How To Evaluate And Treat Calcaneal Fractures

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Continuing Education Course #136 November 2005

I am pleased to introduce the latest article, “How To Evaluate And Treat Clinical Fractures,” in our CE series. This series, brought to you by the North American Center for Continuing Medical Education (NACCME), consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

In order to treat calcaneal fractures, one must have a strong knowledge of the pathomechanics of these highly complicated injuries. Accordingly, Don Buddecke, DPM, and Michael S. Lee, DPM, begin the article by reviewing these pathomechanics and proceed to discuss pertinent diagnostic considerations. They also offer an informative step-by-step guide to surgical treatment.

At the end of this article, you’ll find a 10-question exam. Please mark your responses on the enclosed postcard and return it to NACCME. This course will be posted on Podiatry Today’s Web site ( roughly one month after the publication date. I hope this CE series contributes to your clinical skills.


Jeff A. Hall
Executive Editor
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 76 and successfully answering the questions on pg. 82. Use the enclosed card provided to submit your answers or log on to and respond via fax to (610) 560-0502.
ACCREDITATION: NACCME is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by NACCME are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. Buddecke and Lee have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by NACCME. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
RELEASE DATE: November 2005.
EXPIRATION DATE: November 30, 2006.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss the pathomechanics of calcaneal fractures;
• describe key points of evaluation during the clinical exam of patients with calcaneal fractures;
• discuss pertinent radiographic findings with calcaneal fractures;
• discuss indications for open reduction internal fixation (ORIF) and describe pertinent intraoperative steps; and
• cite key postoperative considerations.

Sponsored by the North American Center for Continuing Medical Education.

This calcaneal axial view demonstrates the primary fracture line and medial sustentacular fragement.
This oblique view demonstrates extension into the calcaneocuboid joint.
This lateral radiograph demonstrates a joint depression fracture with an increase in the crucial angle of Gissane, decreased Böhler’s angle and a loss of calcaneal height.
Here one can see the “no touch” retraction technique with K-wires placed in the distal fibula, talar neck and cuboid. Note the Steinmann pin placed in the tuberosity for reduction.
Note the addition of a bone graft substitute to fill the void after a joint depression fracture of the calcaneus.
This postoperative view demonstrates restoration of calcaneal height and alignment.
This axial view demonstrates restoration of calcaneal height and alignment.
By Don Buddecke, DPM and Michael S. Lee, DPM

   Calcaneal fractures continue to be one of the most complicated injuries of the lower extremity. Satisfactory outcomes are difficult to achieve and require extensive experience and understanding in treating the injury. Calcaneal fractures are much like pilon fractures of the distal tibia in that they are severe soft tissue injuries complicated by fracture of the heel bone. The importance of the soft tissue envelope cannot be overstated.

   There continues to be a wide range of treatment strategies despite the significant ongoing research on this injury. Cast immobilization, percutaneous pinning, limited open approaches, extensile open approaches and fine wire external fixation have all been reported. However, there is still no clear standard in the approach to these complex fractures.

   Having a strong knowledge of the anatomy of the calcaneus is paramount to understanding the fracture patterns one may see with these injuries. The calcaneus has a thin cortical shell laterally with its interior consisting of cancellous bone. Medially, the sustentaculum tali is made up of dense cortical bone with strong ligamentous attachments to the talus. There is also very thick cortical bone that supports the facets on the superior surface of the calcaneus. This dense cortical bone forms an angle of 120 to 145 degrees (Gissane’s crucial angle). Directly under this dense bone is the neutral triangle, an area relatively void of trabecular patterns. This lies directly under the lateral process of the talus. Anteriorly, the calcaneus articulates with the cuboid and transitions to the lateral column of the foot.

   Intraarticular calcaneal fractures are the result of an axial load with varying degrees of shear force. The shear forces are dictated by the position of the calcaneus in relation to the talus at the time of axial load. Calcaneal fractures typically result from a fall from varying heights or a motor vehicle accident. The characteristics of these fractures result from the amount of applied force, the quality of bone and the relationship of the talus and calcaneus (i.e. position of the foot).1,2 This talocalcaneal relationship may change throughout impact depending on the injuring force. This leads to the subtle variations in every fracture.

   The initial axial load causes the impacting of the calcaneus into the talus. The lateral process of the talus then acts like a wedge into the dense cortical bone at the crucial angle of Gissane.3 Once the cortical bone has failed, the lack of dense bone in the neutral triangle offers little resistance to the applied forces. The resulting primary fracture line is oriented from superolateral to inferomedial, producing a posterolateral tuberosity fragment and a medial sustentacular fragment.2

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