Elsevier

Injury

Volume 35, Issue 5, May 2004, Pages 443-461
Injury

REVIEW
Calcaneus fractures: facts, controversies and recent developments

https://doi.org/10.1016/j.injury.2003.10.006Get rights and content

Abstract

The management of calcaneus fractures and their associated soft tissue injuries are challenging tasks for the surgeon. Open reduction and stable internal fixation with a lateral plate and without joint transfixation has been established as a standard therapy for displaced intra-articular fractures with good to excellent results in two-thirds to three-quarters of cases in larger clinical series. Bone grafting appears not useful in the vast majority of cases. Anatomical reduction of joint congruity and the overall shape of the calcaneus are important prognostic factors. The quality of joint reduction should be reliably proven intra-operatively either with Brodén views, high-resolution fluoroscopy or open subtalar arthroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days and individual risk factors such as high body mass index and smoking. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposure of the fractured lateral wall, and the subtalar and calcaneocuboid joints in most fractures. In selected fracture patterns percutaneous screw fixation, possibly with arthroscopic control, is a good alternative. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency cases. Early, stable soft tissue coverage appears promising in treating complex open fractures. The benefits of newly developed plate designs and subtalar arthrolysis at the time of hardware removal remains to be proven in further studies. Calcaneal malunions after conservative therapy of displaced fractures are disabling conditions that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, subtalar in situ, or corrective, arthrodesis and calcaneal osteotomy along the former fracture line.

Introduction

The treatment of displaced calcaneus fractures has generated controversy throughout the past 150 years. Although both diagnostic and therapeutic tools have been improved dramatically over the recent two decades, many aspects of the management of these injuries continue to be topics for debate. The irregular anatomy of the calcaneus, the complicated coupling with the talus and tarsus via three joint facets and the highly specialised, delicate soft tissue envelope have made operative treatment a challenging task to the fracture surgeon. Consequently, the authors of larger series have highlighted a considerable learning curve.5., 86., 112. On the other hand, conservative treatment of displaced calcaneus fractures frequently leads to severe functional impairment with considerable disability.5., 23., 50., 53., 73. To avoid the feared soft tissue complications, several minimally-invasive and percutaneous approaches have been proposed throughout the history of calcaneal fracture treatment and recently gained popularity for selected injury patterns.40., 105. Comparison of the various treatment methods is hampered by the lack of a uniform fracture classification and outcome measurement. A well-accepted fact is, however, that the sequelae of calcaneus fractures have a considerable socio-economic impact since a great percentage of these injuries occur in young and middle-aged male industrial workers.87., 113. The treatment of calcaneus fractures has to be tailored not only to the individual fracture pattern and soft tissue damage but also to the functional demand, comorbidities and compliance of the patient. This article reviews the current concepts and new developments regarding the treatment of these difficult injuries.

Section snippets

Historical review

The apparent difficulties in treating calcaneal fractures are reflected in dramatic changes in the treatment of these injuries. During the 18th and 19th centuries, the prevention of life-threatening infections was the primary goal of fracture treatment. Partial or total calcanectomy was frequently carried out to salvage the limb and prevent the patient from tetanus or gas gangrene. Malgaigne,64 in his landmark atlas of 1856, described the complex anatomy of calcaneus fractures with high

Anatomical and biomechanical considerations

A profound knowledge of the irregular anatomy of the calcaneus and its neighbouring bones and a three-dimensional imagination are indispensable in assessing and treating calcaneus fractures. The calcaneus is the largest bone of the foot. It makes up the essential posterior part of the longitudinal foot arch and the lateral foot column. Through the action of the Achilles tendon, the plantar fascia and intrinsic foot muscles it acts as a strong lever arm during walking, standing and crouching.

The

Pathomechanics

Fractures of the calcaneus are typically produced by axial force. The vast majority result from heavy deceleration, such as a fall from a height or motor vehicle accidents with the foot pressed firmly against a pedal. Men are affected four to five times more often than women.87., 113. The highly variable fracture pattern is affected by the magnitude and direction of the impacting force, the foot position, the muscular tone, and the mineral content of the bone.

The vertical load axis of the talus

Clinical features

Clinical assessment of patients with injuries to the hindfoot is crucial, not only for making the diagnosis in low-energy injuries, but also for staging the soft tissue injury, which is important for further management. Special attention must be paid not to overlook foot injuries in multiply injured patients.113 Typical features of calcaneal fractures are swelling and haematoma of the hindfoot and ankle. The heel is tender to palpation. The patients are unable to bear weight on the affected

Radiographic assessment

The lateral view of the calcaneus allows assessment of Böhler’s and Gissane’s angles, loss of height, compression and avulsion fractures at the calcaneal body and the anterior process (Fig. 2). Broadening of the heel and varus/valgus alignment can be evaluated on axial radiographs of the hindfoot. An anteroposterior (dorsoplantar) view of the foot with a 30° caudally tilted tube allows evaluation of the calcaneocuboid joint. Anteroposterior films of the ankle joint demonstrate the amount of

Classification

Böhler12 was one of the first to provide an extensive calcaneal fracture classification system. Eight groups of fractures were described, four of them extra-articular (groups 1–4) and four intra-articular (groups 5–8). A broad range of different fracture pathoanatomy was covered by this classification, including beak fractures (group 1), isolated sustentacular fractures (group 3), classical dislocations of the posterior facet (groups 5 and 6), as well as dislocations in the talonavicular (group

Indications and timing of surgery

The question whether, when and how to operate calcaneal fractures still generates lively debate. Most authors would agree, that severely displaced extra-articular fractures and those with intra-articular step-offs should be reduced anatomically in the absence of systemic or local contraindications,6., 8., 9., 30., 31., 60., 84., 86., 112. opinions differ on what amount of displacement is considered severe. Since step-offs of 1–2 mm in size in the posterior facet are associated with a substantial

Emergency procedures

For the timing of surgery, the soft tissue conditions and associated injuries are of paramount importance. Open fractures and closed fractures with compartment syndrome, or severe incarceration of the soft tissues from severely displaced sharp fragments, are treated as emergency cases. Emergency procedures for open fractures include initial debridement of the wound which is typically situated medially, temporary closure with skin substitutes, and minimally-invasive fracture reduction with

Non-operative treatment

Non-operative treatment is generally favoured for non- or minimally-displaced fractures and in the presence of local or general contraindications to surgery as outlined earlier.30., 87., 113. Anti-oedematous therapy consists in initial rest, ice and elevation of the affected foot for 3–4 days. After that, ankle and subtalar range of motion exercises are started and patients are mobilised with partial weight-bearing of 20 kg on the affected leg for 6–10 weeks, depending on the severity of the

Minimally-invasive treatment

Indirect, closed reduction and percutaneous osteosynthesis of displaced calcaneal fractures may minimise the incidence of soft tissue-related complications, but carries the risk of inadequate reduction, especially with complex fracture patterns. Patients with simple injury patterns may benefit from minimally-invasive procedures,40., 105. as do patients in a critical overall condition, or with local soft tissue conditions that preclude extensive approaches.113 Some authors have developed

Operative treatment: open reduction and internal fixation

Open reduction and internal fixation of intra-articular calcaneal fractures aims at the restoration of the overall shape of the calcaneus, anatomical reconstruction of the affected joint surfaces and stable osteosynthesis, without joint transfixation, to allow early mobilisation. Several lateral, medial, plantar, posterior and combined approaches have been advocated. Many authors of larger series favour the extended lateral approach for displaced intra-articular calcaneal fractures.6., 9., 60.,

Complications

Injuries to the cutaneous nerves most frequently afflict the sural nerve laterally and the posterior tibial nerve medially.47., 77. These lesions usually result in hypaesthesia and are treated conservatively, except for neuroma formation, for which excision is advised.87 The most frequently observed postoperative complication is superficial wound edge necrosis, which is seen in up to 14% of cases after standard osteosynthesis via an extended lateral approach1., 6., 8., 47., 112. and up to 27%

Results of operative treatment

A multitude of clinical studies deals with the operative treatment of calcaneal fractures. It is still difficult to draw general conclusions because of the relatively low patient numbers in many of the studies, the lack of control groups and the different classification and outcome scores used by the various authors. In five larger clinical series of lateral plate osteosynthesis, including more than 100 patients classified consistently with CT, good to excellent results were observed in 60–85%

Malunions after calcaneus fractures

Calcaneal malunions regularly result from displaced fractures treated conservatively. The observed deformities are a direct consequence of the fracture pathology, as described earlier, and frequently lead to disabling conditions. Typical problems include painful subtalar arthritis, shortening and widening of the hindfoot, varus or valgus malalignment, impingement and/or subluxation of the peroneal tendons, fibulocalcaneal abutment, sural or posterior tibial neuritis, malposition of the talus

Summary

Assessment and treatment of calcaneal fractures have improved substantially over the last two decades. Open reduction and stable internal fixation, without joint transfixation, have been established as standard therapy for displaced fractures with good to excellent results in two-thirds to three-quarters of cases in larger clinical series. In the vast majority of cases, bone grafting is not necessary. Anatomical reduction of subtalar joint congruity and restoration of the overall shape of the

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