Calcaneal Fractures

Incidence

  • Most common tarsal fracture.
  • 10% are bilateral.
  • 10% are open fractures.
  • Up to 80% associated with other injuries:
    • Spine injuries.
    • Femoral neck fractures.
    • Lower limb long bone fractures.

Anatomy

Ossification

  • Two Ossification Centres:
    • Anterior Centre: Visible at birth.
    • Posterior Centre: Last in the foot to ossify (around age 8 years).

Facets

  1. Posterior Facet (largest).
  2. Medial Facet.
  3. Anterior Facet (often continuous with medial facet).

Sinus Tarsi

  • Separates medial and posterior facets.

Sustentaculum Tali

  • Cortical medial process supporting the talus.

Mechanism of Injury

  • Axial Compression:
    • Fall from height.
    • Road traffic accidents (RTA).

Classification

Essex-Lopresti

  • Pre-CT Classification:
    • Primary Fracture Line:
      • Created by the talus’ lateral process driving into the crucial angle of Gissane.
      • Intra-articular involvement of the posterior facet.
      • Runs posteromedial to anterolateral from proximal to distal.
      • Sustentaculum Tali: Always attached to the distal fragment (constant fragment for fixation).
  • Secondary Fracture Line Determines Type:
    • Joint Depression Type:
      • Line runs from the primary fracture line to just posterior to the posterior facet.
    • Tongue Type:
      • Line runs from the primary fracture line to the posterior tuberosity.
  • Problems:
    • Does not indicate prognosis.
    • Limited guidance for management (except tongue type).

Sanders Classification

  • CT-Based Classification (coronal CT at the sustentaculum tali level).
  • Grades based on the number of displaced fracture lines in the posterior facet:
    • Grade 1: Undisplaced (regardless of fracture lines).
    • Grade 2 (A, B, C): 1 fracture line causing 2 displaced fragments.
    • Grade 3 (A, B, C): 2 fracture lines causing 3 displaced fragments.
    • Grade 4: 3+ fracture lines with multiple fragments.
  • Subclassification (A, B, C):
    • A: Lateral position.
    • B: Middle position.
    • C: Near the sustentaculum.
  • Prognostic Notes:
    • Increasing grade indicates more severity and worse prognosis.

Evaluation

Initial Steps

  • ATLS Protocol: Address high incidence of associated injuries.
  • Screen for compartment syndrome (rare).
  • Splint, ICE, and elevate foot.
  • Ensure no skin compromise (especially in tongue-type fractures).

Imaging

  • X-Ray Views:
    • AP.
    • Lateral.
    • Axial.
    • Harris View:
      • Foot dorsiflexed, beam angled 45° cephalad.
    • Broden View:
      • Multiple X-rays showing posterior facet in different positions.
  • Key Angles:
    1. Bohler’s Angle:
      • Formed by the highest points of the:
        • Anterior process.
        • Posterior facet.
        • Tuberosity.
      • Normal range: 20-40 degrees.
    2. Crucial Angle of Gissane:
      • Formed by cortical struts joining the posterior and anterior facets.
      • Normal range: 120-140 degrees.
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