Intraarticular Calcaneus Fractures

Indications

Nonoperative management is indicated for nondisplaced calcaneal fractures or extraarticular calcaneal fractures with near-physiologic hindfoot alignment (computed tomography [CT] confirmation is recommended).
Operative treatment of calcaneus fractures is indicated for displaced intraarticular and open calcaneal fractures.

Indications Pitfalls

When the soft tissues allow, operative treatment should be performed within 2–3 weeks from injury, before the fracture heals in a malunited position.
Operative treatment should be delayed until a positive skin wrinkle test is observed (the skin should wrinkle with ankle dorsiflexion and hindfoot eversion) and pitting edema has resolved.

Indications Controversies

Treatment Options

Closed treatment
Open reduction and internal fixation (ORIF)
Minimally invasive surgery: closed reduction and internal fixation with limited skin incisions; especially applicable to tongue-type fractures (intraarticular fractures exiting the posterior calcaneal tuberosity), for which the Essex–Lopresti maneuver can be employed
Closed reduction and external fixation

The soft-tissue envelope about the hindfoot must be amenable to surgery: edema and fracture blisters (at the operative site) must have resolved.
Plain foot and ankle radiographs should be obtained (anteroposterior, lateral, and oblique foot; Harris axial heel view; Brodén view; and ankle series to rule out concomitant ankle fracture).
- The lateral foot radiograph in Fig. 37.1 demonstrates posterior facet depression.
- The mortise view of the ankle in Fig. 37.2 illustrates lateral calcaneal wall displacement with resultant widening of the heel.
Associated lower back pain and tenderness necessitate lumbar spine radiographs given the association of calcaneal and lumbar spine fractures.
Preoperative fine-section CT is mandatory and defines the intraarticular (posterior facet) fracture pattern, as shown in the posterior facet’s intraarticular comminution in Fig. 37.3 .
- The fracture pattern is determined on the coronal images, using the Sanders classification.
- Sagittal and axial images provide further detail of the fracture pattern.

A lateral soft-tissue flap of hindfoot skin and subcutaneous tissue must be elevated directly from the calcaneus in the lateral extensile approach.
This flap receives its blood supply from the laterally located calcaneal, malleolar, and tarsal arteries ( Fig. 37.4A ).
The commonly used extensile L-shaped incision to the calcaneus respects the vascular anatomy (angiosomes) of the flap.
Relevant lateral structures to be protected in the lateral extensile approach to the calcaneus are shown in Fig. 37.4B .
The peroneal tendons and sural nerve are both elevated with the lateral soft-tissue flap during exposure. The lateral wall includes the peroneal tubercle, which bisects a groove for the peroneus brevis and longus tendons; the brevis tendon courses anterior to the tubercle.
The calcaneofibular ligament attaches posterior to the peroneal tubercle and lies deep to the tendons. Typically, the calcaneofibular ligament is elevated with the lateral soft-tissue flap from the calcaneus (despite this, ankle instability is rare following surgical management of calcaneus fractures).
The sural nerve courses parallel and posterior to the peroneal tendons before passing superficially at the inferior peroneal retinaculum to course along the lateral border of the foot.

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