Extra articular – better prognosis

Intra articular – worse prognosis

• >75% of all calcaneal fractures

 

Rowe

• Mainly for extra-articular fractures
• Type I
  • A - Fracture of the tuberosity of the calcaneus
    • Best visualized on axial views
    • Always secondary to shearing forces
      • Calcaneus is at an angle and forces shear off the tuberosity
    • May be due to  avulsion of plantar structures – fascia, intrinsic muscles
    • If small and not grossly displaced do not need to be fixed
    • If large or grossly displaced they need fixation
  • B - Sustentaculum Tali Fracture
    • Best seen on axial view
    • Hallmark – pain with motion of FHL tendon, right under sustentaculum tali
    • Shear type fractures
    • May be avulsion from eversion sprain – deltoid ligament pulls of sustentaculum
    • Don’t need to be fixed if in good approximation
    • If grossly displaced they need fixation
  • C - Fracture of the Anterior Process of the Calcaneus
    • 2 main causes
      • Avulsion from bifurcate ligament or EDB
      • Compaction when there is dorsiflexion and inversion of the foot and the lateral talar process impacts the anterior process into cuboid

• • • If intra-articular and large they should be fixated for early motion and reduced chance of DJD at CC joint

• Type II - Fracture of posterior superior aspect of calcaneus
  • A - Beak Fracture
    • Dorsal 1/3 of tuberosity
    • Shear or blunt trauma
    • Lateral x-ray
    • Don’t fix if small and non-displaced, just cast
    • If large or displaced it needs fixation
  • B - Avulsion Fracture at insertion of the achilles tendon
    • Achilles avulsion – middle 1/3 of calcaneal tuberosity
    • Often caused by dorsiflexion forces of foot
    • Usually need fixation
    • AK cast if well approximated
    • If long standing (>3 weeks) they may need TAL or gastroc recession to get fragment down
• Type III - Oblique Fracture of the Calcaneal Body NOt Involving the STJ
  • Cast if not grossly displaced, if grossly displaced  then it needs fixation
  • Usually heal well due to vascularity of calcaneus
• Type IV - Intra-Articular Fractures Involving the Subtalar Joint (tongue-type - Essex-Lopresti)
• Type V - Intra -Articular Central Depression with Varying Degrees of Comminution (joint depression - Essex-Lopresti)
  • Depression of posterior facet into main body of calcaneus
  • Severely comminuted

 

Essex-Lopresti - X-ray based classification

• Used for intra-articular
• Tongue Type - non- Joint depression
  • Like Rowe Type IV
• Joint Depression
  • Like Rowe Type V

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Sander's - CT classification (coronal)

• Number of fracture lines
• BEST - gives an idea of the type of clinical outcome and the ease of reducibility
• Type I - all non-displaced articular fractures, regardless of the number of fracture lines present
  • No fractures through the posterior facet
• Type II - 2 part articular fracture of posterior facet - 1 fracture line
• Type III - 3 part articular fracture - Two fracture lines
• Type IV - 4 part articular fracture - Three fracture line

 

• Further classified into location of fracture lines

• • A - Lateral fracture line
  • B - Central fracture line
  • C - Medial fracture line - Sustentaculum Tali Fracture

 

• Reduction Criteria for Sander’s Fractures:
  • Anatomic Reduction
    • No incongruity in joint surface of posterior facet
  • Near Anatomic Reduction
    • <3 mm incongruity of joint surface of posterior facet
    •  An acceptable level of reduction
  • Approximate Anatomic Reduction
    • 3-5 mm incongruity of joint surface of posterior facet
  • Failed Anatomic Reduction
    • >5 mm incongruity of joint surface of posterior facet

 

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