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 ANATOMY
 FRACTURE CHARACTERISTICS
 MANAGEMENT

HISTORY
“ The Man Who Breaks
His Heel Bone Is Done”
- Cotton 1916

HISTORY
“ Calcaneus Fractures
Are Serious And
Debiliting Injuries In
Which The End Result
Continues To Be
Incredibly Bad ”- Conn 1935

HISTORY
“ Operative Treatment Of
Calcaneus Fractures Is
Like Nailing A Custard Pie
To The Wall ”
- McLaughin 1942

 5 CLINICAL SIGNIFICANT ASPECTS OF
BONY ANATOMY
› 3 SUPERIOR ARTICULAR FACETS
› SUSTENTICULLUM TALI
› MEDIAL WALL
› LATERAL WALL
› DISTAL ANTERIOR CUBOID ARTICULATION

 BOHLER’S ANGLE
 CRITICAL ANGLE OF GISSANE
 CALCANEUM DIMENSIONS
› HEIGHT
› WIDTH
› HORIZONTAL LENGTH

 Force through subtalar joint driving talus
lateral process into everted calcaneus to
create fracture patterns described by Essex-
Lopresti.
 The “axe” of the lateral process of talus is
driven into lateral wall of calcaneus.
 This produces a fracture that runs superior
lateral to inferior medial.
Ref - 5. Essex Lopresti P. The mechanism, reduction technique, and results
in fractures of the os calcis. Br J Surg 1952;39:395-419.

 A secondary fracture line is then resulted
from increased force
› Joint Depressed type
› Tongue-type fracture
Ref- Essex-Lopresti, P (March 1952). "The mechanism, reduction technique, and
results in fractures of the os calcis.". Br J Surg. 39 (157): 395–419.

 Posterior facet comminution
 Sub fibular impingement
 Heel widening
 Horizontal Attitude of talus

 Bohler 8 types
› Extra – Articular - 4
› Intra – Articular - 4
No correlation between fracture type and outcome.
Ref - Bohler L. Diagnosis, pathology, and treatment of fractures of the os calcis. J
Bone Joint Surg 1931;13:75 – 89

 Palmer - Essex-Lopresti
› TONGUE TYPE
› JOINT DEPRESSION–TYPE
Based on mechanism and secondary fracture line
Ref - Palmer I. The mechanism and treatment of fractures of the calcaneus. J
Bone Joint Surg Am 1948;30:2 – 8
Essex-Lopresti P. The mechanism, reduction technique, and results in
fractures of the os calcis. Br J Surg 1952;39:395 – 419.

 Soeur and Remy
Based on the number of articular fracture
fragments - Plain radiographs
 No mention - comminution - calcaneal body
or of the articular facet
 Did not correlate results with outcomes
Ref - Soeur R, Remy R. Fractures of the calcaneus with displacement of the
thalamic portion. J Bone Joint Surg Br 1975;57:413 – 21

 Sanders et al –
widely
accepted
Ref - Sanders R, Fortin P, DiPasquale A, et al. Operative treatment in 120 displaced
intra-articular calcaneal fractures. Results using a prognostic computed tomographic
scan classification. Clin Orthop 1993;290:87 – 95.

Virtually every aspect of management of
complex calcaneum fractures is controversial.

 Closed
› Without reduction
› With reduction
 Extensile lateral
 Minimal invasive
 Salvage procedure – primary fusions

 84 fractures
 Ankle arthritis – 100%
 Sub-talar arthritis -90%
 Cheaper and low rate of sof tissue
complications

 471 fractures, followed up to 2-8 years
 VAS and SF-36
 No appreciable difference

Certain subgroups showed better results
treated operatively including:
 Women
 Younger patients
 Patients with a lighter workload
 Patients not involved in workers’ comp claims
 Patients with a higher initial Bohler’s angle
 Those with an anatomic reduction on post-op CT
evaluation.

 82 fractures, 12 year follow up
 VAS and SF-36(non-responsive),
AOFAS(non-validated)
 One year – no appreciable diffrences

 8-12 years – surgical group
› lower rate of post-traumatic subtalararthritis(risk
reduction – 41%)
› Trend in VAS (pain and function) and physical
component of SF-36 – improved
› Higher complications rate – in terms of soft tissue
healing

 malposition of the talus which leads to tibiotalar
impingement and ankle pain,
 shortening or widening of the hindfoot,
 fibulocalcaneal impingement,
 varus or valgus malalignment,
 impingement or subluxation of the peroneal
tendons, or
 sural or posterior tibial neuritis
 Malunions can be responsible for painful
subtalar arthritis

 painful subtalar joint arthritis - treated with an
isolated subtalar fusion
 the deformity of the calcaneus must be
corrected to restore adequate function to
the hindfoot
Ref - Gallie WE. Subastragalar arthrodesis in fractures of the os calcis. J Bone
Joint Surg 1943;25: 731 – 6

 47 cases
 10 years follow up
 Reduction co-related with outcomes
 38.3% excellent results

 Retroscpective review, 112 fractures
› SF-36, foot function index, VAS
 More wound complications and secondary
surgeries with extensile lateral
 No difference in Bohler’s angle or angle of
Gissane
 Similar clinical results

 35yrs male
 h/o fall from bike
 Right calcaneal Fracture
 No co morbidity

 42yrs male
 h/o fall from 10 feet height
 With spinal injuries T9 and L1 compression
fracture
 With B/l calcaneum fracture

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