|Year : 2006 | Volume
| Issue : 3 | Page : 147-153
|Displaced intra-articular fractures of calcaneum
SN Medical College, Agra, India
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|How to cite this article:|
Srivastava K P. Displaced intra-articular fractures of calcaneum. Indian J Orthop 2006;40:147-53
Fractures of calcaneum account for approximately 60% of all tarsal injuries, 10% of which are bilateral and another 10% are associated with fractures of spine. Usually they are the result of fall from height, 80-90% in men in their prime working years. Only 2% are compound fractures and 75% of all calcaneal fractures are intra-articular.
The close treatment of these fractures had been unsatisfactory, as is evident from the statements of various workers.
- The man who breaks his heel is done (Cotton and Wilson) 
- The end results of fractures calcaneum continue to be incredibly bad (Conn) 
- The results of crush injuries of Os calcis are rotten (Bankart) 
Despite the relative prevalence of these injuries, the definitive management has been controversial, but the current techniques of radiographic imaging, improved methods of fixation and proper rehabilitation have changed the scenario by remarkable improvements in the results. Now there is better appreciation of this complex fracture and its bony anatomy, and the standard treatment of intra articular fractures by open reduction and stable internal fixation holds good, due to current developments in diagnostic and therapeutic measures  .
When we talk of intra articular fractures of calcaneum, our attention is mainly focussed on the posterior articular facet of calcaneum forming the subtalar joint. Bohlers  angle, (normal 25-30˚) and crucial angle of Gissane (normal 120-145 0 ) help in the correction of displacement and the prognosis of this fracture [Figure - 1].
Mechanism of Injury
The calcaneal body is placed slightly lateral to the talus. After the injury the primary fracture line runs obliquely separating the calcaneus into two main fragments. Lateral is bigger and is pushed laterally to make the heel broader. The medial part including the sustentaculam tali remains undisplaced in the anatomical position being bound by strong talo-calcaneal interosseus ligaments [Figure - 2].
The dense bone of sustentaculam tali along with the smaller facets provides an optimal site of rigid screw fixation. The lateral wall of calcaneum is relatively flat, which facilitates the placement of plates and screws [Figure - 3].
An effective gait is achieved by the maintenance of lateral column, length and heel height coupled with smooth sub talar motion indicating the importance of good reduction of fracture. Subtalar inversion locks the mid-tarsal joints allowing the foot to function as a rigid plateform for the push off, and subtalar eversion creates motion of subtalar joints allowing the foot to absorb energy during heel strike.
Anatomy of fracture
During the fall from height the inferior portion of the talus impacts with calcaneum as a wedge fracturing the calcaneus  . Certain consistent fracture patterns have been observed , . A primary fracture line is common to most intra articular fractures of calcaneum, which begins in the sinus Tarsi near the lateral wall and travels through the posterior facet to the medial wall from the angle of Gissane to a point posterior to sustentaculum tali.
Secondary fracture lines invariably occur in addition to the primary fracture line. Two common patterns have been identified .
- A fracture line that travels in a transverse plane and exits the calcaneal tuberosity on the upper posterior surface resulting into a tongue type fragment. This fragment includes lateral posterior facet and the superior aspect of the tuberostiy.
- The secondary fracture line separates the lateral posterior facet from the body and tuberosity of calcaneum. The line passes behind the posterior facet leaving a loose fragment called isthmus  . This fragment is depressed into the substance of the body, therefore it is called joint depression fracture. Gross comminution of the posterior facet and depression drives the lateral wall further laterally causing sub fibular impingement and broadening of the heel. The calcaneal height is diminished, there is loss of Bohler's angle affecting tibio-talar and talo-navicular mechanism. The involvement of calcaneo cuboid joint affects the mobility of mid tarsal joints.
Based on X-ray picture (lateral, axial, antero posterior and oblique views). Essex Lopresti  gave the classification, which still holds good for all practical purposes.
Intra-articular displaced fractures are of two types [Figure - 4]:
- Tongue Type
- Joint Depression Type
The classification systems are based on three characteristics:
- Presence of posterior facet involvement
- Severity of posterior facet involvement
The first two can be assessed by lateral, axial and oblique X-rays but the severity of the posterior facet involvement can only be known by computed tomography (CT). The diagnosis of most calcaneal fractures is made by initial Xrays. The lateral view allows assessment of posterior facet position and loss of calcaneal height (Bohler's angle) and gives general impression of overall comminution. The axial view shows the primary fracture line, widening of heel due to lateral wall displacement, varus angulation and fibular abutment. The oblique view also called Broden's view is taken by placing the cassette behind the heel and distal tibia. Xrays are taken at 0 to 40 degrees to give the details of posterior articular facet [Figure - 5] .
After the advent of CT, Broden's view has lost its importance. CT facilitates the pre-operative plan and shows previously unrecognized comminution. It should be done in two planes. Transverse plane shows secondary fractures lines traversing the sub- tantacular fragment and calcaneo-cuboid involvement. The other is in semi coronal plane perpendicular to the posterior facet. This view further enhances the comprehension of the complex fractures , .
Eastwood et al  studied the C T scan of 120 calcaneal fractures in coronal plane and found 115 three parts fractures and only 5 two part fractures. All were intra articular fractures. They classified the three part fractures into three subtypes depending on the relationship of the thalamic fragment to the body fragment and the formation of lateral wall.
Type 1 - The lateral wall solely formed by lateral joint fragment.
Type 2- The lateral wall solely formed by lateral joint fragment superiorly and body fragment inferiorly.
Type 3- The lateral wall solely formed by the body fragment [Figure - 6].
The broadening of the heel is due to the lateral displacement of the body fragment and lateral rotation of the lateral joint fragment. The medial rotation of the supero-medial fragment further adds to the broadening of the heel.
Sanders  gave a simple classification, which is being widely followed.
Type 1-Undisplaced fracture. (Non operative treatment)
Type 2-Displaced two part fractures. (Open reduction and internal fixation)
Type 3-Displaced three part fractures. (Open reduction and internal fixation)
Type 4-Comminuted fractures (Not possible to reduce the fragments) Subtalar fusion.
Short heel - Restoration of heel length improves the lever arm of the gastrocneminus - soleus complex.
Wide heel - Narrowing of heel restores valgus inclination and stablilizes the foot and ankle during weight bearing. Fibular impingement is prevented.
Heel height - Restoration improves the tibio talar position and tendo-achillis function.
The management of displaced intra-articular fractures of calcaneum is controversial. Long term study of intra-articular fractures managed non-operatively showed that most of the patient had long term symptoms ,,,. Other authors have reported satisfactory long term results in severely displaced fractures managed conservatively  . Early motion aids functional recovery and seems to be more important than maintaining position with immobilization. Compression dressing and early splinting prevent the equinus deformity and progressive weight bearing between 6 to 12 weeks are started. A good to excellent outcome is witnessed in less time , .
Close manipulative reduction has been recommended for restoring Bohler's angle and normal height and weight, but they are not effective in obtaining congruity of posterior facet joint. Displaced fracture seems to have worse outcome than non displaced fractures and the displacement ofposterior facet has worst outcome than those with less involvement of the posterior facet. Anatomical restoration of the posterior articular facet correlates with good results  .
Prognosis of the displaced intra articular fractures is decided by -
- Degree of displacement of posterior articular facet (step between the medial and lateral articular fragments). More than two millimeter step gives bad prognosis.
- Decrease in Bohler's angle
- Increase in angle of Gissane [Figure - 7]
Indication of reduction and stable fixation is therefore, displacement of posterior articular facet fragments more than 2 mm. Severe comminution is the contra indication, since it cannot be reduced. It may require primary subtalar fusion. In gross swelling with blisters one can wait for a week or two for the operation.
Aim of treatment
Aim of treatment is to have stable internal fixation with normal motion in talo-calcaneal, calcaneo-navicular and calcaneo-cuboid joints with sound union of fractured fragments with restoration of heel height and weight.
Most of the surgeons prefer lateral approach ,,, .The lateral approach allows direct examination of posterior and middle facets and calcaneo-cuboid joints. Depressed fragments can be elevated under direct vision and putting the cancellous grafts is convenient. Also the lateral surface is well suited for buttressing with plate and screws.
In the lateral position of the foot an incision starting 4 cm. proximal to the tip of lateral malleolus is given curving 1 cm. behind the fibula along the lateral border of the foot to the calcaneo-cuboid joint at the level of malleolar tip [Figure - 8].
The superior skin flap is retracted upwards along with the sural nerve. The inferior flap is dissected subperiosteally on the lateral wall of calcaneum. The superior retinaculam is incised and peroneal tendons are dislocated anteriorly. The calcaneo- fibular ligament is incised to expose the posterior sub-talar joint.
The depressed fragment is elevated to restore the Bohler's angle and held with K wire with the sustentaculum tali, which is strongest part of the calcaneum. The fixation is done with a 4 mm lag screw. The space left after the elevation of the depressed fragment is filled with cancellous bone grafts [Figure - 9].
The lateral wall is buttressed with plate and screws. The peroneal tendons are brought back to the original place and retinaculum is repaired. The wound is loosely sutured to avoid skin necrosis. A POP cast is applied.
Precautions: Sural nerve should be protected. Skin incision may be extended to prevent skin necrosis and loose stitches are applied. Retinaculum is repaired thoroughly to prevent anterior subluxation of peronial tendons. Penetration of screws in subtalar joint is prevented with the help of image intensifier.
Post Operative Care
The foot is elevated to minimise oedema. Drainage tube is removed on third day. Passive motion is started on the day of operation and active movements are started after the pain and swelling subside. Partial weight bearing is started after 6 weeks and full weight bearing after 8 to 10 weeks.
| Results|| |
Leung  treated displaced intra-articular fractures of calcaneum by open reduction through lateral approach, stable internal fixation with plate and screws and bone graft. He followed the cases for more than 3 years and compared the results with conservative treatment [Figure - 10].
He made clinical assessment (Creighton Nebraska scoring system) and radiological assessement by examining Bohler's angle and angle of Gissane, height of calcaneum in lateral view and width of calcaneum in axial view.
Leung obtained 90% excellent and good results with operative fixation without poor results, whereas in nonoperative cases there was no excellent result and three poor results with painful heel, which needed subtalar fusion  . Arthritic changes were very common in the conservative group.
All three cases with poor results needed subtalar fusion
In grossly comminuted calcaneal fractures there are two options -
- Compressive dressings, elevation of the part, ice-packs and early movements of ankle and foot.
- Primary arthrodesis of subtalar joint, as there is no expectation for an anatomical reduction of posterior articular facets  .
Our Cases (24)
Screw Fixation (Tongue Type) 08
Plating (Joint Depression Type) 12
Non-Operative (Grossly comminuted #s) 04
Complications: Complications seen were wound complications (2), stiff joint (4), malunion (2), painful heel (4) and infection in one case.
- Screw fixation in tongue type of fractures of calcaneum give uniformly excellent results.
- Displaced intra articular fractures give excellent and good results after good reduction and plate fixation.
- Fixation of lateral fragment to sustantacular fragment gives good stability.
Complications in general
Mal union: Malunion resulting into
- Incongruity of Subtalar joint > OA > Pain
- Impingment of Calcaneus to Lat. Malleolus (Calcanofibular abutment)
- Pressure on Peroneal tendons.
- Loss of height of the heel.
- Widening of the heel.
- "Smashed Heel Pad Syndrome"
- Tarsal tunnel syndrome
- Nerve entrapment
Heel pain lateral, medial and heel point pain:
(a) Lateral heal pain: It is more common. The excess bone under lateral malleolus causes peroneal tenosynovitis, which is managed by removal of excessive bone under the lateral malleolus or excision of tip of fibula. Subtalar arthritis should be managed by subtalar arthrodesis if the local hydrocortisone injection fails.
Kasiwaagi excised all the excessive bones existing lateral to the subtalar joint and inferior to lateral malleolus. [Figure - 14]
(b) Medial heel pain: Pain below the medial malleolus may be caused by tenosynovitis of flexor tendons. Local hydrocortisone injection is effective. Tarsal tunnel syndrome due to compression of posterior tibial nerve may need decompression
(c) Pain over the point of heel: The cause is excessive bone formation at the tip or plantar displacement of fractured fragment. If injection hydrocortisone fails, excision of the offending bone mass may be needed. Paley tried to prevent Fibrosis of heel pad by early weight bearing on the heel after the use of ring fixator. [Figure - 15]
Skin necrosis: 10% of operated cases may develop skin necrosis, which needs debridement and closure. It heals in due course. [Figure - 16]
Consensus of about 20 surgeons in the country, engaged in the treatment of calcaneal fractures was taken, which is as follows -
Tongue type - close reduction & screw fixation.
Joint depression type - open reduction, plate fixation, bone grafting.
Comminuted fractures - two options
- Screw fixation to sustentacular fragment and ring fixation, early weight bearing.
- Primary subtalar arthrodesis [Figure 17] Old malunited fracture with painful heel
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K P Srivastava
Delhi Gate Agra
Source of Support: None, Conflict of Interest: None
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12], [Figure - 13], [Figure - 14], [Figure - 15], [Figure - 16]
[Table - 1], [Table - 2], [Table - 3]
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