1. King Edward
Medical University
Rabia Mustafa
King Edward medical university

2. Contents
Type IV fractures consist of fractures with more than three intrarticular fractures..........................................
Intraarticular Fractures:...........................................................................................................................................
Type C involve the posterior calcaneus, the posterior tuberosity and medial tubercle
included.......................................................................................................................................................................
Extraarticular Fractures:..........................................................................................................................................
Recovery: The recovery period of a calcaneus fracture is an important aspect in
determining how well a patient will return to his pre-injury level of activity. Patients will be
required to keep weight off of the foot for as long as three months. The other critically
important aspect of treatment is controlling swelling, especially in patients who have had
surgery. The best ways to control swelling includes elevation. Conclusions:.......................................................
References:..................................................................................................................................................................
Calcaneus Fracture:
The calcaneus is the bone in the back of the foot, commonly
referred to as the heel bone. This bone helps support the foot and
is important in normal walking motions. The joint on top of the
calcaneus is responsible for allowing the foot to rotate inwards
and outwards. Fractures of the heel bone, or calcaneus, can be
disabling injuries. They most often occur during high-energy
collisions — such as a fall from height or a motor vehicle crash.
Because of this, calcaneus fractures are often severe and may
result in long-term problems
Causes: The calcaneus can be injured in a fall, twisting
injury, or motor vehicle collision. A simple twisting injury may
result in the calcaneus being cracked. The force of a head-on car
collision may result in the bone being shattered (comminute
fracture).Different causes can result in similar fracture patterns.
For example, when landing on your feet from a fall, your body's

3. weight is directed downward. It drives the talus bone down into
the calcaneus. In a motor vehicle crash, the calcaneus is driven up
against the talus. In both cases, the resulting fracture patterns are
similar. The greater the impact, the more the calcaneus is
damaged.
Anatomy:
 (Left) In some injuries, the talus is forced downward and
acts like a wedge to fracture the calcaneus. (Right) This
computerized reconstruction of a calcaneus fracture shows
the amount of damage that can occur. Anatomy Particular
facets
 Superior particular surface contains three facets that
articulate with the talus.
 posterior facet is the largest and is the major weight bearing
surface
 the flexor hillocks long us tendon runs just inferior to this
structure and can be injured with errant drills/screws that
are too long
 middle facet is anteromedial on sustentaculum tali
 anterior facet is often confluent with middle facet
 Sinus tarsi
o between the middle and anterior facet lies the
interosseous sulcus (calcaneal groove) that together
with the talar sulcus makes up the sinus tarsi
 Sustentaculum tali
o project medially and supports neck of talus
o FHL passes beneath it

4. o deltoid and talocalcaneal ligament connect it to the
talus
 fragment remains "constant" and does not
typically move
 Bifurcate ligament
o connect the dorsal aspect of the anterior process to the
cuboid and navicular
Mechanism :
 Axial load (MVC, fall from height)
 Impaction of the talus causes a "primary" shear fx of
calcaneus and lateral wall blowout that results in two
fragments
 anteromedial fragment (contains sustentaculum tali)
 The medial fragment
 is not substantially displaced relative to the
 talus because of the medial talocalcaneal and interosseous
ligaments.
 often only minimally displaced secondary to medial
talocalcaneal and interosseous ligaments
 super lateral fragment (contain intra-particular facets)
 additional energy results in a "secondary" fx line and
additional fragments
 extension into the calcaneocuboid joint occurs in 63%
 Associated injuries
o injuries of spine in 10%
contralateral calcaneus in 10%
types of calcaneus fracture:
The Sanders Classification system is the most commonly used
system for categorizing intrarticular fractures. There are 4 types:

5. 1. Type I fractures are non-displaced fractures (displacement <
2 mm).
2. Type II fractures consist of a single intrarticular fracture
that divides the calcaneus into 2 pieces.
o Type IIA: fracture occurs on lateral aspect of
calcaneus.
o Type IIB: fracture occurs on central aspect of
calcaneus.
o Type IIC: fracture occurs on medial aspect of
calcaneus.
3. Type III fractures consist of two intrarticular fractures that
divide the calcaneus into 3 articular pieces.
o Type IIIAB: two fracture lines are present, one lateral
and one central.
o Type IIIAC: two fracture lines are present, one lateral
and one medial.
o Type IIIBC: two fracture lines are present, one central
and one medial.
Type IV fractures consist of fractures with more than three
intrarticular fractures.
Intraarticular Fractures:
Approximately 75% of calcaneal fractures are intraarticular and
result from axial loading, which produces two separate fracture
lines: shear and compression A shear fracture occurs in the
sagittal plane and runs through the posterior facet, dividing it
into anteromedial and posterolateral fragments The fracture line
may extend anteriorly to involve the cuboid facet. The position of
this fracture line depends on the position of the foot at the time of
the shear force. If the hindfoot is in varus position, the line
extends more anteromedially; if the hindfoot is in valgus position,
the line tends to be more posterolateral. If the foot is in extreme
valgus position, the fracture line may be lateral to the posterior
facet and extraarticular. A sagittal shear fracture splits the
calcaneus into two fragments: the anteromedial or
“sustentacular” fragment and the posterolateral or “tuberosity”

6. fragment The medial fragment is not substantially displaced
relative to the talus because of the medial talocalcaneal and
interosseous ligaments. The lateral fragment is dislocated
laterally and remains impacted following release of the axial load,
leading to a “step off” in the posterior facet Occasionally, the
talus continues to impact on the lateral edge of the medial
fragment, creating a “double split” in it The resultant fragment is
called the “middle fragment” and typically is displaced by about
1–2 mmIntraarticular calcaneal fractures produce typical
features, including (a) loss of height due to impaction and rotation
of the tuberosity fragment, (b) increase in width due to lateral
displacement of the tuberosity fragment
Extrarticular fractures include all fractures that do not involve
the posterior facet of the subtalar joint.
 Type A involve the anterior calcaneus
 Type B involve the middle calcaneus. This includes the
sustentaculum tali, trochlear process and lateral process.
Type C involve the posterior calcaneus, the posterior tuberosity
and medial tubercle included.
Extraarticular Fractures:
Extraarticular fractures account for approximately 25%–30% of
all calcaneal fractures. All fractures that do not involve the
posterior facet are included in this category. Extraarticular
calcaneal fractures are classified as (a) anterior process fractures;
(b) fractures of the mid calcaneus, which includes the body,

7. sustentaculum tali, peroneal tubercle, and lateral calcaneal
process; and (c) fractures of the posterior calcaneus, which
include those of the tuberosity and medial calcaneal tubercle
When contemplating extraarticular calcaneal fractures, it is
important to differentiate complex fractures that separate
articular facets and distort the three-dimensional anatomy of the
subtalar joint from the more simple extraarticular fractures.
Anterior process fractures are uncommon and are usually
produced by forced inversion that results in increased tension
across the bifurcate ligament which connects the anterior process
to the cuboid and navicular Other mechanisms include forced
abduction of the forefoot with a fixed calcaneus and exaggerated
dorsiflexion .Patients often present with localized pain and
commonly without deformity. The fracture is best seen on oblique
views and may not be seen on anteroposterior and lateral views.
CT is particularly helpful for evaluation of anterior process
fractures. Protected weight bearing is the usual treatment for
small fractures. Displaced fractures involving more than 25% of
the calcaneocuboid articular surface are usually treated with
open reduction and internal fixation .Nonunion is the most
common complication.
Symptoms:
The most common symptoms of a calcaneus fracture are:

8.  Pain
 Bruising
 Swelling
 Heel deformity
 Inability to put weight on the heel or walk
Imaging:
Im AP/LAT foot
 Bohler angle (normal is 25-40 degrees)
 flattening (deceased angle) represents collapse of the
posterior facet
 measured by angle between the following two lines
 line connecting anterior process and highest point on
posterior articular surface
 line connectin highest point on posterior articular surface
and superior tuberosity
 Gissane angle (normal is 130-145 degrees)
 an increase represents collapse of posterior facet
 Harris view
 allows visualization of subtalar joint involvement,
comminution, loss of height, widening, and impingement on
peroneal space
 take with foot maximally dorsiflexed and beam angled at 45
degrees
 Broden views
 allows visualization of posterior face

9.  ankle internally rotated 40 degrees and ankle in neutral
dorsiflexion. Views taken at 10, 20, 30, 40 degrees
 largely replaced by CT scan
 AP ankle
look for lateral wall extrusion and impingement
 CT scan is gold standard
 MRI typically used only to diagnose calcaneal stress
fractures in the presence of normal radiographs and/or
uncertain diganosis
Tests:
Other tests that may help your doctor confirm your diagnosis
include:
X-rays. This test is the most common and widely available
diagnostic imaging technique. X-rays create images of dense
structures, like bone, so they are particularly useful in showing
fractures.
Computed tomography (CT) scan. After reviewing your
x-rays, your doctor may recommend a CT scan of your foot. This
imaging tool combines x-rays with computer technology to

10. produce a more detailed, cross-sectional image of your body. It
can provide your doctor with valuable information about the
severity of the fracture. Studying CT scans helps your doctor plan
your treatment. He or she will often show you the images to help
you understand the nature and severity of your injury.
HISTORICAL BACK GROUND:
 1908 cotton and willson
Recommended closed treatment with use of a medially
placed sandburg a laterally placed felt pad and a hammer to
reduce the lateral wall and “reimpact” pf the fracture
 1920 s
Abandoned the treatment of acute fractures altogather and
had turned instead of healed malunious
 1931 bohler
Advocated open reduction
Technical problems associated with operative treatment
Infection, malunion, non-union and possible need for
amputation
 1935 Conn
Delayed primary triple arthrodesis
 1943 gallie
Subtalar arthrodesis as definitive treatment only for
fractures that healed this techniquee became standard for
healed malunited calcaneal fracture
 1948 palmar
Dissastified with both nonoperative and late treatment
Described the operativeoperative treatment of acute
displaced intra articular calcaneal
Standard lateral kocher approach to reduce the joint
Holding up the fragment with bone graft

11. He stated that is patient did well and that many returend to
work
 1952 essex
Reported similar findings
In the last twenty years
 Better anasthesia
 Antibiotics
 Asif principles of internal fixataion
 Computed tomography
 Flucoscopy
Goog outcomes with use of operative intervention
Treatment:
In planning your treatment, your doctor will consider several
things, including:
 The cause of your injury
 Your overall health
 The severity of your injury
 The extent of soft tissue damage
Because most calcaneus fractures cause the bone to widen, the
goal of treatment is to restore the normal anatomy of the heel. In
general, patients whose normal heel anatomy is restored have
better overall outcomes. Recreating normal anatomy, however,
most often involves surgery. Surgery is associated with a higher
risk of complications.
Your doctor will discuss the treatment options with you.
Surgical Treatment:

12. If the bones have shifted out of place (displaced), you may need
surgery.
Timing of surgery. If the skin around your fracture has not been
broken, your doctor may recommend waiting until swelling has
gone down before having surgery. Keeping your leg immobilized
and elevated for several days will decrease swelling. It also gives
skin that has been stretched a chance to recover. This waiting
period before the operation often improves your overall recovery
from surgery and decreases your risk of infection.
Open fractures, however, expose the fracture site to the
environment. They urgently need to be cleansed and require
immediate surgery.
Early surgery is also often recommended for an avulsion fracture.
Although uncommon, a piece of the calcaneus can be pulled off
when the Achilles tendon tears away from the bone (avulsion).
For this type of fracture, early surgery can decrease the risk of
injury to the skin around the Achilles tendon.
Surgical procedure:
The following procedures are used for various types of calcaneus
fractures.
 Open reduction and internal fixation. During this operation,
the bone fragments are first repositioned (reduced) into

13. their normal alignment. They are held together with
special screws or metal plates and screws.
 Percutaneous screw fixation. Sometimes, if the bone pieces
are large, they can be moved back into place by either
pushing or pulling on them without making a large
incision. Special screws can be placed through small
incisions to hold your bone pieces together.
(Left) A displaced fracture of the calcaneus. (Right) The fracture
has been reduced and the bones held in place with screws.
The typical method of realigning the bone fragments and holding
them in place with metal plates and screws.
Nonsurgical Treatment:
If the pieces of broken bone have not been displaced by the force
of the injury, you may not need surgery. Casting or some other
form of immobilization may be an option. This will keep the
broken ends in proper position while they heal.
You will not be able to put any weight on your foot until the bone
is completely healed. This may take 6 to 8 weeks, and perhaps
longer.

14. Recovery:
The recovery period of a calcaneus fracture is an important
aspect in determining how well a patient will return to his pre-
injury level of activity. Patients will be required to keep weight off
of the foot for as long as three months. The other critically
important aspect of treatment is controlling swelling, especially in
patients who have had surgery. The best ways to control swelling
includes elevation. Conclusions:
Calcaneal fractures are complex injuries that commonly occur in
male patients and that result in substantial morbidity. Recently,
there has been an exponential proliferation of CT examinations of
trauma patients who have sustained multiple injuries. In addition,
dramatic advances have occurred in imaging technology,
particularly multi-detector CT and image processing. This
combination has resulted in dramatic improvements in the
visualization of calcaneal injuries, which in turn has led to
improved fracture characterization for the trauma patient
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