The authors concluded that a minimally invasive approach can improve radiographic parameters consistent with the goals of restoration of articular congruity, calcaneal morphology, and calcaneal height and can achieve satisfactory results with minimal risk of wound complication. The Sanders classification system is used to assess intraarticular calcaneal fractures, which are those involving the posterior facet of the calcaneus. Mechanism and pathoanatomy of the intraarticular calcaneal fracture. BMC Surg. Ideally, the CT scans are formatted in two planes: the semicoronal or oblique coronal plane, which is perpendicular to the posterior facet . if (!document.MAX_used) document.MAX_used = ','; Burdeaux BD Jr. Fractures of the calcaneus: open reduction and internal fixation from the medial side a 21-year prospective study. Minimally Invasive Treatment of Displaced Intra-Articular Calcaneal Fractures. Thermann H, Krettek C, Hfner T, Schratt HE, Albrecht K, Tscherne H. Management of calcaneal fractures in adults. 2016 Mar. 6. Patients A total of 33 patients with a unilateral calcaneal fracture and a minimum follow-up of 13 months participated. - frx of contra-lateral foot; Foot Ankle Int. Three part fractures. Mann's Surgery of the Foot and Ankle. Radiographics. - The management of soft-tissue problems associated with calcaneal fractures. Clin Orthop Relat Res. (2018) ISBN: 9780323568845 -. Comparing different types of calcaneal fractures, associated treatment options, and outcome data is currently hampered by the lack of consensus regarding fracture classification. Res. Sanders et al.'s original description of intraarticular calcaneal fracture classification was based on coronal and axial CT cross-sections with the widest undersurface of the posterior facet of the talus . - threaded Steinman pin is inserted through the posterior inferior corner of the calcaneus, across posterior facet and into the talar body; Mahmoud K, Mekhaimar M, Alhammoud A. Fractures of the calcaneum: the anterolateral fragment. The most common method for classifying these fractures is the Rowe classification scheme, with five types. Curr Rev Musculoskelet Med. [QxMD MEDLINE Link]. Crosby LA, Fitzgibbons T. Intraarticular calcaneal fractures. Results of fractures of the os calcis. Materials and methods: [QxMD MEDLINE Link]. 2022. In the more frequent joint-depression fracture, the secondary fracture line begins at the angle of Gissane and extends posteriorly but deviates dorsally to exit the bone just posterior to the posterior articular facet. Often non-displaced because of extensive ST attachmentRowe 1b sustentaculum tali, inversion Rowe 1c anterior process. Jimnez-Almonte JH, King JD, Luo TD, Aneja A, Moghadamian E. Clin Orthop Relat Res. [QxMD MEDLINE Link]. - anteromedial (sustentacular) frag is rarely comminuted but varies in size; Calcaneal fractures are the most common tarsal fracture and can occur in a variety of settings. Rowe CR, Sakellarides H, Freeman P. Fractures of os calcis - a long-term follow-up study one hundred forty-six patients. Teaching & Learning - intra-articular The Bhler and Gissane angles are used to assess the severity of calcaneal fractures, and their postoperative appearance is correlated with functional outcomes 12. Rowe Classification of Calcaneal Fractures 10 views Mar 28, 2022 High-Yield Podiatry 37 subscribers 1 Dislike Share It's not an easy one, but repetition will burn the Rowe. Please. Causes of fractures include the following: Extra-articular injuries are more likely to occur with a sudden twisting force applied to the hindfoot than with other mechanisms. Calcaneus fractures. Limited Approaches to Calcaneal Fractures. Surgical management of calcaneal fractures. Fracture characterization is essential to guide the management of these injuries. Eckstein et al reported long-term (20 y) follow-up of 22 patients who underwent surgical treatment of displaced calcaneal fractures. JAMA. 2010 Aug. 41 (8):804-9. Int Orthop. Wechsler R, Schweitzer M, Karasick D, Deely D, Morrison W. Helical CT of Calcaneal Fractures: Technique and Imaging Features. Application of medial column classification in treatment of intra-articular calcaneal fractures. - all frx are initially treated by strict bed rest, elevation, until acute swelling has subsided; 41 (6):689-697. 2016 Feb. 40 (2):365-70. Vol 2: Chap 67. Juliano P, Nguyen HV. Abstract. Axial radiograph reveals comminuted fracture of calcaneal body. Background: Sinus tarsi approach and mini-calc plate have been used for intra-articular calcaneal fractures. 2002 Jan. 33 (1):263-85, x. Are you sure you want to trigger topic in your Anconeus AI algorithm? Foot Ankle Orthop. Grant, Nyree Griffin. 1993 May. Clin. a) Tuberosity fracture NoYes Lack of first rocker sagittal plane block 2000. fracture of the anterior tubercle due to plantarflexion on a supinated foot Most common type 1 fracture Most common in females Tx: CR and BK WB cast for 6 weeks. Badillo K, Pacheco J, Padua S, Gomez A, Colon E, Vidal J. Multidetector CT Evaluation of Calcaneal Fractures. A prospective study, Intraarticular calcaneal fractures. 3) Vertical Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. The medical approach for calcaneal fractures. Check for errors and try again. Results After Percutaneous and Arthroscopically Assisted Osteosynthesis of Calcaneal Fractures. Calcaneus fractures are the most common fractured tarsal bone and are associated with a high degree of morbidity and disability. 11. The Sanders classification corrrelated with the AOFAS score (p = 0.007), MFS (p = 0.001), Rowe (p = 0.001), CNHF (p = 0.024), FOA (p = 0.021), MFA score (p = 0.036), and VAS (p = 0.014). 1993 May. Foot Ankle Int. - heel becomes shortened and widened; Schuberth et al performed a retrospective study of 24 cases of minimally invasive ORIF of intra-articular calcaneal fractures. fracture, Rowe Classification: Anatomy [QxMD MEDLINE Link]. Front Surg. [QxMD MEDLINE Link]. Data Trace is the publisher of 2021 Jun 1;479(6):1265-1272. doi: 10.1097/CORR.0000000000001634. AJR Am J Roentgenol. Injury. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). As the most common tarsal bone fracture, calcaneal fractures accounting for approximately 2% of all fractures are typically caused by high-energy injuries, such as motor vehicle accident or falls from height [].Displaced intra-articular injuries represent 60 to 75% of all fractures [].The treatment of displaced intra-articular calcaneal fractures has long been a controversial topic among . 1992. Type 5 Intra-articular fracture of body with collapse/depression, Essex-Lopresti Classification (most widely used): Foot Ankle Int. [QxMD MEDLINE Link]. 2022 Sep 29;34:357-363. doi: 10.1016/j.jor.2022.09.016. The calcaneal composition has a significant influence on preoperative planning. Type II or beak fractures are uncommon. Public Health There are, however, several important areas of increased bony density that are particularly amenable to screw placement, including the following: The tibial artery, nerve, posterior tibial tendon, and flexor hallucis longus tendon course along the medial wall of the calcaneus, though they are rarely damaged in calcaneus fractures caused by blunt force. Open Fractures of the Calcaneus: Soft-Tissue Injury Determines Outcome. Intra-articular fractures of the calcaneus. Because of distraction of fracture fragments, injury was treated with open reduction and internal fixation. Cohort study on the percutaneous treatment of displaced intra-articular fractures of the calcaneus. - references: - Operative Versus Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures:A Prospective, Randomized, Controlled Multicenter Trial. Feng SM, Zhao JJ, Ma C, Xu W. [All-inside subtalar arthroscopy through three portals combined with rafting screws technique for the treatment of the calcaneal fractures of Sanders and ]. - vasculopath: Surgeon experience Signs & symptoms Compartment syndrome - common!! 8600 Rockville Pike J Orthop Trauma. - manual position across the calcaneal body; The posterior facet is a major weightbearing surface, though the anterior and middle facets bear more weight per unit area. C- Medial Third. Biomechanics 95 (4):555-76. Scott Nicklebur, MD Assistant Professor of Emergency Medicine, Texas A&M Health Science Center College of Medicine 2007;36(1):1-10. 4. Type 3. Foot Orthotics Cotton commented in 1916 that "the man who breaks his heel bone is done so far as his industrial future is concerned." 2% of all fractures and 60% of all rearfoot trauma. encoded search term (Calcaneus Fractures) and Calcaneus Fractures. - Closed reduction and percutaneous pinning for comminuted intra-articular fractures of the calcaneus: Preliminary results. - Intra-articular fractures of the calcaneum treated operatively or conservatively. Foot Ankle Orthop. 2012 Sep;33(9):727-33. doi: 10.3113/FAI.2012.0727. 128-34. LIVIN' ON THE MD EDGE: Drive, Chip, and Putt Your Way to Osteoarthritis Relief, Osteoporosis and Osteopenia: Latest Treatment Recommendations, Osteoporosis: A Bare-Bones Guide to Diagnosis and Treatment. 2002 Oct. 84 (10):1733-44. Physical Therapies 2015;205(5):1061-7. Become a Gold Supporter and see no third-party ads. Philadelphia: Elsevier Saunders; 2014. Park YH, Cho HW, Choi JW, Choi GW, Kim HJ. Abstract. Surgical excision for anterior-process fractures of the calcaneus. - may also use lateral pin to manipulate the fracture fragments; Soft-tissue involvement is an important aspect of calcaneal fracture assessment because it has been linked with poor functional outcomes. Minimally invasive arthroscopic-assisted reduction with percutaneous fixation in the management of intra-articular calcaneal fractures: a review of 24 cases. Towson, MD 21204 Sustentaculum tali fractures are rarely seen as isolated injuries. Besch L, Waldschmidt JS, Daniels-Wredenhagen M, Varoga D, Mueller M, Hilgert RE, et al. Unauthorized use of these marks is strictly prohibited. [Full Text]. Bridgman SA, Dunn KM, McBride DJ, Richards PJ. Outcomes according to the AOFAS score were excellent or good in 80% of cases. Rowe Type 1A Click the card to flip - fracture of plantar calcaneal tuberosity -2 to abduction or adduction force exerted when heel strikes the ground either in inversion or eversion -eversion >>> medial tuberosity fracture -inversion >>> lateral tuberosity fracture -radiographs: axial calcaneal, lateral foot The resultant primary fracture line extends from the lateral aspect of the angle of Gissane in a posteromedial direction, initiating an oblique, primary fracture line. Type 1B Sustentaculum tali fracture - references: Calcaneal fractures are relatively uncommon, comprising 1 to 2 percent of all fractures, but important because they can lead to long-term disability. Philadelphia: Wolters Kluwer; 2022. 1958 Apr. Type Ib - Fracture of the sustentaculum tali. 9th ed. Orthop Clin North Am. Intra-articular Calcaneus Fractures: Current Concepts Review. Status post open reduction and internal fixation. Part I: Pathological anatomy and classification, Mechanism and pathoanatomy of the intraarticular calcaneal fracture, Fractures of the calcaneum: the anterolateral fragment, Computed tomographic assessment of soft tissue abnormalities following calcaneal fractures, Magnetic resonance imaging evaluation of calcaneal fat pads in patients with os calcis fractures, Intra-articular fractures of the calcaneus: Present state of the art, Intra-articular fractures of the calcaneus, Fractures of the calcaneus: open reduction and internal fixation from the medial side a 21-year prospective study, Operative Compared with Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures. Operative Compared with Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures. Rubino R, Valderrabano V, Sutter PM, Regazzoni P. Prognostic value of four classifications of calcaneal fractures. Because it is the type of fracture that could . [20]. 60-75% of injuries are intra-articular fractures, no significant increase in infection rates, peak incidence in women in seventh decade of life, violent contaction of the triceps surae with forced dorsiflexion, strong concentric contaction of the triceps surae with knee in full extension, intrinsic tightness of the gastrocnemius and achilles tendon, peripheral neuropathy leading to decreased pain sensation and proprioception resulting in recurrent microtrauma, increased physical activity in the setting of relative energy deficiency, primary fracture line results from oblique shear and leads to the following, includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments, dictate whether there is joint depression or tongue-type fracture, strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus, more common in osteopenic/osteoporotic bone, inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament, superolateral fragment contains the articular facets, superior articular surface contains three facets that articulate with the talus, the flexor hallucis longus tendon is medial to the posterior facet and inferior to the medial facet and can be injured with errant drills/screws that are too long, between the middle and posterior facets lies the, projects medially and supports the neck of talus, connects the dorsal aspect of the anterior process to the cuboid and navicular, calcaneal tuberosity (Achilles tendon avulsion), the primary fracture line runs obliquely through the posterior facet forming two fragments, the secondary fracture line runs in one of two planes, the axial plane beneath the facet exiting posteriorly in, when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly, behind the posterior facet in joint depression fractures, based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet, One fracture line in the posterior facet (, Two fracture lines in the posterior facet (, based on fracture morphology of the calcaneus tuberosity, tenting, ecchymosis, or lack of skin blanching with tuberosity fractures, neccessitates urgent sugical reduction and fixation to avoid posterior heel skin necrosis, must be debrided and epithelialized prior to surgical intervention, lack of heel cord continuity in avulsion fractures, lack of posterior heel skin blanching with tenting fractures, assess for compartment syndrome secondary to swelling, presence of Langer's lines and skin wrinkles suggests skin is appropriate for surgical intervention, decreased ankle plantarflexion strength with avulsion fractures, assess for neuologic compromise due to swelling, severe peripheral vascular disease may preclude surgical treatment due to poor wound healing potential, useful for evaluation of intraoperative reduction of posterior facet, with ankle in neutral dorsiflexion and ~45 degrees internal rotation, take x-rays at 40, 30, 20, and 10 degrees cephalad from neutral, visualizes tuberosity fragment widening, shortening, and varus positioning, place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees, demonstrates lateral wall extrusion causing fibular impingement, indicates partial separation of facet from sustentaculum, angle between line from highest point of anterior process to highest point of posterior facet + line tangential to superior edge of tuberosity, represents collapse of the posterior facet, angle between line along lateral margin of posterior facet + line anterior to beak of calcaneus, demonstrates posterior and middle facet displacement, demonstrates calcaneocuboid joint involvement, used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis, cast immobilization with nonweightbearing for 10 to 12 weeks, anterior process fracture involving <25% of calcaneocuboid joint, comorbidities that preclude good surgical outcome (smoker, diabetes, PVD), avoids the high wound complications seen with these fractures, minimally displaced tuberosity fractures (<1 cm of displacement) without threatened soft-tissue envelope in elderly patients with reduced function or physical capacity, begin early range of motion exercises once swelling allows, early reduction prevents skin sloughing and need for subsequent flap coverage, ideal in patients with sever peripheral vascular disease or severe soft-tissue compromise, lag screws from posterior superior tuberosity directed inferior and distal, require urgent reduction and fixation to avoid skin necrosis (disastrous consequence), open reduction allows for sufficient debridement of contaminated tissue, inability to participate in closed treatment, large extra-articular > 2 mm displacement, posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity, anterior process fracture with >25% involvement of calcaneocuboid joint, wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days, no benefit to early surgery due to significant soft tissue swelling, displaced tuberosity fractures with posterior skin compromise should be addressed urgently, number of intra-articular fragments and the, surgical treatment decreases the risk of post-traumatic arthritis, age > 50 (similar outcomes with surgical and nonsurgical treatment), initial Bhler's angle <0 (these injuries do poorly regardless of treatment), lower Bhler angles suggest greater energy absorbed, open fractures (significant soft tissue injury and engery absorbed), bilateral calcaneal fractures (significant gait problems following bilateral injuries), factors associated with most likely need for a secondary subtalar fusion, male worker's compensation patient who participates in heavy labor work with an initial Bhler angle less than 0 degrees, standard short-leg cast for calcaneal stress fractures, standard short-leg cast applied with mild equinus, windowed over posterior heel to allow for frequent skin checks, requires close follow-up to determine if pull of gastrocnemius-soleus dispaces fracture, weekly cast changes are necessary due to high incidence of skin complications, high incidence of vascular insufficiency and diabetes in this population, ideal for poor soft tissue coverage or patients with peripheral vascular disease, Steinmann pin placed into the fracture site anteromedially-to-posterolateral to leverage fragments into place, additional K-wires and Steinmann pins are placed from posterior-to-anterior and lateral-to-medial to secure remaining bone fragments, calcaneal transfixin pin can be used to distract fracture, percutaneus tamps and elevators can be used to raise the articular surface, pins are cut flush with the skin and removed 8-10 weeks post-op, can be combined with distracting external fixator, pins placed in calcaneal tuberosity, cuboid, and distal tibia, restor calcaneal height, width, and alignment, can be combined with percutaneous cannulated screws, extensile lateral L-shaped incision is most popular, vertical portion inbetween posterio fibula and achilles tendon, horizontal portion in line with 5th metatarsal base, a more inferior incision protects the sural nerve, provides access to the calcaneocuboid and subtalar joints, full-thickness skin, soft tissue, and periosteal flaps are developed, lateral calcaneal branch of peroneal artery, superior flap contains the calcaneofibular ligaments and peroneal tendon sheath, sural nerve and peroneal tendons are retracted superiorly, fracture opened and medial wall reduced going medial to lateral, reduction confirmed indirectly via fluoroscopy, tuberosity reduction is done under direct visualization, manual traction, Schanz pins, and minidistractors, height and length of tuberosity is recreated, definitive fixation with plates and screws, restore Bhler's angle and calcaneal height, minimally invasive incision that minimizes soft tissue dissesction, reduces wound complications associated with extensile lateral incision, allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall, same incision can be utilized for secondary subtalar arthrodesis or peroneal tendon debridement, patient placed in lateral decubitus position, incision made in line with the tip of the fibula and the base of the 4th metatarsal, extensor digitorum brevis retracted cephalad to expose sinus tarsi and posterior facet, Schanz pin inserted percutaneously in posteroinferior tuberosity going from lateral to medial, provides distraction and aids with reduction, fibrous debris and fat removed from sinus tarsi, small elevator or lamina spreader placed under posterior facet fragment to aid in reduction, K-wires inserted for provisional fixation aimed towards the sustentaculum, two screw are placed lateral-to-medial to engage sustentaculum and support facet, one large fully threaded screw from posterior-to-anterior to support axial length of calcaneus, low-profile plate is applied underneath a well developed soft tissue envelope with screws engaging anterolateral and tuberosity fragments, nonweight bearing for 6-8 weeks post-op with ankle range-of-motion exercises beginning 2 weeks post-op, manipulate the heel to increase the calcaneal varus deformity, manipulate the heel to correct the varus deformity with a valgus reduction, stabilize the reduction with percutaneous K-wires or open fixation as described above, arthroscopic-assisted reduction and internal fixation, improved visualization of articular surface and carilage lesions, increased swelling from fluid extravasation, can be combined with sinus tarsi approach, patient positioned in lateral decubitus position, fluoroscopy unit positioned posterior and oblique to patient, anterolateral and posterolateral portals are used to visualize posterior facet, loose bodies and cartilage fragments are removed with a shaver, Freer elevator is introduced into one of the portal sites and used to elevate the posterior facet, Schanz pin to control tuberosity fragment, cannulated screws from the posterior aspect of the calcaneal tuberosity to the anterior aspect of the calcaneus, lateral-to-medial screws placed in sustentaculum, buttress screw from the posterior aspect of the calcaneal tuberosity to the subchondral bone of the posterior facet, posterior approach for calcaneal tuberosity fractures, fracture fragment is mobilized and debrided, plantar flexion of foot aids with reduction, presence of gastrocnemius tightness may preclude reduction, Strayer procedure may be performed to aid in reduction, figure-of-8 tension-band wire passed around ends of K-wires or cannulated screws, Krackow sutures passing through bone tunnels, restricted weight bearing for 6 weeks followed by progression of weight bearing an additional 6 weeks, performed in highly comminuted Sanders IV intraarticular fractures, high rate of secondary fusion after ORIF with these injuries, avoids added treatment costs and decreases time off from work, can be performed through an extensile lateral or sinus tarsi approach, fracture reduction is perfromed in a similar fashion as ORIF, articular cartilage of the subtalar joint denuded to bleeding subchondral bone, cannulated compression screws are placed from the posterio calcaneal tuberosity to the talar dome, lateral fixation plate applied to hold reduction, increased risk in smokers, diabetics, and open injuries, may consider nonoperative treatment in these patients, tongue type fractures at high risk (>20%) for posterior skin necrosis, should be splinted in 30 degrees of planarflexion to relieve soft tissue tension, keep all hardware away from the corner of the incision, delayed wound healing is the most common complication, can be addressed with ankle bracing (gauntlet type), NSAIDs, injections, and physical therapy, may require bone block subtalar arthrodesis to address loss of calcaneal height, important when there are symptoms of anterior ankle impingement, Lateral impingement with peroneal irritation, at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment), loss of height, widening, and lateral impingement, distraction bone block subtalar arthrodesis, incongruous subtalar joint/post-traumatic DJD, results from posterior talar collapse into the posterior calcaneus, Lateral exostosis with no subtalar arthritis, Lateral exostosis with subtalar arthritis, Lateral exostosis, subtalar arthritis, and varus malunion, increased due to mechanism (fall from height), smoking, and early surgery, lateral soft tissue trauma increases the rate of complication, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries.

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