Calcaneus Fracture Case File

Calcaneus Fracture Case File

Eugene C. Toy, MD, Andrew J. Rosenbaum, MD, Timothy T. Roberts, MD, Joshua S. Dines, MD

CASE 37

A 51-year-old man presents to the emergency department (ED) after falling 6 feet from a ladder onto his left foot while moving heavy boxes. The patient has no past medical history, works as a self-employed engineer, and is a nonsmoker. On initial presentation, he complains of isolated left foot and heel pain. He states he cannot bear any weight on his affected limb. Physical exam of the foot reveals no open wounds, marked soft tissue swelling, ecchymosis, and tenderness to palpation. Sensation to light touch is grossly preserved, but his ankle and foot range of motion is significantly limited by pain. Pedal pulses are palpable and symmetric to the contralateral side. Initial radiographic evaluation with anteroposterior (AP), lateral, and Harris views of the foot are shown in Figures 37–1 , 37–2 , and 37–3 .

Figure 37–1. AP view of the foot.

► What is the most likely diagnosis?

► What additional studies should be obtained?

► What are the treatment options?

► What are the potential complications?

Figure 37–2. Lateral view of the foot.

Figure 37–3. Harris view of the foot.

ANSWER TO CASE 37:

Calcaneus Fracture                     

Summary: A 51-year-old man presents with left foot pain, swelling, and ecchymosis after a 6-foot fall. He is unable to bear weight on his left foot. Radiographs are consistent with a left displaced intraarticular joint depression calcaneus fracture.

• Most likely diagnosis: Displaced intraarticular joint depression calcaneus fracture.
• Additional studies: To further define the calcaneus fracture pattern and plan for definitive management, an axial computed tomography (CT) scan of the left calcaneus should be obtained. Coronal and sagittal plane reconstructions are frequently useful as well. Physical exam of the spine with further imaging is indicated, as there is a 10% incidence of associated spine injuries with calcaneus fractures. Although this patient complains of isolated foot pain, other regions such as the ipsilateral hip and knee should also be examined for pain, and if pain is present, appropriate radiographs of the affected area should be obtained.
• Treatment options: Nonoperative with immobilization in a nonweightbearing short leg splint or cast; open-reduction internal fixation.
• Potential complications: Wound complications/infection, calcaneal malunion, peroneal tendon irritation, anterior ankle impingement, subtalar arthritis, calcaneocuboid arthritis.

ANALYSIS

Objectives

1. Identify the calcaneus fracture pattern using AP, lateral, and Harris radiographs.
2. Define and measure the Bohler angle and the critical angle of Gissane.
3. Recognize the fracture pattern on CT scan and apply the Sanders classification.
4. Understand the indications for open-reduction internal fixation.
5. Identify common complications of either nonoperative or operative treatment.

Considerations

On initial presentation of a fractured calcaneus, the patient’s chief complaint will be pain about the hindfoot and an inability to bear weight on the affected limb. Observation of the skin and soft tissues may reveal soft tissue swelling, ecchymosis, and fracture blisters. The limb must be fully uncovered and circumferentially examined. A detailed motor and sensory examination should be performed. Because of the violent nature of the axial heel loading, there often exist fine disturbances to the plantar sensory nerves, which should be fully documented. A pulse exam must similarly be documented. Any lacerations, typically medially, reflect an open calcaneal fracture unless proven otherwise. Open fractures, especially those associated with contamination, should undergo emergent debridement and irrigation in the operative theatre.

    Extensive soft tissue swelling may also predispose the patient to compartment syndrome of the foot. There are 9 compartments within the foot, which are individually defined by an inflexible investing fascia. As muscle swelling increases, the closed spaces within the foot do not permit an increase in volume, and the individual compartment becomes pressurized. This pressure head exceeds the venous outflow pressure, which results in ischemia to the nervous and muscular components in a time-dependent manner. The most common signs are increasing pain requirements and pain on passive stretch, specifically great toe abduction and adduction. Diagnosis requires a coherent patient, not under the influence of excessive sedating medications. If the patient is unable to interact appropriately, pressure measurements may be objectively obtained through needle manometry. If compartment syndrome is present, the compartments must be emergently released via surgical fasciotomies.

    In addition to the calcaneus fracture, the patient may present with additional injuries. A thorough history and physical exam should be performed, with additional imaging obtained as indicated. Approximately 10% of patients with calcaneus fractures have associated spine injuries, and upward of 26% of patients have other extremity injuries. Missed injuries can be avoided by a careful clinical and radiographic evaluation of the coherent patient at the time of injury.

APPROACH TO:

Calcaneus Fracture                                

DEFINITIONS

INTRAARTICULAR: With respect to the calcaneus, a fracture that extends into the subtalar joint. More specifically, a fracture that exists within the posterior facet of the talocalcaneal articulation.

EXTRAARTICULAR: The fracture does not extend into the subtalar joint, particularly the posterior facet of the talocalcaneal articulation.

BOHLER ANGLE: An angle created from the intersection of 2 radiographic lines observed on a lateral calcaneus x-ray. The first line connects the most cephalad point of the calcaneal anterior process with the most cephalad point of the calcaneal posterior facet. The second line connects the most cephalad point of the calcaneal posterior facet with the most cephalad point of the calcaneal tuberosity. An uninjured calcaneus typically demonstrates an angle between 20 and 40 degrees.

CRITICAL ANGLE OF GISSANE: Another angle created from the intersection of 2 radiographic lines observed on the lateral calcaneus x-ray. The first line runs tangential along the superior aspect of the anterior process. The second line runs tangential to the superior border of the posterior facet. A typical value for the uninjured calcaneus measures between 95 and 105 degrees.

CLINICAL APPROACH

Etiology

Fractures of the calcaneus typically result from high-energy trauma such as falls from a height or motor vehicle collision and represent approximately 2% of all fractures.

DIAGNOSIS

Initial radiographic evaluation of a suspected calcaneus fracture should include an AP of the foot, lateral of the foot, and a Harris axial projection, along with AP, lateral, and mortise views of the ankle. These radiographs will help classify the fracture pattern, whether joint depression or tongue type. The diagnosis is most evident on the lateral projection, which will demonstrate the degree of calcaneal compression quantified by the Bohler angle ( Figure 37–4). The degree of height loss has prognostic implications, with a smaller Bohler angle correlating with poorer functional outcomes. CT will help identify each fracture line and fracture fragment. Reformats in the coronal and sagittal planes parallel the findings in the Harris axial and lateral views, respectively. Additional information can be obtained from the CT, including an evaluation of lateral wall expulsion and peroneal tendon impingement or dislocation.

    From the CT scan, the fracture can be classified according to Sanders. The posterior facet is divided into 3 fragments: lateral, central, and medial. With the addition of the sustentaculum, there are 4 defined fragments. The primary fracture line is identified and the number of fragments created by the fracture line is noted. A letter is assigned to where the fracture line crosses the posterior facet. The number and location of posterior facet fracture lines have been demonstrated to correlate with outcomes after surgical fixation, with poorer outcome measures associated with more comminuted patterns. The collective information obtained by careful evaluation of the radiographs and CT scan aid in definitive management and preoperative planning.

Figure 37–4. Calcaneus fracture: Bohler angle. The Bohler angle is formed by the intersection of lines

drawn tangentially to the (A) anterior and (B) posterior elements of the (C) superior surface of the

calcaneus. A normal angle is approximately 20 to 40 degrees. (Reproduced, with permission, from

Knoop KJ, Stack LB, Storrow AB, et al. Atlas of Emergency Medicine. 3rd ed. New York, NY: McGraw-Hill; 2009:Fig. 11-83.)

TREATMENT

Nonoperative

Nonoperative treatment consists of early ankle and subtalar range-of-motion exercises and nonweightbearing for approximately 3 months. Initial management consists of splinting the foot and ankle in neutral dorsiflexion to prevent an equinus contracture, ice, elevation, and pain control. Once the swelling subsides, the splint is removed while ankle and subtalar range-of-motion exercises are performed. Clinical and radiographic follow-up is carried out at routine intervals to document healing. Specific indications for nonoperative treatment include a nondisplaced fracture, a patient too physiologically compromised to tolerate surgery, or a nonambulatory patient. In addition, patients unable or unwilling to comply with postoperative weightbearing restrictions are best managed nonoperatively. Factors that affect local wound healing, such as a history of smoking, severe peripheral vascular disease, or insulin-dependent diabetes, are relative contraindications to surgery.

Open-Reduction Internal Fixation

Historically, fractures of the calcaneus were treated nonoperatively by means of re-impacting the fracture by striking the lateral heel with a hammer. Surgeons would rather perform this procedure over open surgery because of fears over infection, malunion, nonunion, and need for amputation. With the development of aseptic techniques and the modern principles of reduction and fixation, calcaneal surgery could be performed with an improved complication profile. A prospective, randomized, controlled multicenter trial by Buckley et al warrants mention. In this study, 309 patients were prospectively randomized to either nonoperative or operative treatment and followed for a minimum of 2 years. Operative treatment demonstrated improved outcomes in women, patients not receiving worker’s compensation, young men (< 30 years of age), patients with a higher Bohler angle, patients with a lighter workload, and patients with a simple displaced intraarticular fracture pattern. Anatomic reductions also improved outcomes. Patients treated nonoperatively were more likely to require late arthrodesis. As our understanding of the outcomes of nonoperative and operative treatment improves, we can identify those patients best managed by open-reduction internal fixation.

    Once the decision has been made to proceed with open-reduction internal fixation, timing and surgical treatment goals must be discussed. Timing of surgery is an important consideration. Calcaneal fractures are the result of high-energy trauma, and the associated soft tissue injury is often extensive. Incisions across a compromised soft tissue envelope risk postoperative wound complications and deep sepsis. Serous and hemorrhagic fracture blisters should be unroofed and treated with dry bandages until epithelialization occurs. Despite signs of healing, the blister beds should be avoided if possible. Before surgical intervention, the foot must achieve soft tissue quiescence. This readiness of the soft tissues is indicated by the appearance of fine skin wrinkles with passive foot dorsiflexion, known as a positive “wrinkle test.” A waiting period of 10 to 14 days is common before proceeding to surgery. Although waiting for an appropriate surgical window is critical, treatment within the first 3 weeks is recommended to avoid a malunion. This is a situation in which the fracture heals in an undesirable position. The malunited calcaneus is frequently shortened and in varus.

    The goal of surgical intervention is to anatomically restore the calcaneus. Critical components in this restoration include anatomic reduction of the posterior facet and reconstitution of calcaneal height, width, and length. Medial and lateral approaches to fixation have been described. An extensile lateral approach is most often used. The vertical limb of the incision is made anterior to the lateral border of the Achilles tendon and continued in a right angle fashion horizontally along the border of the foot where the glabrous and plantar skin meet. This approach allows for direct reduction of the anterior process, the posterior facet, and the tuberosity. Kirschner wires can be used to temporarily hold the reduction, which should be checked fluoroscopically and under direct visualization. Calcaneal height is checked on the lateral view. Width and varus heel positioning is imaged on the axial view. The reduction of the posterior facet is directly visualized and can be imaged through the use of the Broden view. Once the reduction is satisfactory, the Kirschner wires are replaced with screws or a combination of screws and plates for the final construct. Careful handling of the flap is crucial during wound closure to minimize the risk of skin necrosis and wound complications. A Hemovac drain is typically left in place and a splint applied in neutral dorsiflexion to prevent an equinus contracture. Postoperative radiographs and CT are performed to check the accuracy of the reduction. The patient is made nonweightbearing for approximately 3 months, at the discretion of the treating surgeon. During the healing period, range-of-motion exercises for the ankle and subtalar joint can be initiated as soon as the incision appears stable and healing. Postoperative follow-up is at routine intervals to document fracture healing. Good to excellent results can be achieved with an anatomic articular reduction.

Complications

Subtalar Arthritis: Posttraumatic arthritis of the subtalar joint can develop after both nonoperative and operative treatment. A nonanatomic articular reduction and cartilage damage from the injury itself are the primary contributing factors. Patients will primarily complain of pain. The pain is dependent on activity and worsens as the day progresses. As a result of subtalar stiffness, patients will complain that it is difficult to navigate over uneven walking surfaces. Radiographic evaluation with standard x-rays and CT may reveal joint space narrowing, osteophyte formation, and subchondral sclerosis. Injecting a local anesthetic into the subtalar joint and documenting relief of symptoms can confirm the diagnosis. Nonoperative measures include nonsteroidal anti-inflammatory medications, shoe wear modifications, or custom orthoses. These measures should be tried before operative intervention is considered. If nonoperative measures fail, operative treatment consists of a subtalar fusion.

Wound Complications/Infection: The most common complication after openreduction internal fixation is related to the surgical wound. Wound complications including dehiscence and infection have been noted to occur in up to 20% of patients with closed fractures. The reported rates of deep infections and calcaneal osteomyelitis range from 0% to 20% in closed fractures and from 19% to 31% in open fractures. Cellulitis and superficial wound sloughs can be treated with dressing changes and the administration of antibiotics. Persistent drainage or purulence necessitates open debridement coupled with administration of antibiotics. In the case of superficial infection, the hardware can be retained. If a deep infection is noted or there is evidence of diffuse osteomyelitis at the time of open debridement, the hardware must be removed. Patient selection, meticulous surgical technique, and compliance with postoperative protocols can minimize the risks of wound complications.

Calcaneocuboid Arthritis: Arthritis can develop after both nonoperative and operative treatment secondary to an imperfect reduction of the anterolateral fragment. Similar to the diagnosis of subtalar arthritis detailed previously, physical exam, radiographs, and a trial injection can be performed to elucidate whether the calcaneocuboid joint is the source of the patient’s pain. First-line treatment is nonoperative with nonsteroidal anti- inflammatory medications, shoe wear modifications, or custom orthoses. If nonoperative treatment fails, calcaneocuboid fusion may be considered and is typically performed in conjunction with a talonavicular and talocalcaneal fusion.

Peroneal Irritation: This occurs more commonly in patients managed nonoperatively. During the axial loading event, the lateral wall often becomes a separate fragment, which translates laterally. Both the peroneus longus and brevis tendons traverse the lateral calcaneus in this region and are subjected to compression and irritation. Dislocations or subluxations are common. Operative treatment addresses both the lateral wall displacement and the peroneal tendon instability. In operative cases, postoperative scarring or prominent hardware is more frequently the culprit. The initial treatment is nonoperative with nonsteroidal antiinflammatory medications and shoe wear modifications or orthotics. Elective surgery includes removal of hardware, lateral wall reconstruction, or exostectomy, along with a peroneal tendon reconstruction. These procedures should be considered if the patient is experiencing pain refractory to nonoperative measures.

Anterior Ankle Impingement: Anterior ankle impingement can occur after nonoperative or operative treatment. The impingement is the result of loss of calcaneal height and a decreased lateral talocalcaneal angle. With nonoperative management or incomplete restoration of calcaneal height, the talus adopts a pathologic horizontal position. The result is direct contact with the dorsal talar neck

and the anterior tibial plafond. On clinical evaluation, the patients present with pain and restriction in ankle dorsiflexion. Often the examiner can feel a firm block when the ankle is passively dorsiflexed. Surgical management can include exostectomy of the talar osteophytes, but distraction subtalar bone block fusion is the preferred procedure. The goal of this procedure is to restore the calcaneal height and thus create an improved lateral talocalcaneal angle.

Calcaneal Malunion: Malunion can occur in both nonoperative and operative management of calcaneal fractures. Varus angulation of the hindfoot is the most common residual deformity. This usually occurs from a varus malunion of the tuberosity. Treatment with subtalar fusion and a calcaneal osteotomy has been described, with variations, by several authors. To plan the malunion repair, Stephens and Sanders developed a CT classification for malunions. Type I involves a large lateral exostosis with or without arthrosis of the subtalar joint and is treated with peroneal tenolysis and a lateral exostectomy. Type II involves a lateral exostosis with arthrosis across the subtalar joint and is treated with peroneal tenolysis, a lateral exostectomy, and in situ subtalar fusion. Type III involves a lateral exostosis, severe subtalar arthrosis, and varus or valgus angulation of the calcaneal body and is treated with peroneal tenolysis, a lateral exostectomy, subtalar fusion, and a calcaneal osteotomy.

COMPREHENSION QUESTIONS

37.1 A 29-year-old man presents with significant right hindfoot swelling and pain after a 25-foot jump from a cliff. Imaging confirms a comminuted intraarticular calcaneus fracture involving the posterior facet. As the treating physician, you request that radiographs of the spine be obtained. What percentage of patients with fractures of the calcaneus have associated spine injuries?

A. 10%

B. 30%

C. 50%

D. 80%

37.2 Which of the following factors is associated with worse outcomes after operative treatment of fractures of the calcaneus?

A. Female sex

B. Age < 30 years

C. Worker’s compensation

D. Bohler angle > 0 degrees

E. Simple articular fracture pattern

37.3 A 42-year-old man presents with a displaced comminuted intraarticular calcaneus fracture. On physical exam, there is extensive soft tissue swelling and hemorrhagic blisters. The patient is splinted and discharged home, as the soft tissues are not ready for open-reduction internal fixation. He returns to clinic 10 days later with clawing of his toes. What is the most likely explanation for this finding?

A. Tendon laceration from displaced fracture fragment

B. Nerve injury from displaced fracture fragment

C. Compartment syndrome

D. Weakness secondary to pain and prolonged immobilization

ANSWERS

37.1 A. Approximately 10% of patients who present with calcaneus fractures have associated spine injuries. A thorough history and physical exam, with additional imaging as indicated, is important to avoid missed injuries.

37.2 C. A prospective, randomized, controlled multicenter trial by Buckley et al followed 309 patients for a period of 2 to 8 years. Overall the outcomes for nonoperative and operative management were not found to be different. After closer examination of the patient population, operative treatment demonstrated improved outcomes in women, patients not receiving worker’s compensation, young men (< 30 years), patients with a higher Bohler angle, patients with a lighter workload, and patients with a simple displaced intraarticular fracture pattern. Anatomic reductions also improved outcomes. Patients treated nonoperatively were more likely to require late arthrodesis.

37.3 C. Foot compartment syndrome is a known complication of calcaneus fractures. There are 9 compartments within the foot, which are individually defined by an inflexible investing fascia. As muscle swelling increases, the closed spaces within the foot do not permit an increase in volume, and the individual compartment becomes pressurized. This pressure head exceeds the venous outflow pressure, which results in ischemia to the nervous and muscular components in a time-dependent manner. If this is unrecognized, nerve and muscle death occur. This can result in contractures of the muscles in the affected compartments, which is evident on clinical evaluation.

    CLINICAL PEARLS    

► Fractures of the calcaneus represent high-energy trauma with a significant incidence of associated spine and extremity injuries. A thorough history and physical exam are crucial at the time of presentation. ► AP, lateral, and Harris radiographs should be ordered along with a CT scan in the axial plane with sagittal and coronal reconstructions to evaluate the fracture pattern and plan for treatment. ► Open-reduction internal fixation should be delayed until soft tissue swelling is reduced and blisters have epithelialized. ► Wound complications including dehiscence and infection are the most common problems associated with operative management. ► Outcomes after operative treatment are best in women, non–worker’s compensation cases, young (age < 30 years) men, higher Bohler angle (> 0 degrees), patients with a lighter workload, and those with simple articular fracture patterns.

REFERENCES

Benirschke SK, Kramer PA. Wound healing complications in closed and open calcaneal fractures. J Orthop Trauma. 2004;18:1-6. 

Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am . 2002;84-A:1733-1744. 

Howard JL, Buckley R, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma. 2003;17:241-249. 

Sanders R. Current concepts review: displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82-A:225-250. 

Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop. 1993;290:87-95. 

Sanders R, Gregory P. Operative treatment of intra-articular fractures of the calcaneus. Orthop Clin North Am. 1995;26:203-214.

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