CALCANEAL FRACTURE. Romeo and Juliet, Ford Maddox Brown, oil on canvas, 1870 JULIET. Wilt thou be gone? It is not yet near day:

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1 CALCANEAL FRACTURE Romeo and Juliet, Ford Maddox Brown, oil on canvas, 1870 JULIET Wilt thou be gone? It is not yet near day:

2 It was the nightingale, and not the lark, That pierced the fearful hollow of thine ear; Nightly she sings on yon pomegranate-tree: Believe me, love, it was the nightingale. ROMEO It was the lark, the herald of the morn, No nightingale: look, love, what envious streaks Do lace the severing clouds in yonder east: Night s candles are burnt out, and jocund day Stands tiptoe on the misty mountain tops. I must be gone and live, or stay and die. JULIET Yon light is not day-light, I know it, I. It is some meteor that the sun exhales, To be to thee this night a torch-bearer, And light thee on thy way to Mantua: Therefore stay yet; thou need st not to be gone. Romeo and Juliet, Act 3, Scene 5: William Shakespeare, Romeo has just spent the night with Juliet, but as the dawn approaches, night s candles are burnt out, he knows it is time to flee over the balcony and down his improvised rope ladder. Juliet is desperate, as she fears she will never see her lover again. She foresees a vision of Romeo dead in a tomb and becomes frantic as she tries to dissuade him from leaving. She tells Romeo that the bird he heard was the nightingale and not the lark, which would signal sunrise, believe me love, it was the nightingale, but Romeo does not believe her. He points out the sun s morning rays, look love, what envious streaks do lace the severing clouds in yonder east. Juliet tries to dissuade him a second time by explaining them away as a meteor streaking through the night sky, it is some meteor that the sun exhales. Alas, however Romeo is not to be dissuaded. He kisses her goodbye, explaining that if he were to die, he would die well content having spent just one night with Juliet. She never sees him alive again. Perhaps Juliet could yet have dissuaded Romeo from leaving by pointing out the particular hazards of a rope ladder and a great height the lover s fracture! JULIET Though thou doest fear death not, dear Romeo, consider this, A fall from yonder ladder may verily lead to severe bilateral calcaneal fractures, And a right fine assortment of associated mischief to thine axial skeleton, Resulting in long term, nay chronic, wicked disability

3 CALCANEAL FRACTURE Introduction The calcaneum is the most commonly fractured tarsal bone. It is frequently associated with other fractures of the axial skeleton and / or the opposite leg. Mechanism Calcaneal fracture is usually the due to an axial compression force as a result of a fall from a height (commonly from a ladder). Classification Only with the advent of CT scanning has the capability to accurately evaluate complex fractures of the calcaneus been realized. Current classification systems are therefore based on CT appearances. The most widely accepted currently is the Sanders Classification for categorizing intra-articular (into the posterior facet of the sub-talar joint) fractures. There are 4 main types of Sanders fractures, (see also appendix 2 below): Type I: Fractures are non-displaced fractures (displacement < 2 mm). Type II: Fractures consist of a single intra-articular fracture that divides the calcaneus into 2 pieces. Type IIA: fracture occurs on lateral aspect of calcaneus. Type IIB: fracture occurs on central aspect of calcaneus. Type IIC: fracture occurs on medial aspect of calcaneus. Type III: Fractures consist of two intra-articular fractures that divide the calcaneus into 3 articular pieces. Type III AB: two fracture lines are present, one lateral and one central. Type III AC: two fracture lines are present, one lateral and one medial. Type III BC: two fracture lines are present, one central and one medial. Type IV: Fractures consist of fractures with more than three intra-articular fractures. Extra-articular fractures include all fractures that do not involve the posterior facet of the subtalar joint:

4 Type A involve the anterior calcaneus Type B involve the middle calcaneus. This includes the sustentaculum tali, trochlear process and lateral process Type C involve the posterior calcaneus, the posterior tuberosity and medial tubercle included. Complications 1. Associated fractures of the axial skeleton are not uncommon, in particular: Lumbar spine Tibial plateaus (both sides) Less commonly: hips, cervical spine. 2. Swelling: This can be very significant and may lead to compartment syndrome with neurovascular compromise. 3. Significant long-term complications can occur with these fractures, especially if comminuted, with non-union or mal-union leading to: Chronic pain / sub-talar arthritis Nerve entrapments: medial calcaneal nerves or the nerve to quadratus plantae Tendon entrapments: Peroneal tendon. Clinical Features 1. Swelling: This can be significant over the following hours, a may even lead to a local compartment syndrome. 2. Ecchymosis: Typically distributed to the medial aspect of the sole and proximal calf. 3. Pain is usually severe. 4. Deformity In severe injuries, the heel when viewed from behind may appear wider, shorter, flatter and tilted laterally into valgus Inability to bear weight (in particular tip toe gait)

5 6. Look for associated injuries especially to: The axial skeleton: Tibial plateau, hips, spine. The other heel: Not uncommonly both will be injured; one more so, providing a distracting injury such that the opposite injury initially goes unnoticed. Investigations Plain radiography If a calcaneal fracture is suspected, ask for calcaneal views, this will include, AP and Lateral as well as axial views. Bohler s angle Look specifically for a Bohler s angle deformity on a lateral view of the calcaneum

$Severely comminuted fracture of the calcaneum in a 25 year old male, following a fall from a ladder. Bohler s angle is demonstrated.$ Bohler s angle is defined as the posterior angle formed between the intersection of the line that joins the tip of anterior articular process of calcaneus to posterior articular surface with talus

Bohler s angle is defined as the posterior angle formed between the intersection of the line that joins the tip of anterior articular process of calcaneus to posterior articular surface with talus

6 Severely comminuted fracture of the calcaneum in a 25 year old male, following a fall from a ladder. Bohler s angle is demonstrated. This man had multiple associated factures, including the talus and the medial malleolus of his other leg. Bohler s angle is defined as the posterior angle formed between the intersection of the line that joins the tip of anterior articular process of calcaneus to posterior articular surface with talus and a second line that joins the posterior articular surface with talus to superior angle of the calcaneal tuberosity. Normally this angle is degrees. If the angle is less than 20 degrees, then a calcaneal fracture should be suspected. The smaller the angle, the more serious will be the fracture. Calcaneal fractures with a markedly diminished Bohler s angle in association with displaced intra-articular fractures have a much poorer two-year outcome regardless of treatment. 1 If less than 10 % operative reduction is usually undertaken. Axial view Left: Dedicated axial calcaneal view, of the above patient. Right: Calcaneal view showing a fracture - always check the opposite foot as well! The axial view is also useful in more subtle cases of fracture that may not be apparent on the A-P and lateral views. It may show a simple step in the cortex indicating the presence of the fracture. CT scan

7 This is done routinely as a follow up to the plain radiographs to better define the extent of the injury and so assist in planning any operative management. It is important to determine whether there is involvement of the sub-talar joint. It is also important when clinical suspicion remains high, in cases where plain radiographs are equivocal or normal. Management 1. Analgesia as clinically indicated: Pain is usually severe and titrated IV opioid will frequently be required. 2. Elevation and backslab: Elevate the leg, as swelling can become severe. An initial backslab should be applied for comfort and to assist immobilization. 4. Conservative management: Conservative management with crutches and Tubigrip or plaster backslab or full below knee plaster immobilization may be sufficient in more minor cases. Non weight bearing is generally for a minimum of 6 weeks 5. Surgical management: Disposition: Definitive management for more serious cases will frequently require operative reduction and surgical fixation. Those with sub-talar joint involvement in particular will need accurate reduction/ re-alignment. Surgery for calcaneus fractures is usually delayed, ideally for days in the presence of significant oedema, unless there is a more urgent indication for operation such as compartment syndrome or compound fractures of neurovascular compromise. All patients with calcaneal fractures need to be discussed with the orthopaedic unit. Most cases will require admission (whether or not ORIF is undertaken) as swelling and pain can be significant over ensuing days. Rehabilitation can be prolonged and should be under the supervision of a physiotherapist as well as the orthopaedic surgeon. Prognosis

$Even with optimal treatment, the more severe fractures may result in chronic pain$

8 Even with optimal treatment, the more severe fractures may result in chronic pain and disability. Appendix 1 The Anatomy of the Calcaneus: Left calcaneus, lateral surface

9 Left calcaneus, medial surface (Gray s Anatomy 1918)

10 Appendix 2 The Sanders Classification of Calcaneal Fractures: The Sanders Classification of intra-articular calcaneus fractures (Radiographics teaching slide:

11 References 1. Loucks C, Buckley R, Bohler s angle: correlation with outcome in displaced intraarticular calcaneal fractures. J Orthop Trauma Nov; 13(8): McRae R Practical Fracture Treatment, 3rd ed 1996 p Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intra-articular calcaneal fractures: results using a prognostic computed tomography scan classification. Clin Orthop Relat Res1993; 290: Dr. J. Hayes Dr. P. Papadopoulos Reviewed 29 May 2013

Radiographic Evaluation of Calcaneal Fractures. Kali Luker, PGY-1

Radiographic Evaluation of Calcaneal Fractures Kali Luker, PGY-1 Anatomy Extraarticular Fractures Involve body, anterior process or tuberosity Treated with immobilization and NWB x 6 wks UNLESS Displaced