CALCANEAL FRACTURES
by
-Dr.Nisarg shah

indexANATOMY

MECHANISM

CLASSIFICATION

RADIOLOGY

TREATMENT

OUTCOMES

COMPLICATIONS

PEDIATRIC PECULIARITY

introduction

Largest tarsal bone

Most frequent tarsal bone to be #ed

Majort wt bearing bone

2% of all #s

Bone- irregularly cuboid, axis direted forwards upwards & laterally

Dense cancellous bone with thin cortical cover.

Inferior aspect triangular, apex anteriorly

Medial process wt bearing

Attaches abd hallucis , flexor retinacula, plantar aponeurosis, flexor digitorum brevis

Lateral process attaches abductor digiti minimi

Anterior tubercle attaches short plantar ligament

Long plantar ligament central rough area

Flexor digitorum accesorius also has attachments on inferior surface

Superior surface- articular

Anterior middle and posterior articular facets

Posterior facet- subtalar joint -largest & convex

Sinus tarsi sulcus calcanei -interrosseous lig. Cervical lig.And bifurcate ligaments

Attachment of extensor digitorum brevis

Medial surface concave
sustentaculum tali

slip from Tibialis posterio
flexor Digitorum brevis
posterior tibial Art, Vn, Nr
tendon of flexor Hallucis longus

plantaris

flexor retinaculum

spring lig.
Medial talocalcaneal lig.
Deltoid lig.

Lateral surface

Flat , subcutaneous

Peroneal tubercle

Peroneus brevis

Peroneus longus

Calcaneofibular lig.

Functions

Lever arm for propulsion by tendoachillies

Body wt foundation

Lateral column support

Inversion at subtalar jnt locks transverse tarsal joint stability for toe off. Axes NOT parellel.

Eversion at subtalar jnt unlocks transverse tarsal jnt supple foot for ground accomodation at heel strike. Axes parellel.

Windlass mechanism plantar fascia. During propulsion toes dorsiflex causing shortening of foot and elevation of longitudinal arch

Blood supplyLateral calcaneal art -> peroneal art -> popliteal art. ~ sural nerve Perfusion of lateral flap Medial calcaneal art -> lateral plantar art -> PostTibialArt~PostTibial nerve

Mechanism of injury

60%-75% are i/a

30%-25% are e/a

50% have other associated injuries

10% with ls spine. 25% L/L

63% involve calcaneo-cuboid joint

Eccentric Axial loading

Depends on htbonesurface-position of foot and ankle

Contact point of calcaneum is lateral to the wt bearing axis of L/L

Centre of tuberosity lateral to talus

Causes talus to exert shear force obliquely across body

The wedge like lateral talus process splits the angle of gissane at lateral wall anterio to the posterior facet

The initial # line in vertical plane along lateral cortex anterior to the post.facet

The primary # line runs from portereomedial to anterolateral calcaneus results into two thalamic fragments

The anteromedial/superomedial /sustentacular/constant fragment

Attached to deltoid lig. Will move inferiorly medially and posteriorly

Posterolateral/superolateral/ semilunar/comet fragment

Will move superiorly laterally and anteriorly

Foot in pronation - #line posterolateral to post.facet [2A]

Foot Neutral # line roughly through middle of post.facet [2B]

Foot Supination # line anteromedial to post.facet [2C]

Secondary # line

Exists proximal to tendo achillies insertion then it is joint depression type

Exits distal to tendoachillies insertion then it is tongue type

Anteriorly the secondary # line may extend to calcaneo-cuboid joint [I/A] or [E/A] plantar surface , lateral wall , medial wall

Clinical feature

Pain / tenderness

Soft tissue injuries

Skin blisters

Open # are 7%-17%

Compartment syndrome

Skin necrosis at posterior edge

Thompson test loss of plantar flexion with manual calf compression [tuberosity #]

Hoffa's sign laxity of achillies tendon and weakness of plantar flexion [I/A #]

Evaluate comorbidyties to guide Rx and outcomes --- pvd / dm / smoking / bmi / age / gender / occupation / ?ambulatory

classification

classification

x-ray based - Essex lopresti

Ct based sander's

View the widest articular surface of subtalar joint in semi-coronal

Lateral A - to - medial C

Anterior process #

Sprain # due to misdiagnosis

Forced plantar flexion and inversion injury = avulsion #

Forced Abduction & eversion = impaction #

Oblique foot xray

Usual Rx non-ot

>25% articular then orif

Sustentaculi #