Calcaneus Fractures

Fracture blisters may appear anywhere about the foot secondary to swelling.⁷⁶,⁷⁷,⁷⁸,²³²
The blister results from a cleavage at the dermal-epidermal junction,
and the fluid within the blister represents a sterile transudate. The
fluid remains clear if the dermis retains some epidermal cells. The
fluid becomes bloody if the dermis is completely devoid of epidermal
cells.⁷⁷ Giordano⁷⁶
prospectively evaluated various treatment methods for blister
management, including aspiration of the blister, unroofing the blister
with subsequent application of Silvadene cream or coverage with a
nonadherent dressing, or leaving the blister intact and covered by
loose gauze or exposed to air. Although there was no significant
difference in the outcome of the various soft tissue management
techniques, wound healing complications developed in 2 patients who had
incisions through blood-filled blisters. Additionally, Varela et al.²³²
retrospectively reviewed 53 cases and identified two cases with major
wound infections secondary to incisions passing through the blister.
They noted colonization with normal skin flora in 11 ruptured vesicles
soon after rupture of the blister, which persisted until
re-epithelialization of the area. Thus, surgical incisions should be
modified to avoid areas of blistered skin.

There are four compartments within the foot: the medial,
lateral, central, and interosseous compartments. The central
compartment is divided into two separate compartments by a transverse
septum in the hindfoot: the superficial compartment containing flexor
digitorum brevis muscle, and the deep or calcaneal compartment
containing the quadratus plantae and the lateral plantar nerve.⁶³ The calcaneal compartment communicates directly with the deep posterior compartment of the lower leg.¹³⁶
The long-term sequelae of an unrecognized compartment syndrome in the
foot can include clawtoe deformities with permanent loss of function,
contracture, weakness, and sensory disturbances.

A compartment syndrome develops when increased pressure
within a closed fascial space affects pulse pressure such that arterial
flow is decreased. This classically produces pain out of proportion to
the injury, not unlike that typically associated with a calcaneal
fracture. Thus, care must be taken to ensure that the severe pain
associated with the fracture is not caused by a compartment syndrome of
the foot, particularly in the calcaneal compartment. A self-contained
needle manometer system (Quikstik; Stryker, Kalamazoo, MI) is most
commonly used to measure compartment pressures. Most authors recommend
fasciotomy when the compartment pressure rises to within 10 to 30 mm Hg
of the patient’s diastolic pressure.⁶³,¹⁵²,¹⁵⁵

When a tongue fragment is significantly displaced,
pressure on the posterior skin may occur, causing necrosis if left
untreated. Gardner et al.⁷¹ recently
presented a series of 137 tongue fractures with 21 cases exhibiting
posterior skin necrosis. In those fractures treated emergently with
percutaneous reduction, soft tissue compromise did not occur. The
authors concluded that because of the high incidence of posterior skin
compromise in tongue-type calcaneus fractures, consideration should be
given to immediate percutaneous reduction, plantarflexion splinting,
and close monitoring (Fig. 59-5).

Open fractures of the calcaneus are distinct injuries relative to closed fractures and thus require different treatment⁹⁴ (Fig. 59-6). Between 7.7% and 17% of fractures to the calcaneus are open.¹²,¹⁴,⁹⁴
They are generally associated with a higher complication rate than
their closed counterparts, including deep infection, osteomyelitis, and
possible need for amputation.¹⁵,¹²⁷,¹⁵³,¹⁵⁸,¹⁹⁰ Coughlin,⁴²
in a review of calcaneal fractures in industrial workers, also found
that open fractures were associated with increase in the total cost of
treatment and time off from work.

Folk et al.⁶⁷
reported wound complications in 13 of 18 open calcaneal fractures that
were operatively treated (72%) and calculated that patients with an
open fracture were 2.8 times more likely to develop a wound
complication than those with a closed fracture. The incidence of these
major complications also seems to increase with increasing severity of
the soft tissue injury. Siebert et al.¹⁹⁸
reviewed the results of 36 open intra-articular fractures treated with
internal fixation with an average follow-up of 44 months. Nine of 15
(60%) type III open fractures developed osteomyelitis, resulting in
five amputations. Aggressive surgical treatment of the soft tissue
envelope and nonoperative management of the open fracture were
recommended.

Heier et al.⁹⁴
reported on the results of 43 open fractures in 42 patients managed
according to a standard treatment protocol of immediate intravenous
antibiotics, aggressive surgical débridement of the wound, and
provisional limb stabilization. There were many injuries that defied
classification because of the irregular shape and size of the wound.
Definitive soft tissue coverage was completed at an average of 10.6
days; final fracture stabilization was delayed until the wound was
clean and soft tissue swelling had dissipated. All Gustilo type I open
fractures, and Gustilo type II open fractures with a medial wound, were
treated with ORIF and a lateral incision after debridement and when
tissue edema had resolved. Gustilo type II fractures with lateral,
posterior, or plantar wounds and Gustilo type IIIA fractures had
limited or no internal fixation. All Gustilo type IIIB open fractures
required vascularized free tissue transfer as soon as possible. The
overall infection rate was 37%, and osteomyelitis developed in 19%,
including 7 of 26 (27%) type III open fractures. All six amputations
occurred in patients with open type IIIB fractures. The authors
concluded that the degree of soft tissue injury was the most important
variable in predicting outcome; thus, all open type I and those open
type II fractures with a medial wound could be treated by delayed ORIF
once the soft tissues were suitable for surgery. They recommended
either external fixation or limited percutaneous fixation for those
open type II injuries with nonmedial wounds and all open type IIIA
wounds and delayed or late reconstruction for all open type IIIB wounds
and for fractures caused by penetrating trauma.

Aldridge et al.⁵
reviewed the results of 19 open calcaneal fractures treated by a
similar standard protocol at an average follow-up of 26.2 months.
Definitive fracture stabilization was completed through a lateral
approach, regardless of wound location, at an average of 7 days
following injury, at which point soft tissue swelling had adequately
dissipated. Two of 19 patients (10.5%) developed a deep infection and
subsequent osteomyelitis: one open type II fracture and one open type
IIIC fracture, the latter being the only one that went on to
amputation. Their results confirmed that open type I fractures had a
predictably good outcome with respect to soft tissue infection or
osteomyelitis, while the open type II and type III fractures were
associated with a less predictable outcome, although the overall
complication rate was considerably lower than most reported series to
date.

Berry et al.¹⁴
reviewed the results of 30 open fractures in 29 patients managed with a
standard open fracture protocol and various methods of fracture
treatment. There were 2 Sanders type II, 6 type III, and 6 type IV
fractures. There were 5 Gustilo type I fractures, 12 type II fractures,
and 13 type III fractures (9 IIIA, 2 IIIB, and 2 IIIC injuries). Most
of the open wounds occurred along the medial foot²⁵
with two posterior injuries and three plantar wounds. There were no
lateral open wounds. Two patients with Gustilo type IIIC injuries
underwent a below knee amputation within the first 24 hours postinjury
because of massive crush injuries and dysvascular feet. Only five
fractures underwent acute ORIF. Functional outcome was evaluated using
validated assessment tools. Although the authors reported only one
superficial infection and no cases of deep infection or osteomyelitis,
most patients had only fair to poor functional results. Those with
plantar wounds had significantly worse functional outcomes relative to
those with medial wounds. They concluded that aggressive débridement of
open wounds with provisional stabilization of the limb was critical in
limb salvage, and based on their five cases, that delayed ORIF was a
safe treatment option.

In Lawrence and Grau’s series of 48 open fractures treated over a 7-year period,¹¹⁸
more than 80% of the wounds were medial injuries, with 23% of these
associated with a significant neurovascular deficit. Five patients
required a free-tissue transfer, while two patients underwent
below-the-knee amputations as the primary treatment. The authors
stressed the need for soft tissue management and delay of definitive
internal fixation.

In contrast, Benirschke and Kramer¹²
reviewed the results of 39 open calcaneal fractures in 38 patients
treated by open reduction and rigid internal fixation through an
extensile lateral approach as part of a large series of calcaneal
fractures. Their series included 19 open Gustilo⁸⁴
type IIIA and 3 open Gustilo type IIIB fractures. Although wound
location data were not included, they reported only a 7.7% “serious”
wound complication rate, and none required amputation. They concluded
that

patient noncompliance was the single biggest issue precluding wound healing.

Open fractures of the calcaneus may present with a
puncture wound medially from a spike of bone protruding from the medial
wall of the calcaneus or may present with a more substantial wound with
significant soft tissue disruption, typically laterally. When a
calcaneal fracture is associated with an injury to the soft tissue
envelope, it is important to categorize the wound, noting its size and
location as well as its Gustilo type.⁸⁴,⁸⁵
The fracture is then classified, and together these factors can give
the surgeon an estimation of the severity of the injury and its
eventual outcome, as all of these factors play a role in prognosis.⁵,¹²,¹⁴,⁹⁴,¹¹⁷

Treatment should include irrigation with 9 L of normal
saline and débridement of the wound with stabilization of the fracture
to protect the soft tissues. When in doubt regarding the degree of soft
tissue trauma, closed reduction and percutaneous stabilization may be
performed to realign the extremity. This may be with Kirshner wires
(K-wires), an external fixator, or both. Standard antibiotic
prophylaxis is begun, and subsequent treatment must be tailored to the
injury, but early and aggressive internal fixation should be avoided as
the additional operative trauma will compromise the limb, and
amputation may result.¹⁷⁵ Three or
more months may be required to allow the soft tissues to heal
sufficiently before surgical salvage can be contemplated, and these
subsequent procedures are invariably for treatment of a severe
calcaneal malunion.

The initial radiographic evaluation of the patient with
a suspected calcaneal fracture includes a lateral radiograph of the
hindfoot, an anterior posterior radiograph of the foot, a Harris heel
view, and an ankle series. In this way, all fractures, subluxations,
and/or dislocations can be diagnosed. Because of the association with
lumbar spine fractures, routine lumbar spine radiographs should also be
obtained.⁹⁵ If the radiographs
reveal an intra-articular component to the calcaneal fracture, computed
tomography (CT) scanning is indicated. Multiple radiographic
projections have been described; however, most of these views are hard
to read and even more difficult to consistently reproduce.⁷,¹⁰³,²⁰³,²³³ In contrast, CT evaluation, when interpreted correctly, provides a wealth of data for both diagnosis and treatment.

Lateral Radiographs. Traction trabeculae extending from
the inferior cortex of the calcaneus combine with compression
trabeculae supporting the posterior and anterior articular facets. The
area between these trabeculae creates a space known as the neutral triangle⁹⁰ (Fig. 59-7).
The lateral radiograph of the hindfoot demonstrates two important
angles: the tuber angle of Böhler and the crucial angle of Gissane (Fig. 59-8). The tuber angle of Böhler
is composed of a line drawn from the highest point of the anterior
process of the calcaneus to the highest point of the posterior facet
and a line drawn tangential to the superior edge of the tuberosity.¹⁸
The angle is normally between 20 and 40 degrees; a decrease in this
angle indicates that the weight-bearing posterior facet of the
calcaneus has collapsed, thereby shifting body weight anteriorly.
McLaughlin¹⁴¹ determined that
reduction or reversal of this angle indicates only the degree of
proximal displacement of the tuberosity and thus can be decreased in
both intra- or extra-articular fractures, limiting

its usefulness.²¹⁰ The crucial angle of Gissane
is formed by two strong cortical struts extending laterally: one along
the lateral margin of the posterior facet and the other extending
anterior to the beak of the calcaneus. These cortical struts form an
obtuse angle⁶² and are visualized directly beneath the lateral process of the talus.¹⁹⁴

The lateral radiograph should confirm the diagnosis of a
calcaneal fracture. Radiographs of intra-articular fractures usually
show a loss in the height of the posterior facet, with a decrease in
the angle of Böhler and an increase in that of Gissane, but only if the
entire facet is separated from the sustentaculum and depressed. If only
the lateral half of the posterior facet is fractured and displaced, a
split in the articular surface will be seen as a “double density” and
Böhler’s and Gissane’s angles may appear to be normal¹⁸⁹ (Fig. 59-9).
The articular surface can be found within the body of the calcaneus;
usually, it is rotated 90 degrees in relation to the remainder of the
subtalar joint. The lateral radiograph also indicates whether the
fracture is of the joint-depression- or tongue-type according to the
classification of Essex-Lopresti.⁶²

Other Plain Radiographic Views. The anteroposterior
radiograph of the foot shows extension of the fracture line into the
calcaneocuboid joint (Fig. 59-10). This
radiograph provides very little information and usually may be omitted.
The Harris axial radiograph of the heel allows visualization of the
joint surface as well as loss of height, increase in width, and
angulation of the tuberosity fragment (Fig. 59-11). Unfortunately, this radiograph is very difficult to obtain in the acute setting because of pain.

Tomograms are rarely indicated, as they provide no
additional information when CT is available, and they expose the
patient to increased doses of radiation.⁸⁶ Deutsch et al.⁵⁰ pointed out that tomograms may fail to show the extent of articular incongruity.

Broden’s view, however, is a reproducible means of
demonstrating the articular surface of the posterior facet on plain
radiographs.²⁴ This view, known as
Broden Projection I, is obtained with the patient supine and the x-ray
cassette under the leg and the ankle. The foot is in neutral flexion,
and the leg is internally rotated 30 to 40 degrees. The x-ray beam then
is centered over the lateral malleolus, and four radiographs are made
with the tube angled 40, 30, 20, and 10 degrees toward the head of the
patient. These radiographs show the posterior facet as it moves from
posterior to anterior; the 10-degree view shows the posterior portion
of the facet, and the 40-degree view shows the anterior portion. While
this view is difficult to explain to, and

obtain from, a technician, a mortise view of the ankle will recreate this view perfectly (Fig. 59-12).
Therefore, an ankle series should be requested. Furthermore, this view
should be obtained intraoperatively using the fluoroscope and is
indispensible to verify the reduction of the articular surface.¹¹³

CT scanning has vastly improved the understanding of
calcaneal fractures and has subsequently allowed for consistent
analysis of treatment results.^* CT images are obtained in
the axial, 30-degree semicoronal, and sagittal planes. The coronal
views provide information about the articular surface of the posterior
facet, the sustentaculum, the overall shape of the heel, and the
position of the peroneal and flexor hallucis tendons. The axial views
reveal information about the calcaneocuboid joint, the anteroinferior
aspect of the posterior facet, and the sustentaculum. Sagittal
reconstruction views provide additional information as to the posterior
facet, the calcaneal tuberosity, and the anterior process (Figs. 59-13 and 59-14).

The use of three-dimensional CT scanning for intra-articular calcaneal fractures was recently evaluated in several studies.³,²³¹ Although this is an interesting modality, the definition of the

articular surface was not sufficient to assist in preoperative planning or to justify the costs. Vannier et al.²³¹ concluded that the diagnostic value of three-dimensional CT was equivalent to that of conventional two-dimensional CT.

Although described as early as 1851 by Malgaigne,¹³⁴ Essex-Lopresti in 1952⁶²
popularized the concept of two distinct fracture patterns: a
tongue-type fracture, where the articular fragment remained attached to
a tuberosity fragment, and a joint-depression-type fracture, in which
the articular fragment was separate from the adjacent tuberosity. The
advantage of this distinction was that the surgeon could accurately
choose the correct treatment method. Unfortunately, this classification
provided little prognostic information. Several other authors described
fracture patterns and classifications, but these systems were in
essence variations of the Essex-Lopresti classification.⁸,⁷²,²³³,²³⁷

In 1975, Soeur and Remy²⁰³
reported on a new classification system, which was uniquely based on
the number of articular bony fragments as determined on
anteroposterior, lateral, and Harris axial heel views. First-degree
fractures were nondisplaced shear-type fractures with widening of the
joint surface. Second-degree fractures included secondary fracture
lines, resulting in a minimum of three fragments, two of which included
the articular surface. Third-degree fractures were highly comminuted
such that they could not be classified, and therefore the authors

could
not specify if the comminution referred to the body or the articular
surface of the posterior facet. Although they proposed that displaced
intra-articular fractures should be managed surgically with internal
fixation, their results could not be correlated to their classification.

The use of CT scanning in the diagnosis and treatment of calcaneal fractures was first described by Segal et al.¹⁹⁷ and was also used by Stephenson.²¹¹ Zwipp et al.,²⁴⁴
however, were the first to apply information provided on CT evaluation
into a rational understanding of the injury. In his classification, the
entire calcaneus was considered, with a total of five possible
fragments, similar to the systems of Essex-Lopresti and Soeur and Remy,
but based on CT scan data⁶²,²⁰³ (Fig. 59-15). Although surgical outcomes were evaluated, no prognosis based on fracture classification was made.

Crosby and Fitzgibbons⁴⁴
were the first authors to correlate clinical outcome (albeit as a
result of nonoperative treatment) with a fracture classification system
based on CT evaluation. They divided their fractures into three types
based on the articular surface displacement: type I, nondisplaced; type
II, displaced; and type III, comminuted. Subsequently, Sanders
developed a scan classification system based on the number and location
of articular fracture fragments alone.¹⁸⁷,¹⁹⁰ This was the natural progression of fracture patterns identified by Soeur and Remy.²⁰³ The classification was found to be useful in determining both treatment methods and prognosis after surgical fixation.¹⁹⁰ Many additional authors have since used this classification and found it to be prognostic with respect to outcome as well.^* During the analysis of the results of operative treatment, it became clear to Sanders et al.¹⁹⁰
that the body of the calcaneus could be restored surgically to virtual
anatomic shape by using a lateral approach, regardless of the degree of
comminution. Because the prognostic factor for outcome was the
articular reduction and the degree of cartilage damage, the
classification has been purposely limited to articular displacement.

The articular fracture classification system of Sanders et al.¹⁷² is based on images in the coronal plane (Fig. 59-16).
Although all coronal sections were analyzed, the original
classification arbitrarily used one CT scan view with the widest
undersurface of the posterior facet of the talus (in reality, the
entire CT scan should be evaluated to watch fracture lines move in and
out of plane, and to determine which are artifact, and which are real).
The talus was divided into three equal columns by two lines that were
then extended across the calcaneal posterior facet; with the addition
of a third line, just medial to the medial edge of the posterior facet,
the posterior facet of the calcaneus could be arbitrarily divided the
into three potential fragments: medial, central, and lateral. These
fragments plus the sustentaculum resulted in a total of four potential
articular pieces. All nondisplaced articular fractures (less than 2
mm), regardless of the number of fracture lines, were considered type I
fractures; type II fractures were two-part fractures of the posterior
facet. Three types—IIA, IIB, and IIC—existed, based on the location of
the primary fracture line. Type III fractures were three-part fractures
that usually featured a centrally depressed fragment. Types included
IIIAB, IIIAC, and IIIBC, and again were based on the location of the
primary fracture line. Type IV fractures, or four-part articular
fractures, were highly comminuted and often had more than four
articular fragments. While the subclassification of articular fracture
lines by medial to lateral location is important prognostically, most
surgeons simply identify the number of articular fragments¹⁷¹ (Fig. 59-17).

Originally, this classification system was described for joint

depression fractures exclusively. With the addition of the initial
lateral radiograph, however, the surgeon can determine whether the
fracture is a joint-depression- or a tongue-type fracture. Once this is
established, tongue-type fractures can be classified using this system
as well. The true extra-articular tongue is typically a type IIC, where
the entire facet is displaced but intact. If the tongue fracture
extends intra-articularly, the fracture is typically a type IIB. In
addition, tongue-type fractures with joint-depression components (mixed
fractures) can clearly be evaluated using this CT scan classification.
It is important to understand and identify these tongue variants, as
the treatment methods will be dictated by the presence or absence of an
intraarticular component (Figs. 59-18 and 59-19).

Preoperative planning also requires evaluation of the body of the calcaneus on CT scans. Miric and Paterson¹⁴⁸ described the patterns of comminution of the anterior process (Fig. 59-20).
These typically mirror the lines that divide the articular surface and
are best seen on the transverse CT scan. Importantly, they reaffirmed
the need to obtain an anatomic reduction of the body of the calcaneus
as well as the joint. Finally, on the

transverse
CT scan, a medial-to-lateral extra-articular fracture at the level of
the anterior edge of the posterior facet can often be seen, as
originally described by Carr.³³
This fracture line is important to find, as its presence indicates that
the medial component of the joint can be rotated in a plantar direction
and must be brought out from under the anterior process to obtain an
anatomic joint reduction. It is our belief that the main limitation of
this classification, as well as all CT scanning at the present time
(even with the advent of reformatting techniques), is that it cannot
determine whether the sagittally split fragment is additionally
fractured in the coronal plane. Often, this cannot be determined until
the fracture is surgically treated, and occasionally not until the
fragment separates while being repositioned.

Specific indications for nonoperative treatment include
(a) nondisplaced or minimally displaced extra-articular fractures, (b)
nondisplaced intra-articular fractures, (c) anterior process fractures
with less than 25% involvement of the calcaneocuboid articulation, (d)
fractures in patients with severe peripheral vascular disease or
insulin-dependent diabetes, (e) fractures in patients with other
medical comorbidities prohibiting surgery, and (f) elderly patients who
are household ambulators. It must be noted that chronological age is
not a contraindication to surgery, as many older patients are healthy
and active well into their 70s. Nonoperative treatment may also be
necessary when fractures are associated with (a) blistering and massive
prolonged edema, (b) large open wounds, or (c) life-threatening
injuries.

Nonoperative treatment consists of a supportive splint
to allow dissipation of the initial fracture hematoma, followed by
conversion to a prefabricated fracture boot with the ankle locked in
neutral flexion to prevent an equinus contracture, and an elastic
compression stocking-to-minimize dependent edema. Early subtalar and
ankle joint range-of-motion exercises are initiated, and
non-weight-bearing restrictions are maintained for approximately 10 to
12 weeks, until radiographic union is confirmed.

Operative treatment is primarily indicated for (a)
displaced intra-articular fractures involving the posterior facet, (b)
anterior process of the calcaneus fractures with more than 25%
involvement of the calcaneocuboid articulation, (c) displaced fractures
of the calcaneal tuberosity, (d) fracture-dislocations of the
calcaneus, and (e) selected open fractures of the calcaneus. Basic
fracture patterns can be delineated with plain radiographs. A decision
can then be made regarding ancillary tests, most commonly CT scans.
Surgery should be performed within the initial 3 weeks of injury prior
to early consolidation of the fracture. Surgery should not be
attempted, however, until swelling in the foot and ankle has adequately
dissipated, as indicated by a positive wrinkle test.¹⁸⁷
The test is performed by direct palpation and visual assessment of the
lateral calcaneal skin with dorsiflexion and eversion of the involved
foot. The test is positive if skin wrinkling is seen and no pitting
edema is evident, indicating that operative intervention may be safely
undertaken (Fig. 59-25).

A variety of methods may be used to reduce swelling of
the affected extremity. If the patient is seen initially in the
emergency department, immediate elevation in combination with a
Jones-type compression dressing with a posterior splint may be used,
with or without a compressive pneumatic foot pump.²¹⁸ In the event of an isolated injury, the patient may be discharged

from the hospital and converted to an elastic compression stocking and
fracture boot locked in neutral flexion several days later. CT scans
and plain radiographs may be reviewed with the patient, and a
management plan outlined at that time. Full resolution of soft tissue
edema may require up to 21 days. We prefer to proceed with surgical
intervention within 2 weeks of injury, although surgery may be safely
performed up to 3 weeks from injury. Beyond this interval, early
consolidation of the fracture occurs, and the fragments become
increasingly difficult to separate and reduce. Furthermore, at the time
of attempted reduction, the articular cartilage may be left behind,
completely delaminating from the underlying subchondral bone, leaving a
facet fragment without any accompanying cartilage.

Crosby and Fitzgibbons⁴⁴
reviewed their results of nonoperative management of calcaneal
fractures using a CT classification based on the fracture pattern
involving the posterior facet. Small or nondisplaced fractures were
classified as type I fractures, displaced fractures as type II, and
comminuted fractures as type III fractures. In their series, there were
13 type I, 10 type II, and 7 type III fractures. They reported good
results with closed treatment in all type I fractures, but poor results
in most type II and type III fractures, and suggested operative
treatment was indicated for these fractures.

Kitaoka et al.¹¹²
reviewed fractures in 16 patients treated nonoperatively and used gait
analysis to evaluate outcome. Most patients in their series exhibited
an altered gait pattern, especially on uneven ground, thus confirming
that nonoperative management of calcaneus fractures led to at least
some persistent functional impairment.

In recent years, several studies have been published comparing operative to nonoperative treatment.^* Jarvholm et al.¹⁰⁵
evaluated 20 patients treated operatively over a 12-year period and
compared the results to a historical control group treated
nonoperatively over the same time period by other surgeons. They
concluded that the problems associated with internal fixation did not
justify operative treatment; however, several limitations in their
study design were apparent: only a few operative procedures were
performed each year; the surgeons did not consistently use lag screws
and never stabilized the calcaneal body with a plate or staple;
intraoperative fluoroscopy was not available; and the authors conceded
they were never able to obtain a perfect reduction. This study
illustrates many of the inherent flaws seen in the published literature
on calcaneal fractures and thus prohibits the reader from reaching
meaningful conclusions.

Parmar et al.¹⁶¹
compared 31 displaced fractures treated nonoperatively to 25 treated
operatively. They used their own classification and fixed fractures
with K-wires through a lateral Kocher approach. No attempt was made to
reduce the calcaneal tuberosity, and they encountered difficulty in
evaluating the postoperative CT scans. Using their own scoring system,
they found no difference in clinical outcome between the two groups.
The limitations of this study include poor operative fixation
techniques and lack of assessment of the postoperative reduction by
scans.

O’Farrell et al.¹⁵⁷
treated 12 patients operatively and 12 patients nonoperatively. CT was
used; however, the fractures were not classified. In those treated
operatively, a Kocher incision was used with lag screw and plate
fixation. Postoperative CT evaluation was completed. Clinical outcome
was based on walking distance, subtalar motion, return to work, and
shoe size. They concluded that operative treatment was superior, but
their limited patient population precluded statistical significance.

Leung et al.¹²⁶
compared 44 patients treated operatively with 19 treated nonoperatively
in a nonrandomized, retrospective study with an average follow-up of 3
years. Fractures were classified according to the Crosby and
Fitzgibbons classification. They used an extensile lateral approach,
and the reduction was held with lag screws and plate fixation. At an
average of 3-year follow-up, they reported significantly better results
in the surgical group with respect to pain, activity, range of motion,
return to work, and hindfoot swelling.

Crosby and Fitzgibbons⁴⁴
first reported on the results of nonoperative treatment of
intra-articular calcaneal fractures in 1990. Because of the poor
outcomes with the displaced and

comminuted fractures, the authors began treating displaced (type II) fractures.⁴⁴,⁴⁵
Results of their operative cases were then compared with their
nonoperative cases using the same outcomes assessment instrument. They
found superior results in those fractures that were treated
operatively; the difference was highly statistically significant. As a
result, they recommended operative intervention for displaced fractures.

Thordarson and Kreiger²¹⁹
performed a randomized, prospective trial comparing operative to
nonoperative treatment in 30 patients. Fractures were classified by CT,
and only Sanders type II and III (displaced) fractures were included in
their study. Nonoperative treatment consisted of non-weight-bearing and
early range-of-motion exercises. Operative treatment was performed by a
single surgeon and consisted of an extensile lateral approach with lag
screw and plate fixation. Clinical outcome using the American
Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot Score¹¹¹
was completed in all 15 operatively treated fractures and in 11 of 15
nonoperatively treated fractures. The functional results and overall
outcome in the operatively treated group were superior to those in the
nonoperative group; the differences were statistically significant.
Despite small numbers and a relatively short period of follow-up, this
study represented the first randomized, prospective trial where many
variables were held constant, and this study confirmed that operative
intervention could lead to superior results.

Buckley and Meek²⁷
first reported their matched cohort series of 34 calcaneal fractures in
1992. Seventeen fractures were treated operatively, and 17 were treated
nonoperatively. The patients were matched with respect to age, sex,
work type, and time to follow-up. They concluded that their best
results were in patients with an anatomic reduction of the posterior
facet and that, if an anatomic reduction was not possible, there
appeared to be no difference between operative and nonoperative
treatment. Unfortunately, no classification was performed, such that
fractures were not consistently classified. More important, 12
different surgeons participated in surgical treatment of the 17
patients, and all used different techniques.

The same group of surgeons then evaluated the literature on this topic. Randle et al.¹⁷³
performed a meta-analysis of articles between 1980 and 1996 dealing
with calcaneal fractures. Of the 1845 articles, 6 compared operative
versus nonoperative treatment for displaced calcaneal fractures using
the minimum criteria for inclusion in the meta-analysis. A statistical
summary of information across the six articles revealed a trend for
surgically treated patients to be more likely to return to the same
type of work as compared with nonoperatively treated individuals. There
also was a trend for nonoperatively treated patients to have a higher
risk of experiencing severe foot pain than did operatively treated
patients. Unfortunately, none of the other outcomes could be summarized
formally across studies using statistical techniques because of
variability in reporting across studies. Although the tendency was
always for operatively treated patients to have better outcomes
(reaching statistical significance in some of the articles), the
strength of evidence to recommend operative treatment for displaced
intra-articular calcaneal fractures remained weak.

Because of these concerns, the Canadian Orthopaedic
Trauma Society performed a prospective, randomized, multicenter trial
and compared operative with nonoperative treatment of displaced
intra-articular calcaneal fractures in 424 patients with 471 fractures.²⁸
Two hundred and eighteen patients with 262 fractures were treated
nonoperatively; 206 patients with 249 fractures underwent operative
treatment through an extensile lateral approach with screw, plate, or
wire fixation. Seventy-three percent of patients were followed for a
minimum of 2 years, with an average of 3 years. Fractures were
classified according to Sanders, and outcomes were evaluated using two
separate previously validated assessment tools. Analysis revealed
significantly better results in certain fracture groups undergoing
operative treatment, including women, younger patients, patients with a
lighter workload, patients not receiving Worker’s Compensation,
patients with a higher initial Böhler angle (less severe initial
injury), and those with an anatomic reduction on postoperative CT
evaluation. There was no difference in overall outcome between the
operative and nonoperative groups; however, those having nonoperative
treatment of their fracture were 5.5 times more likely to require a
subtalar arthrodesis for posttraumatic arthritis than those undergoing
operative treatment.

Radnay et al.¹⁶⁸
recently reported on a matched cohort study comparing patients who had
undergone initial ORIF and subsequently developed posttraumatic
arthritis requiring an in situ fusion with patients treated
nonoperatively who developed a calcaneal malunion and required a late
reconstruction and subtalar arthrodesis. The ORIF group included 36
feet in 34 patients with an average follow-up of 2.7 years. The average
interval from ORIF to late subtalar arthrodesis was 22 months, and 33
of 36 arthrodeses (91.7%) achieved initial union. The calcaneal
malunion group included 45 feet in 40 patients with an average
follow-up of 5.3 years.³⁷ The
average interval from fracture to late reconstruction was 16.4 months,
and 37 of 40 arthrodeses (92.5%) achieved initial union. There was a
statistical trend toward a lower wound complication rate and
significantly higher outcome scores in the ORIF group. This study
suggested that the early operative restoration of calcaneal height,
length, and overall shape is beneficial to outcome. In the event the
patient developed late posttraumatic arthritis, a simple in situ
arthrodesis could be performed.

Percutaneous and Minimally Invasive Fixation. Fixation
techniques for tongue-type fractures using a percutaneous “nail” were
first advocated by Westhues.²³⁶ The technique was modified by Gissane,⁷⁹
who developed the Gissane Spike for this procedure. It was
Essex-Lopresti, however, who described the technique in detail and
popularized the maneuver specifically for tongue-type fractures.⁶²
Over time, this technique was used for all types of calcaneal fractures
with poor results, and thus fell into disfavor. Recently, Tornetta²²⁴
revived the original technique, reporting on the results of 26 patients
with Sanders type IIC (extra-articular tongue-type) fractures using the
Essex-Lopresti maneuver with a modification of fixation (Fig. 59-26).
Steinmann pins were initially used for definitive fixation, but these
were changed to 6.5-mm cannulated screws later in the series. Three
patients were considered intraoperative failures, in that the technique
was abandoned in these patients in favor of traditional ORIF. The
reduction maneuver was successful in 88%. There were 86% good or
excellent results based on the Maryland Foot Score at an average
follow-up of 2.9 years.

Current indications for a percutaneous approach include the emergent reduction and stabilization of fractures with severe

or impending soft tissue compromise from displaced fracture fragments.
Initial, closed or percutaneous reduction and external fixation
supplemented by K-wire fixation may be followed by standard open
treatment if the soft tissues are amenable within 2 to 3 weeks. For
those patients with relative contraindi-cations to open surgery, such
as heavy smokers, patients with severe peripheral vascular disease, or
patients with poorly controlled diabetes, minimally invasive approaches
may be used as definitive treatment. In general, small incisions are
used for the placement of Schantz pins and small periosteal elevators
in assisting with the reduction, followed by multiple small-fragment
screws axially and laterally (Fig. 59-27).

Tongue-type fractures are particularly amenable to these approaches. Sangeorzan and Ringler¹⁹³
reviewed the results of 36 tongue-type calcaneal fractures managed with
a minimally invasive reduction technique and small-fragment fixation
with an average follow-up of 25.5 months. The operative technique
involved small (less than 1-cm) incisions, which were used for the
introduction of Schantz pins and small elevators for the reduction. The
fracture fragments were aligned with the Essex-Lopresti reduction
technique. All reductions were performed under fluoroscopic guidance
and were stabilized with small-fragment screw fixation. Two screws were
introduced in an axial direction, and any subsequent screws were
introduced from the lateral surface to secure the sustentaculum.
Postoperatively, patients were placed in a removable splint and range
of motion was begun postoperatively within 1 to 2 days. Weight bearing
was initiated after 2 to 3 months. There were no infections and no
cases of lost fracture reduction, and only one patient went on to
require a subtalar arthrodesis. They concluded that their technique
lowered the incidence of postoperative risks and reduced the length of
hospital stay compared to historical controls.

Rammelt et al.¹⁶⁹
noted that percutaneous reduction methods play an important role in the
management of calcaneal fractures with severe soft tissue compromise,
particularly open fractures. Percutaneous reduction by pin leverage
(Westhues or Essex-Lopresti maneuver) followed by minimally invasive
screw fixation was a treatment option that yielded good to excellent
results in tongue-type fractures with posterior facet displacement

as
a whole (Sanders type IIC). The authors noted that the method could
also be applied to selected Sanders type IIA or IIB fractures if the
joint reduction was controlled arthroscopically.

Forgon⁶⁸ described a
method of three-point skeletal traction applied to the tuberosity,
talus, and cuboid, using ligamentotaxis to manipulate the main
fragments. The depressed posterior facet is elevated percutaneously
with a K-wire introduced laterally. The reduction is confirmed on
fluoroscopy and the fragments are fixed with percutaneously placed lag
screws. Other authors have described percutaneous or mini-open
reduction with use of small wire circular external fixators.⁶¹,¹⁴⁰ The use of temporary uniplanar, unilateral external fixation has also been described.¹³² The early results of these minimally invasive approaches are comparable to traditional open methods.

In an effort to reduce the risk of problems with wound healing, Weber et al.²³⁴
presented a technique that combined open reduction and fixation of the
joint fragments and the anterior process, with percutaneous reduction
and screw fixation of the tuberosity. A group of 24 patients with
unilateral isolated closed Sanders type II and III fractures was
treated using this technique and, compared with a similar group of 26
patients, managed by the extended approach and lateral plating. The
operation was significantly quicker (p
<0.001) in the first group, but more minor secondary procedures and
removal of screws were necessary. There were no wound complications in
this group, whereas four minor complications occurred in the second
group. According to the authors, the ultimate functional results were
equivalent in both groups. Unfortunately, despite the fact that the
authors thought postoperative CT scans were not needed, since these
were not obtained, the accuracy and maintenance of the joint reduction
using this minimal technique could not be assessed, limiting the
usefulness of this report.

Some authors have expanded the use of percutaneous
reduction by traction, leverage, and compression with subsequent K-wire
or screw fixation for all types of calcaneal fractures.¹⁶⁹,²⁴⁰ Stulik et al.²¹⁴
reported on the treatment of 287 Sanders type II, III, and IV fractures
using minimally invasive techniques. A four-step procedure using a
traction bow, a percutaneous joint reduction using a plantar placed
punch, lateral heel compression, and percutaneous pinning was
performed. A near anatomic reduction was possible in 73.9% of
fractures, with a 4.5% loss of reduction, and a 7% superficial pin
tract infection. Using the Creighton-Nebraska score, clinical outcomes
included 29 excellent, 98 good, 26 fair, and 23 poor results. They
noted that tongue-type fractures had better results than
joint-depression fractures, but Sanders type III tongue fractures were
very difficult

to
reduce using their methods. Results also worsened with an increased
number of fracture fragments, as previously described by Sanders et al.¹⁸⁷,¹⁹⁰
Interestingly, at a minimum of 2-year follow-up, joint narrowing and
subchondral sclerosis were seen in 85.7% of cases, possibly indicating
the arthritic demise of a joint that was not anatomically reduced but
mobile. Nonetheless, the authors stated that 72% of patients returned
to their preinjury work and that this technique would work well in most
cases.

Ziran and Bosch²⁴⁰
described their results in 28 comminuted, Sanders type III/IV calcaneus
fractures treated with closed reduction and percutaneous pinning. With
the help of a traction bow and Steinmann pin, reduction of the body was
performed. There was no attempt made to reduce the subtalar joint.
After fixation, patients were splinted and then braced with a posterior
relief ankle-foot orthosis that allowed ankle motion. Pin care was
performed 3 times a day. Patients remained non-weight bearing for 12
weeks, at which point the pins were taken out in the office and weight
bearing was initiated. Twenty-five fractures in 21 patients were
available for review with an average follow-up of 1 year. Subtalar
motion was less than 10 degrees in all cases. Twelve patients reported
minimal to no pain with full activity. These patients used normal shoes
and had no limp. Seven patients had moderate discomfort with full
activity: two had peroneal tendonitis from the lateral wall of the
calcaneus. Two patients had severe pain with activity and had
difficulties with shoe wear. They both had a shortened hindfoot with 15
degrees of varus of their calcaneus. The authors concluded that in all
their cases an anatomic, open reduction would have been the better
technique.

A major concern surrounding the application of minimally
invasive approaches is the potential for incomplete or malreduction of
the posterior facet. Inadequate reduction and/or loss of reduction of
the articular fragments may occur in a significant number of cases.
Rammelt et al. have successfully used subtalar arthroscopy to assist in
judging the quality of articular reduction.¹⁶⁹,¹⁷⁰
They noted, however, that a uniform application of percutaneous
reduction and fixation methods to all types of calcaneal fractures
carried a considerable risk of inadequate joint reconstruction and
redislocation. As will be discussed later, intraoperative CT scanning
may improve the execution of minimally invasive techniques but is not
readily available in most settings. Finally, prolonged transfixation of
the subtalar and calcaneocuboid joints may be needed to maintain
reduction but should be avoided as significant subtalar stiffness may
result.⁶² In conclusion, minimally
invasive and/or percutaneous techniques should be reserved for
relatively simple tongue-type fracture patterns. Before attempting
these technically demanding approaches, surgeons should be thoroughly
familiar with the pathoanatomy of intra-articular calcaneal fractures
and have mastery of traditional open techniques.

These fractures will present with pain, swelling, and
ecchymosis overlying the anterolateral hindfoot region, along with
tenderness to palpation directly over the anterior process fragment.
Anterior process of the calcaneus fractures typically are mis-diagnosed
as ankle sprains, hence the designation “sprainfractures.”²²,⁴⁷,⁴⁹,⁷⁴,⁸³
They often result from a forced inversion and plantarflexion injury,
which increases tension on the bifurcate ligament, and produces an
avulsion fracture.¹⁰⁴ The fracture
line exits into the calcaneocuboid articulation and typically includes
minimal amounts of the articular surface, although varying proportions
of the joint surface may be involved. The extensor digitorum brevis
muscle may also contribute to the injury pattern. Alternatively, injury
to the anterior process region may result from forced abduction of the
foot, producing an impaction fracture of the calcaneocuboid articular
surface.¹⁰⁰ In this instance, the
fragment is typically larger with more involvement of the articular
surface and may displace posteriorly and superiorly.

Fractures of the calcaneal tuberosity can result in either an open beak-type fracture or an avulsion fracture⁵²,¹⁸¹ (Fig. 59-31). The distinction lies in that the avulsion fracture pulls the entire Achilles tendon from its insertion. Protheroe¹⁶⁷
questioned this as he described cases of open beak-type fractures with
the entire Achilles tendon avulsed. These two fractures most probably
represent a spectrum of injury, resulting most commonly from a violent
pull of the gastrocnemius-soleus complex, such as with forced
dorsiflexion with a low-energy stumble and fall, producing an avulsed
fragment of varying size.

Patients with fractures of the calcaneal tuberosity will
present with pain and swelling in the posterior hindfoot and may also
have weakness with resisted plantarflexion because of the shortened
gastrocnemius-soleus complex. Because of the limited soft tissue
envelope overlying the tuberosity, displacement of the fragment may
endanger the surrounding skin. Thus, care must be taken to assess the
overlying skin, as expedient care of the fracture may be necessary to
avoid skin slough.⁷¹ Surgical repair
of calcaneal tuberosity avulsion fractures is indicated when (a) the
posterior skin is at risk because of pressure from the displaced
tuberosity, (b) the posterior portion of the bone is extremely
prominent and will affect shoe wear, (c) the gastrocnemius-soleus
complex is incompetent, or, rarely, (d) the avulsion involves the
articular surface of the joint.

True extra-articular fractures of the calcaneus, not
involving the subtalar joint, probably account for 20% of all calcaneal
fractures.¹⁸²,²³³ The mechanism of injury is identical to that of an intra-articular fracture, with the difference being that the

lines of force do not cross the posterior facet. Standard radiographs
will typically show the fracture involving the body of the calcaneus,
but a CT scan is required to determine whether an intra-articular
fracture exists, as well as the amount of displacement (Fig. 59-32).
Surgery is based on both these factors. Minimally displaced fractures
(less than 1-cm) are treated nonoperatively with early motion and
non-weight bearing for 10 to 12 weeks.⁵³,⁷³,¹⁹⁵
Those with significant displacement resulting in varus/valgus
deformity, lateral impingement, loss of heel height, or translation of
the posterior tuberosity require either closed manipulation of the
fracture or ORIF.⁵³,⁷³,¹⁴³

Isolated medial or lateral process fractures of the
posterior tuberosity are rare and usually nondisplaced. The mechanism
of injury is typically a fall directly on the tuberosity of the heel
either with the foot inverted, causing a shear fracture of the lateral
process, or with the foot in eversion, causing a fracture of the medial
process (Fig. 59-33). Usually, the heel pad is
exquisitely tender, with the area ecchymotic and swollen. The fracture
is best seen on the axial radiographic view or on the coronal CT scans.
Treatment is based on the amount of displacement. Nondisplaced
fractures can be treated with a short-leg weight-bearing cast until
they heal at 8 to 10 weeks.¹⁸,¹⁴¹,¹⁹⁶ When fractures are displaced, closed manipulation may be considered.⁵³

Peroneal tendonitis and stenosis are generally seen
following nonoperative treatment because of lateral impingement, where
the displaced, expanded lateral wall subluxes the peroneal tendons
against the distal tip of the fibula, or dislocates the tendons.
Entrapment may also occur after operative treatment²⁰⁷ and is more common with a standard Kocher approach, because the

tendons are released from their sheath to allow access to the subtalar
joint. The extensile lateral approach has largely circumvented these
problems⁸²,²²⁷;
however, care must be taken when operating near the fibula to sublux,
but not dislocate, the peroneal tendons when exposing the fracture.

Patients may also develop adhesions and scarring of the
tendons, either from the surgical approach or from prominent adjacent
implants. Differential local anesthetic injections can be used to
document that the source of the pain is the peroneal tendons, but Mizel
et al.¹⁴⁹ proposed that this may not
be completely accurate and suggested that a simultaneous injection of
contrast material be performed with the anesthetic to alert the
clinician to any lack of specificity of the anesthetic test. If the
pain is diagnosed as peroneal scarring or impingement, either tenolysis
or removal of the symptomatic implants may be needed if nonoperative
modalities, such as massage and stretching, fail to provide relief.

The surgeon will occasionally diagnose dislocation of
the peroneal tendons preoperatively, usually by palpation along the
lateral malleolus (Fig. 59-48). Although the
tendons are often reducible after the lateral wall abutment is removed,
occasionally the tendons will continue to dislocate as the surgeon
manipulates the subtalar joint after completing the reduction and
fixation of the calcaneus. In these cases, the surgeon should attempt
to reconstruct the superior peroneal retinaculum and surrounding soft
tissue envelope in order to stabilize the tendons.¹³⁸,²⁰⁰,²⁰²,²⁰⁸
This is most easily performed by tacking the periosteal sleeve back
down to the posterior edge of the fibula with a staple or suture
anchor. This will prevent the tendons from redislocating into the soft
tissue defect created by the injury (Fig. 59-49).

Chronic heel pad pain may result from damage to the unique septated architecture of the heel pad. Sallick and Blum¹⁸⁵
recommended sensory denervation for this problem, but their ability to
distinguish various causes of pain was limited and they performed this
procedure indiscriminately. Both Barnard and Odegard¹⁰ and Lance et al.¹¹⁴
recognized that plantar pain from a damaged heel pad is not improved by
operative treatment. Currently, there remains no effective treatment
for this problem.

Patients may develop painful plantar bony prominences
following a calcaneal fracture. If nonoperative methods, such as heel
pads, are unsuccessful, these painful exostoses can be removed
surgically, as originally described by Cotton in 1921.⁴⁰ A plantar incision should be avoided, as this is associated with painful scarring.

The most common neurologic complication associated with
operative management of calcaneal fractures is iatrogenic injury to a
sensory cutaneous nerve. The sural nerve is the most common nerve
involved because of the frequency of use of the lateral approach, and
this complication may occur in up to 15% of cases.¹²⁸
In this approach, the nerve may be injured at either the proximal or
distal portions of the incision, and the injury may vary from a stretch
neuropraxia, which may be transient or permanent, to a laceration of
the nerve. Nerve injury may also occur with the medial approach, with
the calcaneal branch of the posterior tibial nerve most commonly
involved, occurring in up to 25% of cases.¹⁵⁸
Clinically, the patient may develop a partial or complete loss of
sensation in the affected area or a painful neuroma. Nonoperative
treatment is generally advised and may include pharmacologic management
such as gabapentin or amitriptyline, physical therapy modalities, and
soft accommodative shoe inserts or modifications. In the event of a
painful neuroma that does not respond to nonoperative treatment,
neurolysis or resection of the neuroma and stump burial into deep
tissue or bone may be considered.

Nerve entrapment is most common following nonoperative
management of a calcaneal fracture and typically involves entrapment or
compression of the posterior tibial nerve secondary to soft tissue
scarring, a malunited fracture fragment, or bony exostosis causing
impingement against the nerve.¹¹²,¹²⁸,¹⁵⁶
Patients experience medial-sided heel pain with associated paresthesias
in the distribution of the posterior tibial nerve, and the pain is
commonly worse at night or with activities, such as standing or
walking. Clinically, there may be a positive Tinel sign along the
course of the involved nerve. The diagnosis can be confirmed by
injection of a local anesthetic in the tarsal tunnel or by
electrodiagnostic studies. When clinical and diagnostic tests indicate
nerve entrapment, surgical neurolysis and decompression of the
posterior tibial nerve and its branches may be indicated.

Reflex sympathetic dystrophy, now known as complex
regional pain syndrome type I, may occur following operative or
nonoperative management. Once present, it may result in long-term and
potentially permanent functional impairment of the patient. The
diagnosis is made clinically, and examination initially reveals burning
or aching pain out of proportion to the injury that is refractory to
narcotic pain medication, extreme intolerance to cold, and pain with
passive range of motion and light touch. Patients note irritation from
any contact with the skin, including socks and bed sheets. Later, the
patient may exhibit cold clammy skin, cyanotic discoloration, and scant
hair growth. Radiographs obtained at this point may reveal patchy,
disuse osteopenia, and three-phase bone scan frequently shows altered
uptake in the affected limb. Last, as the limb becomes atrophic, the
skin often assumes a pale, shiny, cyanotic appearance with the absence
of skin folds and significant restrictions in joint range of motion.
Radiographs will typically reveal severe osteopenia.

Those patients diagnosed in the acute stage of this
disease may be managed with aggressive physical therapy, including
manual desensitization and massage, and pharmacologic agents such as
gabapentin or amitriptyline. Protracted cases may require lumbar
sympathetic nerve blockade, epidural or intrathecal pain pumps,
alpha-adrenergic blockers, or other medications. Prompt referral to a
pain management specialist may be beneficial. In the absence of a
specific stimulus as a cause of the underlying pain (e.g., a prominent
screw or a neuroma), further surgical treatment should be avoided.¹²⁸