Summary

Calcaneus fractures are the most common tarsal fracture (60%), typically resulting from a high-energy Axial Load (fall from height). The talus acts as a wedge, splitting the calcaneus and depressing the Posterior Facet (the main weight-bearing surface). Management is complex and controversial (UK Heel Fracture Trial), but the modern consensus favors surgical restoration of joint congruity for displaced intra-articular fractures to prevent painful subtalar arthritis and heel widening. A specific variant, the Tongue-Type Fracture, is a surgical emergency due to posterior skin threat. [1,2,3]

Key Facts

• The "Lover's Fracture": Historically named "Don Juan Fracture" because suitors would jump from balconies to escape jealous husbands.
• Spinal Association: 10% of patients have an associated Lumbar Vertebral Fracture (L1 Burst) derived from the same axial loading mechanism. Always X-ray the spine!
• The Constant Fragment: The Sustentaculum Tali (medial fragment) remains held in place by strong ligaments (Deltoid). It is the reference point for reconstructing the rest of the exploded shell.

Clinical Pearls

"The Mondor Sign": Ecchymosis (bruising) extending to the sole of the foot is pathognomonic for calcaneal fracture.

"Bohler's Angle": On Lateral X-ray, draw a line from the highest point of the anterior process to the highest point of the posterior facet, and another to the tuberosity. Normal is 20-40°. If <20° (or flat), the facet has collapsed.

"Tongue-Type Emergency": If the top of the heel bone (tuberosity) is avulsed by the Achilles tendon, it flips up and presses against the thin posterior skin. If you don't reduce this immediately (plantarflexion cast or screw), the skin dies, leading to osteomyelitis and amputation.

                  CALCANEUS FRACTURE
                        ↓
            TONGUE-TYPE / SKIN THREAT?
           ┌────────────┴─────────────┐
          YES (Urgent)               NO
           ↓                          ↓
    URGENT REDUCTION            CT SCAN (Sanders)
   (Percutaneous Screw)               ↓
           ↓                  DISPLACED FACET?
      PROTECT SKIN           ┌────────┴────────┐
                            NO                YES
                         (Type I)        (Type II/III)
                            ↓                 ↓
                      CONSERVATIVE     OPERATIVE CANDIDATE?
                     (NWB 10 weeks)    (Non-smoker, Young)
                                      ┌───────┴───────┐
                                     NO              YES
                                     ↓                ↓
                               CONSERVATIVE        SURGERY
                                                (ORIF / Sinu Tarsi)

Indications

• Sanders Type I (Non-displaced).
• Sanders Type IV (Too commintud to fix -> Primary Fusion later).
• Smokers / Diabetics / PVD: Surgery risk is too high.
• Ederly: Low demand.

Protocol

• Bulky Jones Bandage: For swelling.
• Elevation: Leg above heart for 1 week.
• Non-Weight Bearing: 10-12 weeks.
• Outcome: Likely to have a stiff, wide foot. Shoe fitting difficulty.

1. Minimal Invasion (Sinus Tarsi Approach)

• Concept: Small incision over the sinus tarsi to elevate the collapsed facet. Fixation with percutaneous screws.
• Pros: Low wound complication rate.
• Indication: Sanders II and simple Sanders III.

2. Extensile Lateral Approach (L-Incision)

• Concept: Massive L-shaped flap to expose the entire lateral wall.
• Pros: Perfect visualization.
• Cons: 25% wound necrosis rate (especially at the corner of the L).
• Timing: Must wait for "Wrinkle Sign" (14-21 days).

3. Essex-Lopresti Maneuver (Tongue Type)

• Percutaneous spike is driven into the tongue fragment to lever it out of the skin. Fixed with 2 large screws.

The UK Heel Fracture Trial (2014)

• Large RCT comparing Surgery vs Conservative.
• Result: No significant difference in pain or function at 2 years.
• Critique: Included many smokers and patients treated by non-specialists.
• Sub-group analysis: Surgery DID benefit those who had open reduction (not possible percutaneous) and highly displaced fractures.

Sanders Classification

• The most prognostic classification. Type IV injuries do poorly regardless of treatment and often proceed to primary fusion (arthrodesis).

Timing

• Never operate on a swollen calcaneus (unless tongue-type threat). The soft tissue envelope determines the timing, not the bone.

The Injury

You have crushed your heel bone. It is like a hard-boiled egg that has been dropped. The shell is cracked and the shape is flattened.

The Impact

This is a life-changing injury. Even with perfect treatment, you will likely have a stiff foot and some ache on uneven ground forever. You may need to wear wider shoes.

The Choice

• No Surgery: It heals in the flattened shape. You will likely get arthritis and need a fusion operation later. Safe from infection.
• Surgery: We try to rebuild the egg shape. Better chance of moving well, but a risk of wound infection which can be serious.

Recovery

You cannot put ANY weight on this foot for 3 months. If you step on it, the screws will punch through the soft bone like a knife through butter.

Q1: What is Bohler's Angle? A: An angle formed by the intersection of two lines on lateral X-ray: 1) Anterior Process to Posterior Facet, 2) Posterior Facet to Superior Tuberosity. Normal = 20-40°. <20° indicates collapse.

Q2: Why is the Sustentaculum Tali the "Constant Fragment"? A: Because it is tethered to the talus by strong medial ligaments (Deep Deltoid and Spring Ligament) and rarely displaces. Surgeons build the reconstruction off this stable fragment.

Q3: Explain the controversy of the UK Heel Fracture Trial. A: The trial showed no overall benefit to surgery. However, critics argue it was underpowered for specific subgroups (severely displaced), had learning curve issues (surgeons not specialists), and high complication rates in the surgical arm. Most specialists still fix displaced fractures in healthy patients.

Q4: What is the "Essex-Lopresti" sign? A: Refers to the "Tongue Type" fracture where the secondary fracture line exits posteriorly through the tuberosity, creating a lever arm that the Achilles tendon pulls up.

(End of Topic)