1. CALCANEAL FRACTURES
Dr.Thanh

2. CLASSIFICATION Essex-LoprestiCLASSIFICATION Essex-Lopresti
Fx of the posterior facet: 2 Types
• Joint depression: fX line producing the
posterior facet fragment exits behind
the posterior facet and anterior to the
attachment of the tendo calcaneus:.
• Tongue: distal to the tendo calcaneus
insertion.

3. INTRA& EXTRA-ARTICULARINTRA& EXTRA-ARTICULAR

8. Sanders’s classificationSanders’s classification
• Type I: All nondisplaced articular fx (less
than 2 mm), irrespective of the number of
fx lines.
• Type II: two-part fx posterior facet. Three
Types: IIA, IIB, and IIC existed, based on
the location of the primary fracture line
• Type III: three-part fX that usually featured
a centrally depressed fragment

9. Sanders’s classificationSanders’s classification
IIIAB, IIIAC, and IIIBC, again based on the
location of the primary fracture line
• Type IV: four-part articular fX, were highly
comminuted and often had more than four
articular fragments
• Although the subclassification of articular fx lines
by medial to lateral location is important
prognostically, most surgeons simply identify the
number of articular fragments

12. Rx EVALUATIONRx EVALUATION
• Rx evaluation should include five views .
• A lateral to assess height loss (loss of
Böhler angle)& rotation posterior facet .
• The axial (or Harris) view assess varus
position of tuberosity & width of the heel.

13. A single Brodén viewA single Brodén view
• AP & oblique views assess the anterior
process & calcaneocuboid involvement.
• A single Brodén view, internally rotating
the leg 40° with the ankle in neutral, then
angling the beam 10 to 15 °cephalad,
evaluate congruency posterior facet

21. CT scansCT scans
• CT scans evaluate the injury completely.
ordered in two planes:
• Semicoronal plane, oriented perpendicular
to the normal position of the posterior
facet
• The axial plane, oriented parallel to the
sole of the foot

28. Goals of operative?Goals of operative?
• Restoration congruency of the posterior facet of
the subtalar joint
• Restoration the height of the calcaneus (Böhler
angle),
• Reduction of the width of the calcaneus,
• Decompression of the subfibular space
available for the peroneal tendons,
• Realignment of the tuberosity into a valgus
position & reduction of the calcaneocuboid joint
if fractured.

32. DISCUSSIONDISCUSSION
• Extra-articular: generally treated in a closed manner. Exceptions
include sustentaculum tali with displacement > 2 mm, posterior
avulsion fX & significant fX of the calcaneal body.
• Intra-articular: may be treated in a closed fashion, but commonly:
open reduction, ostectomy, osteotomy, internal fixation, and/or
arthrodesis of the subtalar and calcaneocuboid joints.
• Nondisplaced (Sanders type I) intra-articular fX are generally treated
closed.
• Severely comminuted (Sanders type IV) intra-articular fX may be
treated with a combination of open reduction and internal fixation
(ORIF) and arthrodesis of the subtalar joint.
• Other factors influencing nonoperative versus operative intervention
include the patient's age, comorbid health conditions, and any
concurrent injuries.

33. DISCUSSIONDISCUSSION
• The timing of surgery is an important factor in
determining surgical success, as measured by long-term
functional outcomes. Ideally, surgery should occur within
3 weeks after injury.
• This period allows for any swelling and fracture blisters
to resolve completely, but the procedure is still
sufficiently early to prevent premature healing and
coalescence of the fracture fragments.
• In the absence of fracture blisters, the return of normal
skin wrinkling is an indication that significant swelling has
resolved and operative intervention may proceed

34. DISCUSSIONDISCUSSION
• Despite improvements in imaging, as well as a better understanding
of the patterns of injury in complex fx of the calcaneus, opinions on
the management of such injuries differ.
• Prospective studies have attempted to show benefit with either
early operative intervention or with nonoperative measures.
• Each modality has at times enjoyed more attention and enthusiasm
in the literature.
• A frustrating factor that perpetuates this disagreement is the subset
of calcaneus fractures with poor long-term outcomes, regardless of
the management.
• Cotton commented in 1916 that "the man who breaks his heel bone
is done so far as his industrial future is concerned."

35. DISCUSSIONDISCUSSION
• Compared with open procedures, closed reduction with
percutaneous fixation has a lower risk of wound
complications, a shorter operative time, and more rapid
healing because the soft tissue is handled less.
• This approach is indicated in patients with significant
comorbidities, soft-tissue compromise or impaired
healing, or true tongue-type fracture patterns.
• The goals of this approach include improvement of heel
alignment and reduction of the posterior facet.
Unfortunately, the limited exposure that this technique
affords sometimes prevents adequate reduction and
fixation of the calcaneal injury.
• If anatomic joint reduction is sought, ORIF may be a
preferred option.

36. DISCUSSIONDISCUSSION
• Calcaneal ORIF has improved as a result of
enhanced preoperative evaluation with CT
scanning.
• Enhancements in equipment and surgical
technique, particularly in the area of soft-tissue
handling, have also improved its surgical
success rates.
• Another exciting development is the use of
subtalar arthroscopy (as Rammelt et al
described) for accurate evaluation of the
posterior facet after the initial reduction is
performed.

37. DISCUSSIONDISCUSSION
• The most popular incision for exposure during ORIF of calcaneus
fractures is an extensile lateral approach.
• This approach allows the surgeon to visualize the entire fracture. It
also allows for complete reduction from the tuberosity to the anterior
process and the calcaneocuboid joint.
• In addition, this approach permits indirect reduction of the medial
wall and the sustentaculum.
• The extensile lateral approach should include a full-thickness skin
flap. Gentle tissue handling is a must, and adequate wound closure
is equally important.
• Flap closure that avoids excessive tension on the skin is critical to
prevent skin necrosis.
• The use of thin plates in calcaneal fixation has significantly
addressed the issue of excessive skin tension, hardware
prominence, and subsequent wound breakdown.