced and intra-articular or extra-articular. The amount of comminution, the presence of open wounds, and the relationship of the posterior facet relative to the tuberosity (Bohler’s angle) (Fig. 4) describe the fracture further.8 Early formal classifications were based on plain radiographs, particularly the lateral image.31, 82, 104 The difference between extra-articular and intra-articular fractures was emphasized by Essex-Lopresti31, 32 and reflects the general impression that extra-articular fractures tend to have better outcomes than fractures involving the subtalar joint. Essex-Lopresti31 identified

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two distinct intra-articular fracture patterns: the joint depression fracture and the tongue-type fracture (see Fig. 2C–F). As described previously, the difference between these two fracture types depends on associated secondary fracture lines relative to the tuberosity fragment. Theoretically, the differences between the two types should be easily discerned. In the more common complex fracture patterns, however, the distinction may not always be obvious. The Essex-Lopresti system is simple to use and relies on readily available radiographs, but the category joint depression is not detailed enough to facilitate prognosis or communication between orthopedists. CT improves the ability to assess articular and nonarticular comminution. Several CTbased classification systems have been created that focus on the articular injury, particularly

Figure 4. A, Bohler’s angle, the complement of the angle subtended by the two lines demonstrated, decreases with depression of the posterior facet or shortening of the heel. B, The angle of Gissane is densely corticated and is a common exit point of the primary fracture line along the lateral aspect of the calcaneus.

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articular injury to the posterior facet.19, 24, 84 The CT classification system of Sanders et al84 is used widely and is based on the number and location of calcaneal posterior facet fracture lines relative to the widest portion of the posterior facet of the talus (Fig. 5).84 Although the ability of treating physicians to assess these parameters has never been validated, it is likely that the greater the comminution, the greater the energy, with worse prognosis.76, 79 The lack of matched, nonoperatively treated patients complicates the ability to draw strong prognostic conclusions from all proposed classifications. Although the subtalar joint has three facets that function as a single complex articular surface, none of the current classifications considers displacement that disturbs the relationships between the three facets. This independent variable may account for discrepancies in the reliability of the classification systems. Alterations in the size and shape of the calcaneus, involvement of the calcaneocuboid joint or the anterior and middle facets, and associated soft tissue injury also may affect outcome. These factors further hinder an effective and comprehensive classification system. IMAGING The acutely traumatized foot (Figs. 6 and 7) is imaged initially with dorsoplantar, lateral,

and oblique plain radiographs. The diagnosis of most calcaneal fractures is made on these initial images, particularly the lateral view. The addition of the axial view generally completes the plain radiographic investigation. The dorsoplantar view shows involvement of the calcaneocuboid joint and lateral wall displacement. The lateral view allows assessment of posterior facet position and loss of calcaneal height (Bohler’s angle) and gives a general impression of overall comminution. The axial view is informative and shows the direction and displacement of the tuberosity along the primary fracture line. Widening of the heel, varus angulation, lateral wall displacement, and fibular abutment also typically are seen. Posterior facet incongruity and its relationship to the sustentacular fragment are visualized, provided that the radiographic technique is satisfactory. Comparative lateral and axial views of the contralateral uninjured calcaneus facilitate the assessment of displacement and help guide fracture reduction. Multiple hindfoot oblique views may be obtained to image the posterior facet further.10 These views are obtained by placing the cassette behind the heel and distal tibia with the foot in varying degrees of rotation. The x-ray beam is aimed cephalad and brought through a 0◦ to 40◦ arc in 10◦ increments. Each image shows a different portion of the posterior facet. Although these views largely have been replaced by CT scanning, they may be helpful intraoperatively.

Figure 5. Sander’s classification emphasizes posterior facet comminution. A, A two-part fracture pattern is visualized on the coronal CT image. Lateral wall (LW) displacement is noted beneath the fibula, B, A severer three-part fracture is demonstrated on this CT coronal reconstruction. The relationship of the fracture lines to the talus (T) further describes the fracture pattern. Bony debris is again noted in the subfibular area.

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Figure 6. This gentleman was injured after falling from a ladder. A, The preoperative lateral image demonstrates a tongue-type fracture pattern with loss of Bohler’s angle and a double density corresponding to displacement of the posterior facet. B, The axial radiograph demonstrates heel widening, and lateral wall displacement beneath the fibula. C and D, The postoperative radiographs reveal satisfactory restoration of heel height, width, and posterior facet congruency.

CT facilitates the preoperative plan and shows previously unrecognized fracture comminution. Surrounding soft tissue injury, particularly of the peroneal tendons, is occasionally observed.9, 30, 81 CT scanning should include 2 planes: a transverse plane that parallels the plantar surface of the foot and a semicoronal plane perpendicular to the posterior facet.87, 88 The transverse plane images show secondary fracture lines traversing the sustentacular segment and anterior process and calcaneocuboid joint involvement. Sagittal

and coronal reconstructions further enhance comprehension of the complex fracture and bony anatomy. Modern computer software programs minimize radiation exposure and scan time by creating these reconstructions with reformatting techniques. The quality of the reformatted images depends on excellent initial CT scans. Three-dimensional CT reconstructions may improve conceptualization of the injury further but are not obtained routinely. Magnetic resonance imaging has been used experimentally to evaluate the status of

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Figure 7. This comminuted calcaneal fracture was the result of a high-speed motor vehicle collision. The patient was polytraumatized. A–E, The preoperative plain radiographs and CT images reveal significant injury to the posterior facet, widening of the heel, and loss of calcaneal height. The horizontal attitude of the talus is noted. The primary fracture line (PFL) can be seen on the axial radiograph. F and G, The postoperative images show satisfactory reduction of the key elements of the fracture. AP = anterior process, CC = calcaneocuboid joint; Cu = cuboid; LW = lateral wall; PF = posterior facet; ST = sustentaculum tali; T = tuberosity; TH = talar head. Illustration continued on opposite page

the plantar fat pad after calcaneal fracture but is used rarely in the acute setting.56

TREATMENT The management of displaced intraarticular calcaneal fractures is controversial. Treatment should attempt to improve on the natural history of the injury. The ideal prospective natural history study has not been performed. Long-term retrospective data of intra-articular calcaneal fractures managed nonoperatively showed that most patients

have long-term symptoms.51, 58, 60 Other authors have reported relatively satisfactory long-term results in severely displaced fractures managed conservatively.60, 79, 83 Closed Treatment The principles of closed functional treatment are acute pain relief, control of swelling, and early motion. Rest, ice, compression, and elevation are emphasized initially. Early motion aids functional recovery and seems to be more important than maintaining position with immobiliztion.32, 58 If closed treatment

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Figure 7 (Continued ).

is selected, the injured foot and lower leg are placed in a compression dressing followed by a removable splint or commercially available boot. The patient should be non–weight bearing on the affected extremity. Early splinting prevents the occurrence of equinus contracture and minimizes discomfort. Rangeof-motion exercises are instituted as soon as the swelling and pain are under control. Progressive weight bearing is started when the fracture is healed, generally between 6 and 12 weeks. Then graduated stretching and strengthening exercises are begun. Custom orthoses may improve standing and walking tolerance. A good-to-excellent outcome occurs less than half the time with this treatment.51 Closed manipulative reduction also has been recommended.4, 8, 31 The goal of this treatment is to restore the overall shape of the calcaneus, with emphasis on restoring Bohler’s angle, obtaining posterior facet congruency, and reestablishing normal heel width. This

operation requires relaxation of the gastrocnemius muscle by knee flexion and some form of traction on the heel.21, 58 A well-molded plaster cast usually is necessary to maintain the reduction. These techniques may be impressive in restoration of heel height and normalizing width, but except in unique circumstances, they are not particularly effective in obtaining posterior facet congruity.31, 38, 89 This method has limited indications but may be useful in managing patients who are not candidates for open treatment. The principles of manipulative reduction, particularly of the calcaneal tuberosity, frequently are used during formal open reductions. Indications and Rationale for Surgical Treatment Virtually every aspect of the surgical management of complex calcaneal fractures is a source of debate. Basic concepts, such as

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the method and need for extra-articular and intra-articular reduction, the choice of surgical approach, bone graft requirements, patient position, implant selection, and outcome assessment, all are controversial issues.91 The inability to show significantly superior outcomes after surgical management fuels this controversy further. The principles of bony reconstruction, particularly in weight-bearing joints, include anatomic reduction and rigid fixation of intraarticular fractures and accurate restoration of coronal, sagittal, and transverse mechanical axes. Adherence to these principles maximizes the chance for optimal outcome, but application of these principles to the calcaneus has been slow. Complex bony and fracture anatomy, a tenuous soft tissue envelope, and the difficulty of achieving anatomic reduction and rigid fixation are important complicating issues. Although clinical experience suggests that there are some instances in which open management is superior to closed management, exact indications are elusive. Long-term symptoms occur in most patients with displaced calcaneal fractures treated nonoperatively.51, 58 The severity of these symptoms is related to the initial fracture pattern and subsequent widened heel; shortened lateral column; and incongruent, stiff subtalar joint. Degenerative changes in the tibiotalar joint are caused by the altered position of the talus during weight-bearing activities. Hindfoot pain and swelling are the major manifestations.19, 52, 58, 76, 79 Early surgical attempts at improving the outcome after calcaneal fractures met with a significant incidence of wound complications, particularly sepsis. In these situations, the results of operative treatment have led to worsened outcomes than the natural history of the initial injury58 and are supportive of nonoperative management. The ideal method of determining treatment for any disease process is first to study prospectively the natural history, then to compare this with the outcomes obtained in a group of patients assigned randomly to a specific treatment. The randomized controlled trial, although ideal in theory, has several problems when used in surgical situations. A few of these problems include factors related to the technical performance of the surgical procedure, the learning curve,84 standardization of the technique, anticipation of special situations, and the experience of the participating surgeons. Specific problems related to

advanced trials of calcaneal fractures include the lengthy follow-up needed, the ability to generalize the results to the orthopedic community, obtaining statistical power, and the validity of the outcome measurement tools. A Canadian multicenter randomized controlled clinical trial comparing operatively versus nonoperatively managed displaced calcaneal fractures is ongoing. Despite the problems inherent to large randomized surgical trials, these results should help substantially in defining the indications and results of operative treatment. As in most orthopedic literature, retrospective studies form most opinions regarding calcaneal fracture management. These include retrospective cohort-matched studies,12 studies using CT to classify the acute injury,24, 61, 84 CT assessment after open treatment,43, 46, 90 and biomechanical studies.3 The value of the prospective studies that have been performed to date has been limited by the small study populations, surgeon-randomized allocations, relatively short follow-up, and suboptimal postoperative radiographic evaluation.74, 98 Variations in surgical technique and other treatment parameters also make direct comparisons between studies difficult.78 Together, these studies suggest several concepts. Displaced fractures seem to have a worse outcome than nondisplaced fractures.24 Increasing numbers of fracture lines and displacement of the posterior facet typically are the result of high-energy forces, and these fractures have worse outcomes than those with less involvement of the posterior facet.46, 76, 84 Anatomic restoration of the posterior facet correlates with, but does not guarantee, a good result.84 Obtaining an anatomic posterior facet reduction becomes more difficult with increased articular comminution. Posterior facet incongruity and degeneration, as measured by CT scan, have been correlated with a loss of subtalar motion and are strong predictors of a poor clinical outcome.46 The clinical importance of posterior facet congruity is supported by biomechanical data. Specifically, articular incongruity alters contact stress patterns across the posterior facet,3, 67 presumably affecting cartilage wear and predisposing to posterior facet arthrosis. The alteration in subtalar mechanics with simulated injury to the lesser facets has not been evaluated. Other factors associated with long-term patient dissatisfaction or painful sequelae include calcaneofibular abutment, peroneal tendon irritation, sural nerve entrapment, heel

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pad dysfunction, generalized swelling, and hindfoot stiffness.44, 45, 58, 63 Maneuvers that allow improved gait correlate with improved clinical and functional scores.20, 51 Although small numbers and multiple categories make the conclusions more empirical than scientific, these predominantly retrospective studies suggest that treatments that diminish swelling, improve posterior facet congruency and subtalar motion, and decompress the subfibular area (narrow the heel) are likely to lead to the best clinical outcome. In all studies, however, only 15% to 20% of patients were completely pain-free. This small percentage suggests a need to identify sources of longterm discomfort to improve the outcome of this injury.46, 58, 61, 76, 79, 84, 85 Based on this historical information, indications for surgical treatment are an incongruous subtalar joint with more than 2 mm displacement; gross displacement of the heel, particularly with subfibular impingement; depression of the talus into a horizontal position; or bony pressure points likely to ulcerate or give mechanical pain. The status of the surrounding soft tissue envelope and the patient’s lifestyle and expectations further modify the decision-making process. Contraindications to surgical treatment include peripheral vascular disease, peripheral neuropathy, advanced age, sedentary lifestyle, inadequate soft tissue envelope, and patient unwillingness to proceed with unproven treatment. All but the last of these items are relative contraindications. Threatened soft tissues secondary to prominent displaced fracture fragments may force intervention in patients with peripheral neuropathy or vascular disease. Under these circumstances, reduction may salvage the significantly jeopardized soft tissue envelope. Age, sedentary lifestyle, and occupation are relative criteria that should be balanced against the degree of deformity and likelihood of poor outcome from closed treatment. Surgical treatment logically addresses the anatomic causes of patient dissatisfaction. Restoring calcaneal height improves the tibiotalar position and may diminish long-term degeneration in the ankle. Reestablishment of heel length may improve shoe comfort, midtarsal mechanics, and the lever arm of the gastrocnemius-soleus complex. Normalizing calcaneal height and length necessarily narrows the heel as the tuberosity is brought back along the primary fracture line beneath and posterior to the posterior facet.44 Reducing the

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lateral wall blowout completes the subfibular decompression. Reduction of the articular facet surfaces and accurate reestablishment of the geometric relationships between the 3 superior calcaneal facets should minimize the subtalar pain associated with the development of arthrosis and stiffness. In situations in which marked comminution of the posterior facet precludes a satisfactory reduction, restoration of extra-articular anatomy followed by acute subtalar arthrodesis has been advocated. Several authors have reported reasonable success with this technique in limited numbers.11, 37, 42, 70 Significant controversy exists as to the most effective means of achieving satisfactory patient outcomes after sustaining a displaced, intra-articular calcaneal fracture. Timing Most calcaneal fractures are repaired surgically in a delayed fashion to allow for the initial swelling to resolve.85 Acute intervention through the significantly traumatized zone has resulted in early wound breakdown and complications.39 Most definitive interventions can be performed between 7 and 10 days. Injuries with associated marked edema and fracture blisters may require delays of 2 to 3 weeks. In these situations, the application of a foot pump has been shown to expedite edema resolution and is well tolerated by the patient.96 Reduction maneuvers become increasingly difficult with the increased delay. Delayed surgery in fractures with marked shortening may decrease significantly the pliability of the anticipated lateral skin flap. Particular attention to closure of this flap is required. Surgical Approach Several surgical methods are available for calcaneal fracture surgery, including minimally invasive and open techniques. Modern percutaneous reduction and screw fixation techniques are an extension of closed manipulative reductions described by Essex-Lopresti and are successful in properly chosen fracture patterns (Fig. 8).99, 100 Minimal open procedures combined with circular ring external fixation also have been described.75 These techniques and others, such as the use of bioabsorbable implants,49 currently are being investigated. Open calcaneal fracture surgery can be performed using medial, lateral, or combined

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Figure 8. A–F, This fracture was managed acutely with percutaneous techniques. Note that the articular surface of the posterior facet is virtually intact. Strategic screw placement secures the major fracture lines and early management facilitates reduction because of increased fracture mobility. AP = anterior process; PF = posterior facet. Illustration continued on opposite page

approaches.6, 14, 54, 64, 77, 92, 93 The medial approach described by McReynolds has the most historical support.13–16 The lateral approach currently is the most popular. The advantage of the medial approach is direct visualization of the posteromedial extent of the primary fracture line. The medial aspect of the calcaneus generally fails under shear forces, producing less comminution than is found laterally. Relatively sharp cortical margins allow anatomic reduction of the tuberosity to the sustentacular fragment, effectively narrowing the heel. Visualization and reduction of depressed posterior facet fragments

cannot be performed from this vantage point. Because of the slope of the medial wall and its close relationship to the medial tendinous and neurovascular stuctures, application of rigid implants along this surface is difficult (see Fig. 1E). The lateral approach allows direct examination of the posterior, middle, and calcaneocuboid joint surfaces, however. Depressed fragments are accessed and elevated under direct vision, and the lateral surface is suited best for application of rigid fixation. Satisfactory relationship between the sustentacular and tuberosity fragments is confirmed radiographically. Most complex

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Figure 8 (Continued ).

calcaneal fractures can be addressed entirely using the lateral approach. The patient is given a satisfactory, usually general, anesthetic and positioned in the true lateral position with the operative side up. Bony prominences are protected, and an axillary roll is placed. The ipsilateral iliac crest can be prepared and isolated in the event that bone graft is needed. The table beneath the operative limb is padded strategically to provide a flat, stable platform for the operation and for obtaining intraoperative radiographs. A proximal thigh tourniquet commonly is used, provided that no contraindications exist. A lateral extensile exposure, popularized by Benirschke and Sangeorzan6 and similar to that suggested by Gould,36 is employed. It differs from the classic lateral approach77 in that it has an acute curve distally instead of following the peroneal tendons (Fig. 9).6,36 The vertical limb parallels the Achilles tendon and is posterior to the sural nerve. At the transition between the lateral foot skin and the specialized, thicker plantar skin, the incision curves sharply, paralleling the plantar surface of the calcaneus and extending across the calcaneocuboid joint. At the apex of the flap, the incision is carried directly to bone, keeping a full-thickness flap of skin, subcutaneous tissue, and periosteum. The peroneal

tendons, sural nerve, and calcaneofibular ligament are left undisturbed and are reflected en masse in the flap. Subperiosteal elevation is continued until the subtalar joint is seen. Distally the calcaneocuboid joint is exposed. When the calcaneus is exposed fully, gentle retraction of the flap is performed by a skilled assistant or, as an alternative, by inserting Kirschner wires into the talus. The vascularity of the flap is based on the peroneal artery blood supply, which remains protected within the substance of the flap.35 Some authors recommend that the vertical limb should run almost in the midline posteriorly to avoid injury to the sural nerve and the terminal branches of the peroneal artery. Clinical series and anatomic dissections have supported this recommendation.27, 35 Reduction The thin lateral wall is reflected outward, exposing the comminuted posterior facet. The anterior and lateral displacement of the tuberosity fragment crowds the central portion of the calcaneus, hampering attempts at reducing the posterior facet. Accurate reduction of the tuberosity relative to the sustentacular fragment decompresses the central

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Figure 9. The classic (A) and lateral extensile (B) incisions are demonstrated. Note that the classic incision follows the course of the peroneal tendons beneath the fibula (Fib). The lateral extensile incision has a much sharper angle at the apex and the distal limb extends toward the base of the fourth metatarsal. The vertical limb is placed near the Achilles tendon to minimize complications with flap vascularity.

part of the calcaneus allowing the potential space for posterior facet reduction. In a simple fracture pattern in which there is no fracture line separating the middle facet from the medial part of the posterior facet, the tuberosity initially is directed plantarward, medially and out of varus. Posterior translation and restoration of calcaneal pitch completes the decompression. A 4.0-mm Schanz pin inserted into the tuberosity provides direct control for this reduction maneuver. After satisfactory reduction of the tuberosity fragment, 2 or more 0.062 inch Kirschner wires are placed from the posterior plantar aspect of the tuberosity into the anteromedial sustentacular fragment. The direction of these Kirschner wires is from posterior plantar to anterior dorsal with a slight lateral-to-medial orientation. In more comminuted fractures, the middle facet may be separated from the medial part of the posterior facet. This medial posterior facet fragment may be driven beneath the middle facet and remainder of the sustentaculum tali. This fracture should be reduced first and provisionally held with Kirschner wires. The medial part of the posterior facet is elevated until it is aligned with the middle facet. This reduction requires satisfactory visualization, which is difficult without a headlamp and adequate retraction. Anterior process fractures, particularly those involving the calcaneocuboid joint, are reduced and provisionally held under direct

vision. Intraoperative axial and lateral views are used to assess reduction of the tuberosity and anterior process. Then the posterior facet is reconstructed, typically by reducing the central and lateral fragments to the stable medial portion. Satisfactory reduction is ensured under direct vision and by palpation using a semicurved instrument, such as a small periosteal elevator. Provisional Kirschner wire fixation is performed strategically in anticipation of definitive plate and screw placement. A second set of intraoperative lateral and axial radiographs confirms the adequacy of all elements of reduction. Several areas are available for optimal screw fixation (see Fig. 6C and D). These areas include the dense bone in the sustentaculum tali, the thickened trabecular or thalamic bone beneath the posterior facet, the cancellous bone deep to the heel cord insertion, and the bone of the dorsal half of the anterior process near the calcaneocuboid joint. Numerous implants are available for application along the lateral calcaneal wall, including locking screw/plate devices and multilimbed plates. A pelvic reconstruction plate contoured into a gentle arc, with the concavity plantarward, is frequently sufficient. It is kept straight in the sagittal plane creating a tensioned implant that resists the inherent varus tendency of the tuberosity. The most distal screw should course just proximal to the calcaneocuboid

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joint and be directed slightly cephalad to take advantage of the thickened bone beneath the anterior process. The most posterior screws should be inserted into the tuberosity. The posterior facet itself is secured with multiple cortical lag screws directed slightly anteriorly toward the middle facet. Strategic and safe screw placement has been described in a laboratory model.48 Empowered posterior facet fixation is obtained with screws inserted through the plate.57 Fixation with additional screws, Kirschner wires, or plates may be required in highly comminuted fractures (see Fig. 7F and G). Fractures with multiple small posterior facet fragments may be assembled extracorporeally, held with 0.045-inch Kirschner wires, then reduced to the remaining intact articular surface. Multiple smaller implants frequently are required to secure these comminuted injuries definitively. The indications for using bone graft are controversial.85 Bone grafting commonly is used in other periarticular injuries, particularly those involving the tibial plafond and tibial plateau. Its purpose is to act as an adjunctive supportive structure preventing collapse of the elevated articular segments. As with other articular fractures, the bone graft should be used when the area beneath the posterior facet is vacant and nonsupportive or whenever enough bone is missing or impacted that a buttress is needed.77 This situation is most likely to occur in high-energy injuries and in patients with poor bone density. Despite the intuitive advantages, there has been virtually no scientific support for the use of bone graft in displaced intra-articular calcaneal fractures. Tufescu and Buckley102 compared patients treated with and without supplemental bone graft and, similar to other authors,84 were unable to show any objective radiographic or functional benefit to its use in the open management of these fractures. Injectable bone graft substitutes improve the initial compressive strength of the posterior facet reconstruction97 and may expedite weight bearing86 ; whether this translates into superior outcomes is unknown. The socalled neutral triangle, an area beneath the anterior part of the posterior facet with minimal bone density, experiences limited mechanical strains and does not need bone grafting. A small closed-suction drain is placed deep to the flap and brought out anteriorly. Closure of the incision is performed in 2 layers to decrease the incidence of wound dehiscence.1 The initial deep interrupted absorbable suture should grasp periosteal tissue, giving a

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secure closure when tied. Interrupted sutures are placed beginning at the ends of the wound and working toward the apex, advancing the flap slightly with each stitch. Ultimately, this technique minimizes tension at the apex of the wound and distributes the tension in the flap along the vertical and transverse limbs of the incision. Then the skin is closed with a nylon flap stitch. Postoperative Management Postoperatively the limb is splinted and elevated with the foot and ankle in the neutral position for 72 hours. Drains are removed 24 to 48 hours after the operation. The patient may be up for limited periods for trials of crutch walking. Range of motion of the toes is encouraged. The detrimental effects of cigarette smoking on wound and fracture healing are reinforced. Active range-of-motion exercises of the foot and ankle are begun when the surgical incision is secure, typically within 3 to 5 days. The patient initially is supplied with a removable, well-padded splint to minimize gastrocnemius-soleus contracture and for comfort. Sutures are removed 2 to 3 weeks after surgery. Patients are fitted with support stockings as needed to control foot and ankle edema and are encouraged to wear them for at least 6 months after the operation. In general, narcotic analgesics are discontinued 3 to 4 weeks after surgery. Weight bearing on the affected extremity is delayed for 8 to 12 weeks, depending on the fracture pattern, degree of comminution, and rigidity of fixation. When the fracture is simple and the fragments can be compressed with lag screws, walking may be started earlier than in fractures that depend on buttress plates to maintain the reduced position. Active rangeof-motion exercises of the ankle and subtalar joints are continued during this non–weightbearing period. Patients should perform much of their physical therapy outside of supervised therapy sessions. Patients with bilateral fractures are confined to bed-to-chair activities for 12 weeks. Weight bearing is resumed according to patient tolerance, and the patient usually is transitioned from a removable cast boot to supportive cushioned shoes. The use of ambulation aids is discontinued by 16 weeks. After healing, patients are encouraged to use shoes with a cushioned or shock-absorbing sole. A custom orthotic insert also may be of value.

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RESULTS Assessing the results of displaced intraarticular calcaneal fractures is difficult because of the lack of standardized fracture classifications, varying surgical techniques, differences in radiographic measurements, and the use of assorted validated and nonvalidated outcome parameters. The data before the common usage of CT scanning are particularly ambiguous.85 A meta-analysis showed a tendency toward return to previous employment, lower risk of experiencing significant foot pain, and generally better overall outcomes with operative management.80 Only 6 suitable studies for analysis were identified in the authors’ extensive literature search, emphasizing further the need for a large randomized clinical trial to clarify the surgical care of these fractures. Accurate clinical assessment of subtalar motion is difficult, but motion is diminished in most patients. Most studies describe an approximate 50% decrease in subtalar range of motion in operatively managed calcaneal fractures.12, 43, 74 Of patients who worked at the time of injury, 40% to 85% return to work within 9 months. Individuals who work in sedentary occupations seem to return to work much sooner. Patients with bilateral calcaneal fractures or other significant injuries and patients who do heavy labor may take longer to return to work and often change jobs. The variability in timing and eventual return to work depends in part on regional social, economic, and cultural differences. Numerous authors have attempted to correlate clinical and radiographic parameters with outcomes. Data have suggested that men, patients with multiple injuries, and heavy laborers may have improved outcomes with operative management.102 O’Farrell et al74 found that operative fixation improved walking tolerance, improved subtalar motion, and returned patients to work earlier. Good outcomes seem to be associated with anatomic reduction, particularly of the posterior facet.43, 46, 76, 84, 90, 98 Paley and Hall76 reported that subtalar incongruity, talonavicular or ankle arthrosis, increased heel width,

and fibulocalcaneal impingement are associated with a poor outcome. In this same study, heel height, heel pad height, and a shortened gastrocnemius-soleus lever arm were not related to outcome. Many authors believe that restoration of Bohler’s angle correlates with a better outcome.21, 41, 51, 58, 59, 76, 85 Others have not found this correlation.43, 46 Tongue-type fractures may have a better outcome than joint depression injuries.72 Laboratory studies indicate that there may be an anatomic rationale for this.29 Most patients either return to previous shoe wear or use a shoe with a shock-absorbing sole. Thirty percent of patients significantly modify their activity and change to a more sedentary occupation. Recreational pursuits often are modified. Patients followed for more than 2 years noted continued improvement in subtalar symptoms and seemed to have durable results.55, 65 A subgroup of patients, presumed to be those with severely injured subtalar joints, may not experience this improvement and have continued pain. COMPLICATIONS Compartmental syndromes are reported to occur in 10% of displaced calcaneal fractures.68 Prompt diagnosis and surgical release, particularly of the quadratus plantae compartment, located on the plantar-medial aspect of the foot, minimize the sequelae of clawed toes and painful nerve dysfunction.62, 66, 68 Open fractures secondary to blunt trauma are infrequent. In these situations, the open wounds are typically on the medial aspect of the foot and are invariably the result of penetration from the sustentacular fragment. Treatment consists of wound d´ebridement and irrigation, followed by provisional closed or percutaneous reduction to restore general alignment and remove soft tissue tension on the injured medial soft tissue envelope. Definitive fixation can proceed in the usual fashion when the overall swelling has decreased (Fig. 10). Major and minor complications attributable to open reduction and internal fixation through a lateral approach are found in

Figure 10. This calcaneal fracture was the result of a motor vehicle collision. The hindfoot was grossly distorted and an open wound with visible bone was present on its medial aspect. A–C, Radiographic investigations, particularly the axial plain and CT images, identify the sustentacular (ST) fragment and its distal extent ( white arrows ) as the cause. D and E, Irrigation and debridement followed by delayed definitive reduction and fixation demonstrate adequate restoration of the anatomy, and also allow healing of the medial traumatic wound.

Figure 10. See legend on opposite page

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10% to 20% of patients. These include infection, wound healing problems, sural nerve symptoms, and failure to achieve reduction. Using the standard lateral approach, the reported infection rate is 2% to 3%.7, 72 In most cases, the infection can be controlled with suppressive antibiotics until fracture union. Removal of fixation and bony d´ebridement are performed when union is ensured. Wound complications, particularly delayed healing and marginal skin flap necrosis, occur in 8% to 9%. When calcaneal length and height are restored during surgery, increased tension at the apex of the incision may contribute to these wound complications. The number of wounds that develop marginal skin loss at the apex of the incision has diminished since the more gently curving classic approach has been modified to include a sharper curve; this is presumably because tension is avoided at the corner of the wound, and undermining of the skin is not needed when applying the plate through the modified incision. Further understanding of the vascular supply of the flap also may contribute to the decreased wound complications. Smoking, diabetes, and open fractures all are independent risk factors for wound complications after open reduction and have a cumulative effect.1, 34 Patients with one or more of these risk factors should be counseled regarding their increased relative risk of wound complications, and the decision regarding operative versus nonoperative management should be reassessed. Sural nerve symptoms occur in a few patients and resolve within a few months in most. The incidence of sural nerve symptoms seems to have lessened with the use of the extended lateral incision.25 Patients who present with neurapraxia of the tibial nerve usually have return of nerve function by 8 months. Most mild nerve symptoms resolve soon after surgery when the shape of the foot is restored. Long-term tibial nerve symptoms may persist and require tarsal tunnel release and tibial nerve exploration.69 Care should be taken to exclude regional pain syndromes. Pain secondary to posterior facet arthrosis responds well to subtalar arthrodesis.2, 33, 70, 95 Correction of residual malalignment optimizes the end result. SUMMARY The ideal treatment for calcaneal fractures is unknown. The natural history of displaced calcaneal fractures is unfavorable. Compared

with other intra-articular fractures of the lower extremity treated by contemporary techniques, the results are not nearly as predictable. For fractures with significant intraarticular displacement, subfibular abutment, anterior ankle impingement, pressure points, or difficulty in shoe fitting, open reduction may be appropriate. A careful lateral extensile approach allows reduction and fixation of all of the key elements of the fracture with sufficient rigidity to allow early motion. The morbidity of open calcaneal treatment when performed by experienced fracture surgeons is comparable to that of other complex fractures. ACKNOWLEDGMENT The authors gratefully acknowledge the invaluable contributions of Ms. Jane Younge in preparing the figures for this article.

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