Reference: Heckmann, James, in Rockwood and Green, 1996, Chapter 32
These are devastating injuries. The jury is out with regards to the treatment. Probably, there are some that are better fixed, particularly by those who are good at them, and some that are better left alone. One hopes that Buckley’s study will delineate some of that…
Points of Interest
Plantar Surface – medial and lateral processes – for attachment of the plantar fascia and intrinsic foot muscles.
Dorsal Surface – posterior, middle, anterior facets
– Posterior facet – convex; makes up most of the subtalar joint
– Middle facet – concave; situated on the sustentaculum tali
– Anterior facet – concave; confluent with the middle facet
The calcaneal groove and interosseous ligament lies between the middle and posterior facets.
Bohler’s angle: the complement of the angle formed by a line drawn from the highest point of the anterior process to the highest part of the posterior process, and a line drawn from this point to the highest part of the tuberosity.
Most fractures are intra-articular – caused by axial loading. But there are many that are caused by twisting injuries – these are usually extra-articular.
– AP and lateral views are good
– Axial view of the calcaneus shows the width
– Broden’s view (a medial oblique view) – internally rotate the foot 45o, then shoot at 40, 30, 20, 10 degrees cephalad to get the right AP projection of the posterior facet
– Lateral oblique view – externally rotate the foot 60o and shoot 10o cephalad to get a good lateral of the posterior facet.
– either avulsion fracture of the anterior process by the “bifurcate ligament” – a ligament the connects the anterior process to the navicular and cuneiform; or a compression fracture (more unusual)
– the pain is noted anterior and inferior to the anterior talofibular ligament, which makes it distinguishable from ankle sprains
– usually treated with cast immobilization; if large and unreduced, you can fix them. If they don’t heal, they may not be symptomatic. If they are, you can excise them with good results.
– avulsion of the Achilles tendon
– if minimally displaced, cast in slight equinus, 6 weeks
– if displaced, ORIF with tension band or screw, then cast in slight equinus
– serves as the origin of the abductor hallucis and the medial portion of FDB and plantar fascia
– avulsion of the plantar fascia
– treat with walking cast with molding to push the medial process laterally.
– a Sanders IIC fracture
– pain is often accentuated by passively extending the great toe (pulls up on FHL)
– axial x-rays and CT are critical
– cast if nondisplaced. If more than 2 mm displaced, need to fix.
– these spare the subtalar joint
– Bohler’s angle may be decreased, but with congruity of the subtalar joint
– generally speaking, require no treatment at all
– the indications to treat these are 1. If Bohler’s angle is significantly reduced (by 10o or more) because of the loss of mechanical advantage of the tendo-achilles. 2. If the heel has been significantly widened (will lead to difficult shoe wear and ulceration)
– If Bohler’s angle is reduced, you can put a Steinman pin transversely through the tuberosity, pull down on it, then put them into a cast, incorporating the pin.
Primary Fracture Line – runs obliquely from plantarmedial to dorsolateral, creating an anteromedial (sustentacular) fragment and a posterolateral (tuberosity) fragment. The sustentacular fragment is rarely comminuted, being attached to the talus by the strong deltoid and interosseous talocalcaneal ligaments. The tuberosity fragment is the one that gets shmucked.
– This primary fracture line is created in this fashion because the talus sits