Calcaneus

Scenario

You are called to A+E to assess a 40 year old male who jumped from a wall and has sustained the following injury. He has no past medical history.

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This is a lateral and anterior-posterior plane film radiograph of a patients ankle. There is a displaced tongue type calcaneal fracture.

Extra-articular (25%)

Intra-articular (75%)

  • Essex-Lopresti classification
    • Tongue type
    • Joint depression type
  • Sanders classification
    • Based on the number of articular fragments seen on the coronal CT images at the widest point of the posterior facet.

Saunders classification

Type 1

Non displaced posterior facet

Type 2

One fracture line in the posterior facet

Type 3

Two fracture lines in the posterior facet

Type 4

Comminuted with more than 3 fracture lines

  • Böhler’s lines (20-40°): angle between the highest point of the anterior facet to the highest point of the posterior facet and a line tangential to the superior edge of the tuberosity.
  • Angle of Gissane (120-145°): Angle between line along lateral margin of posterior facet and line anterior to beak of calcaneus.

They represent collapse of the posterior facet.

Cast immobilisation non-weightbearing for 6 weeks (stress fractures)

Cast immobilisation non-weightbearing for 10-12 weeks

Cast immobilisation requires regular checks as there is a high incidence of skin complications.

 

Operative management can be either:

  • Closed reduction and percutaneous pinning
  • Open reduction + internal fixation
  • Restore congruity of subtalar joint
  • Restore Bohler’s angle and calcaneal height
  • Restore width
  • Correct varus
  • Wound complications (smokers, diabetic and open fractures)
  • Subtalar arthritis
  • Sural nerve neuroma
  • Lateral impingement with peroneal irritation
  • Compartment syndrome
  • Malunion