Which Calcaneus Fractures Should I Operate On?
Calcaneus fractures continue to be a difficult injury to manage. This chapter will focus on the treatment of intra-articular calcaneus fractures. There are extra-articular types, such as anterior process or tuberosity fractures, that we will briefly mention in the discussion of operative indications. In general, intra-articular calcaneus fractures involve a high-energy, axial load mechanism. The lateral process of the talus acts as a wedge driving into the calcaneus, which leads to a predictable fracture pattern. This often leads to intra-articular displacement of the posterior facet of the subtalar joint and calcaneocuboid joint and loss of the normal axial width and height of the calcaneus.
In order to determine which calcaneus fractures require surgery, an understanding of the basic radiographic relationships is critical. Two radiographic parameters that require evaluation are Bohler’s angle and the crucial angle of Gissane. Both are evaluated on the lateral view. Bohler’s angle is determined by drawing a line from the highest point on the anterior process of calcaneus to the highest point of the posterior facet and a second line drawn along the superior edge of the tuberosity (Figure 39-1). The normal value is 20 to 40 degrees, with a decrease indicating collapse of the posterior facet. The critical angle of Gissane is formed by a line along the lateral margin of the posterior facet and another line extending anterior to the beak of the calcaneus (Figure 39-2). The normal value is 95 to 105 degrees with an increase representing posterior facet collapse. Additional imaging views that are useful include a Harris axial view and Broden’s views. A Harris axial view is useful in determining varus or valgus malalignment of the tuberosity, and Broden’s views are useful in viewing the subtalar joint.
Figure 39-1. Lateral view depicting Bohler’s angle.
Figure 39-2. Lateral view depicting Gissane’s angle.
Computed tomography scan imaging is required to access the personality and extent of involvement of intra-articular calcaneus fractures. This should be performed using thin cuts with coronal and sagittal reconstructions. The Sanders classification (Table 39-1) is an extremely useful system for determining operative treatment and prognosis after fixation. The classification consists of separating the posterior facet into 3 separate fragments with the sustentaculum tali as the fourth constant fragment.
General operative indications for calcaneus fractures can be summarized in Table 39-2.
Initial descriptions of surgical results were poor secondary to a high incidence of wound complications and malreduction, but newer open reduction, internal fixation (ORIF) techniques have lead to improved results. The key to improved outcomes with surgery relate to the ability to obtain an anatomic reduction of joint surfaces. The degree of initial fracture severity also correlates with results. A high learning curve should be recognized in the treatment of these injuries.
According to Buckley et al, patients with Bohler’s angle <10 degrees, comminuted fracture patterns, large initial joint step-off, women, non-workman’s compensation cases, and younger patients (age <29) have improved outcomes with surgery.1 We have found these guidelines to be accurate in our practice; in addition, we prefer surgical reconstruction in patients with any amount of intra-articular step-off, significant axial malalignment causing peroneal tendon impairments, nerve impingement such as tarsal tunnel syndrome, sagittal height loss, greater than 5 degrees of tuberosity malalignment, and even in elderly patients. We believe that if wound complications can be avoided, restoration of the normal anatomical shape and alignment of the hindfoot and restoration of articular congruency results in optimal outcomes. We have found that the single most predictable factor in achieving a satisfactory outcome with surgical treatment is restoration of Bohler’s angle, which generally implies that the above goals have been achieved (Figure 39-3).
Figure 39-3. (A) Preoperative image showing calcaneus fracture with depressed posterior facet. (B) Postoperative view after ORIF and restoration of Bohler’s angle.
For patients with Sanders Type IV fracture patterns, we prefer ORIF with primary subtalar arthrodesis in order to achieve the same goals as stated above (Figure 39-4). The benefit lies in restoring the anatomical alignment of the heel and allowing for a single recovery by fusing the subtalar joint during the index procedure.
Figure 39-4. (A) Lateral view depicting comminuted calcaneus fracture. (B) Coronal view confirming Sanders Type IV fracture pattern. (C) Postoperative view after ORIF and primary subtalar fusion.
Relative contraindications for surgery include nondisplaced fractures, fractures in diabetics with significant peripheral vascular disease, or elderly, household ambulators, and smokers. According to Buckley et al, patients older than 50, males, and those who are receiving workers’ compensation and have an occupation involving a heavy workload should be treated without surgery.1 In our practice, we consider the contraindications to be very flexible and soft. We place the greatest importance in the status of the soft tissues and ability to achieve tobacco cessation in smokers in an attempt to prevent complications. Age is really not a significant factor in determining operative versus nonoperative treatment in our practice.
Nonoperative treatment primarily consists of a bulky dressing until soft tissue conditions have optimized, followed by boot immobilization, nonweight bearing for 10 to 12 weeks, and a physical therapy program focused on the preservation of subtalar motion and strengthening.
Operative treatment generally is performed via a standard extensile L-shaped lateral incision for exposure and reduction. For tongue-type fractures and for select intra-articular fractures, a percutaneous minimally invasive technique may be considered. External fixation techniques may be considered for an additional subset of patients who have strong radiographic surgical indications but soft tissue conditions when other relative contraindications are present, preventing the ability to perform open procedures. The description of such surgical techniques is beyond the scope of this chapter.
1. Buckley R, Tough S, McCormack R, et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized controlled multicenter trial. J Bone Joint Surg Am. 2002;84:1733-1744.
Sanders R. Intra-articular fractures of the calcaneus: present state of the art. J Orthop Trauma. 1992;6(2):252-265.
Sanders R, Clare M. Fractures of the calcaneus. In: Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P, eds. Rockwood and Green’s Fractures in Adults
. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:2293-2329.