Calcaneus fractures account for ~ 2% of all fractures.

The calcaneus is the most frequently fractured tarsal (hindfoot) bone.

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  It represents 60% of all tarsal fractures.

  
  
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  Minor avulsion fractures off anterior process are common and usually benign.

Most intraarticular calcaneus fractures are the result of an axial load applied directly to the heel.

A high-energy calcaneus fracture is often a life-altering event for the affected individual.

The socioeconomic burden of calcaneus fractures is significant.

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  90% of these fractures occur in working individuals between 20-40 years of age.

The mechanism of injury (axial loading) often results in concomitant injuries to the lower extremities and the spine.

Always evaluate patients for signs and symptoms of compartment syndrome.

Radiographic examination should include a lateral of the foot and ankle, a mortise view of the ankle, dorsoplantar and oblique x-rays of the foot, and an axial (Harris) view.

Definitive management of intraarticular calcaneus fractures consists of either operative or nonoperative treatment.

The historical aversion to operative treatment of the calcaneus was related to severe complications, including compartment syndrome, nerve injury, wound-healing problems and infection, malunion, subtalar arthritis, and nerve injury.

Treating orthopedists have been guilty of focusing too much attention on the articular reduction of the posterior facet.

Attention to all aspects of the injury, both osseous and soft tissue, will yield the best results.

Surgical treatment of the calcaneus was discouraged through most of the early 20th century.

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  The treatment of acute fractures was all but abandoned.

  
  
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  Focus of treatment was on late reconstruction of healed malunions.

In 1916, Cotton and Henderson concluded that, “The man who breaks his heel bone is done.”

In 1926, Conn wrote, “Calcaneus fractures are serious and disabling injuries in which the end results continue to be incredibly bad.”

Böhler advocated open reduction of calcaneus fractures as early as 1931.

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  However, due to the limitations of poor diagnostic tools and the lack of appropriate implants to achieve stable fixation, the complication rate (i.e., wound problems, infection, and loss of reduction) was high.

Throughout North America, primary triple or isolated subtalar arthrodesis was popularized during the 1930s and 1940s.

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  The results of those treatments continued to be poor.

  
  
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  In 1942, Bankart concluded, “the results of crush fractures of the os calcis are rotten.”

In 1958, Lindsey and Dewar studied the long-term outcome of calcaneus fractures and concluded that nonoperative treatment provided the best outcome.

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  Throughout the 1960s and 1970s, nonoperative treatment continued to be the treatment of choice.

Treatment options for calcaneus fractures remain controversial.

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  However, advances in radiographic imaging, surgical technique, and a better understanding of the pathoanatomy of calcaneus fractures have led to improved results with surgical treatment of these challenging fractures over the past 20 years.

Most intraarticular calcaneus fractures are the result of an axial load applied directly to the heel.

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  High-energy intraarticular calcaneus fractures are usually the result of a fall from height or a motor vehicle accident.

  
  
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  The actual fracture pattern is influenced by the position of the foot and the subtalar joint, the force of the impact, and the quality of the patient’s bone.

Extraarticular fractures are more frequently the result of a twisting or an avulsive force.

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  Isolated fractures of the anterior process of the calcaneus may be the result of forced inversion of the plantar flexed foot, resulting in an avulsive force created by the insertion of the bifurcate ligament.

  
  
  
  
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    Alternatively, forced dorsiflexion and eversion may compress the anterior process between the cuboid and the talus.

  
  
  
  
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  Avulsion fractures of the tuberosity may be caused by a sudden forceful contraction of the gastrocnemius-soleus muscle complex.

  
  
  
  
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    They may occur in patients with a previously tight heel cord (e.g., diabetics).

  
  

In intraarticular fractures, the energy imparted to the calcaneus during axial loading results in 2 characteristic primary fracture lines.

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  The 1st fracture line usually starts at the crucial angle of Gissane.

  
  
  
  
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    The lateral process of the talus acts as a wedge, dividing the calcaneus into an anterior and a posterior 1/2.

  
  
  
  
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  The anteromedial fragment, also called the constant fragment, usually maintains its relationship with the talus, tethered by the strong interosseous and medial ligaments.

  
  
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  The posterolateral fragment usually displaces laterally and into varus alignment.

  
  
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  Secondary fracture lines travel in the sagittal plane along the length of the bone in an anterior and a posterior direction.

  
  
  
  
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    These fracture lines can travel into the calcaneocuboid joint, split the anterior facet, or exit the body of the calcaneus medially or laterally.

  
  

In higher energy fractures, additional secondary fracture lines develop, resulting in higher degrees of comminution.

Initial evaluation of all patients with calcaneus fractures involves a thorough physical examination.

The mechanism of injury (axial loading) often results in concomitant injuries to the lower extremities and the spine.

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  Lumbar spine fracture

  
  
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  Tibia fracture (pilon, plateau)

  
  
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  Ankle fracture

  
  
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  Additional foot fracture

  
  
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  Acetabular fracture

Lumbar spine fractures are most commonly associated, especially in cases of bilateral calcaneus fractures.

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  Some would argue for routine lumbar spine radiographs in any patient with a calcaneus fracture from a fall.

The injured foot is placed into a bulky dressing or a foam boot and is elevated.

The neurovascular status of the fractured extremity should be carefully tested and documented.

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  Numbness or a subjective decrease in sensation may be an early warning sign of impending compartment syndrome.

Evaluation for compartment syndrome is essential on initial evaluation.

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  Carefully monitor for developing or impending compartment syndrome with serial examinations.

  
  
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  Compartment syndrome of the foot may present as excruciating pain, an alteration in sensation, or pain with passive motion of the toes.

  
  
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  Many patients with calcaneus fractures will have pain with passive toe motion, because the origin of the flexor digitorum brevis is on the calcaneus.

  
  
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  It is also common to see plantar nerve paresthesias with high-energy injuries, so the entire clinical picture must be taken into account when evaluating for compartment syndrome.

A patient with suspected compartment syndrome should undergo invasive measurement of the compartments of the foot.

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  Absolute compartment pressure > 30 mm Hg or a 40-mm Hg difference between the measured pressure and the patient’s diastolic pressure is an indication for foot fasciotomies.

The energy imparted to the foot in calcaneus fractures is shared equally by the bone and soft tissues.

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  Therefore, evaluation and close monitoring of the soft tissues is important.

  
  
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  Patients will often present with fracture blisters, which result when there is cleavage at the dermal-epidermal junction.

  
  
  
  
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    Blisters should be covered with sterile dressings and allowed to drain on their own.

  
  

If the patient is to undergo surgical treatment, the operation is delayed until the blisters have reepithelialized, and skin wrinkles are visible over the lateral aspect of the hindfoot.

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  Sequential compression devices for the foot may be of some use in helping to control edema in the preoperative phase.

An exception to delayed treatment is in cases where the soft tissue may be threatened by a displaced fracture.

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  Tuberosity avulsion fractures may result in pressure over the skin of the posterior heel.

  
  
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  The surgeon should consider urgent reduction to prevent additional soft tissue injury, which may quickly lead to full-thickness skin necrosis.

Severe injuries may result in open fractures.

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  Open calcaneus fractures are rare and account for < 10% of all calcaneus fractures.

  
  
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  The traumatic wound tends to be on the medial side, caused by the sharp spike of the medial wall created by the primary fracture line.

  
  
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  The tuberosity is dislocated laterally.

Open fractures should be treated with urgent debridement.

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  The medial wound is debrided.

  
  
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  Closed or minimally invasive techniques to realign the calcaneus can be performed at the time of debridement.

  
  
  
  
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    Given the severe soft tissue injury, extensile approaches should be avoided until the soft tissues have recovered.

  
  
  
  
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  Typically, wires are used to hold the tuberosity in a relatively reduced position until time of definitive treatment.

Occasionally, higher energy injuries will result in fractures with open wounds laterally.

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  Care must be taken in the debridement of these wounds, as the lateral exposure may be later utilized for stabilization of the fracture.

Inspection and palpation of the peroneal tendons should also be performed on initial examination.

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  Often, the initial examination is difficult due to swelling and patient discomfort.

  
  
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  The examination is repeated under anesthesia.

  
  
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  Dislocated tendons usually reduce to their anatomical location with adequate reduction of the fracture.

Several systems have been developed for classification of calcaneus fractures.

Calcaneus fractures can be divided into 2 broad categories: Intraarticular and extraarticular.

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  30% of calcaneus fractures are extraarticular.

  
  
  
  
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    Anterior process fractures represent the majority of extraarticular injuries.

    
    
    
    
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      They account for 10-15% of all calcaneus fractures.

      
      
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      They are more common in women.

    
    

  
  
  
  
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  Intraarticular fractures comprise 70% of all calcaneus fractures.

In 1952, Essex-Lopresti classified intraarticular calcaneus fractures into 2 broad types: Tongue type and joint depression.

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  The Essex-Lopresti classification was primarily descriptive but also helps to distinguish those fractures that could be approached through percutaneous techniques (Essex-Lopresti maneuver).

In 1993, Sanders classified calcaneus fractures based on the number and location of articular (posterior facet) fracture fragments as seen on CT scan.

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  The Sanders classification is unique in that it is prognostic as well as descriptive.

  
  
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  One of the limitations of the Sanders classification is that it is based purely on the posterior facet and does not address injuries to the remainder of the calcaneus.

More recently, the Foot and Ankle Study Group of the Arbeitsgemeinschaft für Osteosynthesefragen has developed the Integral Classification of Injuries to the bones, joints, and ligaments.

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  This system provides a precise descriptive classification for injuries to the foot, including calcaneus fractures.

  
  
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  In this fracture classification scheme, the foot is divided into 3 zones:

  
  
  
  
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    Hindfoot

    
    
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    Midfoot

    
    
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    Forefoot

  
  
  
  
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  A numeric system is used to describe the location of the fracture.

  
  
  
  
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    81.2 is number used to designate calcaneus

  
  
  
  
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  The fracture is then determined to be:

  
  
  
  
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    A (extraarticular)

    
    
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    B (intraarticular)

    
    
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    C (fracture-dislocation)

  
  
  
  
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  Additional subgroups are included for direction of dislocation, number of joints involved, and soft tissue injury.

  
  
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  Although this system provides a comprehensive classification scheme, its reproducibility and usefulness remain to be seen.

Definitive management of intraarticular calcaneus fractures consists of either operative or nonoperative treatment.

Several factors determine which method of treatment is used, including patient factors, type of fracture, and surgeon experience.

A number of patient-related factors can affect the outcome of intraarticular calcaneus fractures and, therefore, will impact the decision to pursue operative or nonoperative treatment.

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  Patients with drug and alcohol addiction, organic brain disease, or other forms of mental incapacitation, and who are unable to cooperate with the postoperative rehabilitation plan, are probably better treated nonoperatively.

Patient factors that may result in an inability to heal surgical wounds are also considered to be relative contraindications for operative treatment.

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  Smoking or other regular nicotine use impairs wound healing.

  
  
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  Patients with diabetes mellitus or peripheral vascular disease carry a higher risk of complications with surgery.

The specific nature of the fracture also influences this decision.

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  Minimally displaced fractures can be treated without surgery.

  
  
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  There is some evidence that dramatically displaced fractures (particularly those with a negative Böhler angle) may have a poor outcome regardless of the treatment.

Occasionally, the fracture type may supersede other factors in determining operative vs. nonoperative approach.

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  For example, an Essex-Lopresti tongue-type fracture that can be reduced and stabilized through percutaneous methods may be treated operatively with a low risk of complications, even in a smoker with diabetes mellitus.

Finally, surgeon experience plays an important role in the operative treatment of calcaneus fractures.

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  The learning curve for surgical repair of the calcaneus is well documented.

  
  
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  Complications and poor results may occur more frequently if complex fractures are managed by inexperienced surgeons.

In 2002, Buckley et al reported the results of a prospective randomized study of operative vs. nonoperative treatment of calcaneus fractures at 2 years’ follow-up.

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  309 patients with 371 calcaneus fractures were randomized to receive a standardized operative or nonoperative treatment conducted at 4 trauma centers.

  
  
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  Based on 36-Item Short-Form Health Survey and visual analog scores, there was no difference in outcome based on treatment groups.

  
  
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  However, when the treatment groups were stratified, operative treatment was shown to be superior in women and patients who were not on workers’ compensation.

  
  
  
  
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    Within the nonworkers’ compensation group, the following groups had better results with operative treatment:

    
    
    
    
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      Younger patients

      
      
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      Patients with injury Böhler angle of 0-14°

      
      
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      Patients with lighter workload

    
    

  
  
  
  
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  This study is helpful in identifying patients who may have an improved outcome with operative treatment.

However, the decision for operative or nonoperative treatment must be made on an individual basis.

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  Although Buckley contends that nonoperative treatment may provide better outcomes at 2 years in certain cases, the surgeon should also consider the long-term effects of a malaligned calcaneus on the remainder of the joints in the foot and ankle.

  
  
  
  
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    Later foot reconstruction is easier and safer with a well-aligned foot.