Calcaneal fractures

Classification and severity grades

Due to the complex anatomy of the area, numerous injury variants are distinguished. Globally, fractures are divided into extra-articular and intra-articular, as well as fragmentary, comminuted (shattered), and compression fractures (accompanied by impression of the cancellous substance).

According to the localization of the fracture line, the following are distinguished:

• Extra-articular marginal vertical.
• Extra-articular marginal horizontal (often described as a "duck-beak" type fracture).
• Intra-articular.
• Compression (there is a pronounced compaction zone).

Depending on the nature of the injuries, three degrees of severity are determined:

1. Mild: the fracture line does not affect the joint, no displacement.
2. Moderate: extra-articular injuries with displacement, or intra-articular injuries without displacement.
3. Severe: the fracture extends into the joint and is accompanied by displacement or shattering into multiple fragments.

Clinical presentation

The victim complains of acute pain in the heel. In mild injuries, weight-bearing on the foot remains possible, although painful, but in severe cases, the patient is completely unable to step on the foot. Severe edema is visually determined, and bruising appears on the lateral surfaces of the heel and the sole.

Palpation reveals sharp tenderness, which is explained not only by bone damage but also by the crushing of the dense subcutaneous tissue that performs a cushioning function. The range of motion in the ankle joint drops sharply, and in the subtalar joint, it is completely blocked.

If the fragments are displaced, specific deformations appear:

• The calcaneal region widens and may deviate outward (valgus deformity) or inward (varus deformity).
• The distance from the sole to the apex of the lateral malleolus is shortened.
• The longitudinal arch of the foot flattens and swells.

Radiological diagnostics

The basis of diagnostics is radiography in two standard projections (lateral and axial), and in complex cases, computed tomography (CT) is used for detailing.

• Lateral projection: must capture the entire foot (up to the tips of the toes). The doctor assesses the fracture line, the involvement of the calcaneocuboid and subtalar joints, and most importantly, measures the talocalcaneal angle (Böhler's angle).
• Axial projection (dorsoplantar): allows visualization of the lateral displacement of the calcaneal tuberosity, evaluation of the posterior part of the subtalar joint and the supporting process (sustentaculum tali).

Conservative treatment and pre-hospital stage

First aid consists of applying transport immobilization (ladder splints are used) and delivering the patient to the hospital. Weight-bearing on the foot is strictly prohibited.

Further tactics depend on the presence of displacement:

• Without displacement (functional method): the leg is elevated, and early passive movements are prescribed. Graded weight-bearing is allowed to be introduced in 1.5–2 weeks, once the edema subsides.
• With displacement (closed reduction): the displaced fragment is returned to its place by traction using a Kirschner wire (for example, in horizontal fractures of the tuberosity, the Yumashev-Silin method with a staple and wire is used). After this, a cast is applied with a carefully molded arch. The immobilization period ranges from 1 to 2 months (the plaster cast itself stays on for 4–6 weeks).

Skeletal traction and surgery

If closed reduction is ineffective, semi-active and active methods are used:

• Skeletal traction: a wire is passed through the calcaneal tuberosity, setting the vector of traction downward and backward (Kaplan and Yumashev methods). The procedure lasts 3–4 weeks, after which a cast is applied. The total treatment period reaches 2.5–3 months.
• Surgical treatment: internal fixation (screws, contoured plates) is used with possible bone grafting for defects. External fixation devices (EFD) are also actively used, allowing earlier weight-bearing on the foot. The fixation period in the apparatus is 1–2 months.
• Special cases: in extremely severe comminuted intra-articular injuries, when reconstructing the joint is impossible, surgeons resort to primary arthrodesis (fusion) of the subtalar joint.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Technique of reduction for horizontal fractures using the Yumashev-Silin method
• Biomechanics of skeletal traction: differences between Kaplan and Yumashev methods
• Tarsal bone fractures: navicular, cuboid, and cuneiforms
• Diagnosis of metatarsal fractures and identification of Jacobson's sign

Other topics in the "Specialized Adult Traumatology" section

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