The normal angle is 25 degrees to 40 degrees. Medartis provided the implant material without cost. Clin Interv Aging. J Foot Ankle Surg. no medical contraindications to operative care. Avulsion Fracture of the Calcaneus Treated with a Soft Anchor Bridge and Lag Screw Technique: A Report of Two Cases. The .gov means its official. 2002;69(4):209-18. Percutaneous Fixation of Calcaneal Tuberosity Avulsion Fracture. Connect with peers, All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors, and the reviewers. However, in other types, they were more common in relatively younger male patients. To our knowledge, no biomechanical study has been conducted regarding the use of 2.3- or. -Ant. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). NCI CPTC Antibody Characterization Program. Miller ME. Bioeng. Jordan MC, Hufnagel L, McDonogh M, Paul MM, Schmalzl J, Kupczyk E, Jansen H, Heilig P, Meffert RH, Hoelscher-Doht S. Front Bioeng Biotechnol. Severe trauma in the form of falls or jumps from great heights as well as motor vehicle accidents are the main culprits for a fractured calcaneus. Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. (D) 2.3-mm plate fixation. Calcaneoplasty coupled with an insertional Achilles tendon reattachment procedure for the prevention of secondary calcaneal impingement: a retrospective study. The .gov means its official. doi: 10.1097/BOT.0000000000001582. Sci. At 200N load, the means were 0.4 0.3mm in Group A, 2.1 2.1mm in Group B, and 0.5 0.2mm in Group C. Data showed a significant difference between groups A and B with p = 0.013. doi:10.3113/FAI.2007.1183, Lee, S.-M., Huh, S.-W., Chung, J.-W., Kim, D.-W., Kim, Y.-J., and Rhee, S.-K. (2012) Avulsion Fracture of the Calcaneal Tuberosity: Classification and its Characteristics. Type II describes fractures with a solid bone fragment, where an oblique fracture line runs toward the posterior end of the posterior facet (Figures 1, 2, and Figure 7A). Type I were usually caused due to an accidental trip causing a fall by the patient. Foot Ankle Surg. Please see also Supplementary Material at the end. type B: fracture of the mid calcaneus, trochlear process, and sustentaculum tali Calcaneal fractures are best assessed with a calcaneal series of radiographs, though are often identified on a lateral ankle radiograph if the presentation does not lead the requesting of calcaneal views specifically. Epub 2013 Mar 4. Pathology. Type III (20%) are oblique fractures. Results: The most important feature of this fracture is its association with significant soft-tissue injury and potential soft-tissue complications. The results are presented as the mean with standard deviation. Visual data: Means at the load level of 100N were 0.09 0.12mm in Group A, 0.26 0.25mm in Group B, and 0.22 0.13mm in Group C. At this level, there was no statistical difference. Julius-Maximilian-University of Wrzburg, Wrzburg, Germany. Our data confirm the biomechanical stability of 4.0- and 6.5-mm cannulated partially threaded screws with round washers. Out of 764 cases of calcaneal fractures, we examined 20 cases (2.6%) that involved the tuberosity of the calcaneus. The horizontal column represents the groups tested (AE). When using conventional screws, the screw head and washer can be placed at the level of the Achilles tendon insertion, usually without interfering with the surrounding tissue. All data were statistically analyzed for normal distribution using the ShapiroWilk test. Calcaneus fractures are the most common fractured tarsal bone and are associated with a high degree of morbidity and disability. eCollection 2022. A custom-made aluminum fixation device was developed to fit into the testing machine. Bookshelf [Duck beak fracture the posterior tuberosity of the calcaneus: about one case] [Duck beak fracture the posterior tuberosity of the calcaneus: about one case] Pan Afr Med J. (2020). Please enable it to take advantage of the complete set of features! sharing sensitive information, make sure youre on a federal and transmitted securely. sharing sensitive information, make sure youre on a federal Main outcome measurement was need for secondary surgical procedures. JS: manuscript revision and figure modification. In Group E, the same mode of failure could be seen as in the majority of Group D. All objects failed by breakout of the fragment at the site of the screws (Figure 6; Supplementary Video S1). Br. The available data indicate Secondary complications such as soft tissue complications and loss of fixation were noted. The Treatment of Avulsion Fracture of the Calcaneal Tuberosity: A New Technique of 180-Degree Annular Internal Fixation. Of the 22 that underwent surgery, 6 (27%) had failure of fixation. Pan Afr Med J. Test set-up and fixation in the material testing machine. The purpose of this study was to evaluate prognostic predictors of complications and need for secondary surgery in a series of calcaneal avulsion fractures. LH: conducting biomechanical tests, statistics, and data processing. FOIA (E) 2.8-mm plate fixation. Giordano V, Godoy-Santos AL, de Souza FS, Koch HA, de Cesar Netto C, Rammelt S. Case Rep Orthop. 1952 Mar;39(157):395-419. Unable to load your collection due to an error, Unable to load your delegates due to an error. Each case was classified depending on the avulsed fracture patterns as follows; type I is a 'simple extra-articular avulsion' fracture, type II is the 'beak' fracture, type III is an infrabursal avulsion fracture from the middle third of the posterior tuberosity, and finally in type IV there is the 'beak', but a small triangular fragment is separated from the upper border of the tuberosity. Fractures of the calcaneus, or os calcis, have been observed and documented for centuries. Despite this, we do not recommend plating of beak fractures as a first-line treatment. Hence, it is necessary to limit prolonged weight-bearing after the operation. Before Locking screws from 1420mm were used. 2 Classification for calcaneal avulsion fractures. Keywords: Would you like email updates of new search results? [ 1] However, a true consensus regarding the management of these fractures has However, the dominant cause of type II (5/20 cases) fractures a direct blow or hit directly to the bone. SH-D received funding from Medartis for biomechanical projects not related to this work. J. In addition, the small proportions of the plates used may be responsible for their poor biomechanical performance compared to screws. A combination of plate and screw fixation is also possible (Yu et al., 2013). Res. beak fracture; calcaneus fracture; posterior tuberosity avulsion fracture. Please enable it to take advantage of the complete set of features! Please enable it to take advantage of the complete set of features! This site needs JavaScript to work properly. 2018 Nov 11;2018:6207024. doi: 10.1155/2018/6207024. HJ: clinical case assembling and manuscript revision. In each group, ten synthetic bone specimens of the calcaneus were used. Implant material was purchased from DePuy Synthes with a 30% research discount. Not much is known regarding avulsion fractures of the calcaneal tuberosity. J. Orthop. A total of 50 synthetic bone specimens of the calcaneus (LD 9118; Synbone, Zizers, Switzerland) were used in this study. In cases where plates are used for surgical revision, limited postoperative mobilization is vital. The stability is inferior compared to screws. A dangerous extraarticular subtype of a tongue-type fracture with severe displacement of the superior margin of the calcaneal tuberosity (beak fracture) is a surgical emergency. Despite this success, an open exposure and visually controlled reduction to ascertain anatomic fixation of the fragment may be necessary for more complex fractures and may be superior to percutaneous fixation (Banerjee et al., 2012; Blum et al., 2019). 2019 Nov;33(11):e422-e426. Type II or beak fractures are uncommon. Different traction force levels were applied through an Achilles tendon surrogate in a material-testing machine on all stabilized synthetic bones. What remains unclear, however, is which type of screw is least likely to result in complications such as screw pull-out or screw cut-out (Banerjee et al., 2012; Lee et al., 2012; Carnero-Martn de Soto et al., 2019). doi:10.1016/j.jos.2015.06.011, Warrick, C. K., and Bremner, A. E. (1953). 2022 Lineage Medical, Inc. This unusual displaced calcaneal fracture can be intra- or extraarticular. Choose treatment. Accessibility (C) Band mimicking the Achilles tendon to apply tension to the fragment. 22, 111120. process becomes displaced upward. Careers. Avulsion Fractures of Posterior Calcaneal Tuberosity: Identification of Prognostic Factors and Classification. Results for peak-to-peak displacement at different load levels. 10:896790. doi: 10.3389/fbioe.2022.896790. It is useful in separating the joint fractures into two types. Orthop. Clipboard, Search History, and several other advanced features are temporarily unavailable. Percutaneous treatment of high-risk patients with intra-articular calcaneus fractures: a case series. We believe this technique would prove useful in surgical management of calcaneal tuberosity avulsion fractures. Comorbid conditions and increased age portend a poor prognosis with a significant association with wound complications and need for additional surgeries. J Orthop Trauma. Radiographic viewsLateral ankle x-rays show the dramatic displacement of the posterior tuberosity of the calcaneus. PMC Clinical cases further underline our findings. Based on the results of this biomechanical study, we implemented headless cannulated compression screws in a clinical case of a calcaneal avulsion fracture with critical soft tissue findings. Common causes and fracture types. 29, 863866. Main indications. 2007;28(11):11831186. The site is secure. Using a cannulated 2.7mm drill bit, the cannulated screws and washers (REF 419.980) were inserted over the k-wires. [Analysis and prevention of skin necrosis after operation of calcaneus fracture]. Results: If this angle remains above 15 degrees, nonoperative care can be suggested. Outcomes of operatively treated calcaneal tuberosity avulsion fractures. Clinical case of a calcaneal avulsion fracture successfully treated using 5.0-mm headless cannulated compression screws. White arrows indicate fracture. Richard Buckley, Andrew Sands. We propose a modified classification scheme that presents the four types of calcaneal avulsion fracture as described by surgical and magnetic resonance imaging (MRI) findings, and evaluation of their specific features. Foot Ankle Surg. 4:134138. But the clinical advantage of these headless cannulated compression screws requires evaluation through clinical studies and cannot be confirmed by our biomechanical study. Copyright 2022 Elsevier B.V. or its licensors or contributors. Accessibility Open all Displaced articular calcaneus fractures: classification and fracture scores: a preliminary study. FIGURE 5. MM: manuscript development and language editing. EK: data collection and processing. Yeungnam Univ J Med. Innovative Fixation Technique for Avulsion Fractures of the Calcaneal Tuberosity. The calcaneal beak fracture is a rare avulsion fracture of the tuber calcanei characterized by a solid bony fragment at the Achilles tendon insertion. [The so-called duck beak fracture] [The so-called duck beak fracture] Hefte Unfallheilkd. type II: "beak" fracture with oblique fracture line running posteriorly from just behind Bohler's angle. Disclaimer, National Library of Medicine official website and that any information you provide is encrypted Bhlers angleA decrease in Bhlers angle demonstrates the severity of joint injury and displacement (depression) as measured on the lateral x-ray. AO Davos Courses 2022. Diagnosis is made radiographically with foot radiographs with CT scan often being required for surgical planning. In Group D, almost all specimens failed by breakout of the fragment at the site of the screws. Would you like email updates of new search results? The screw fixation methods presented here allow percutaneous fixation with minimal soft tissue irritation. Levels of evidence: 1), S44S45. Beak fracture - oblique fracture line runs posteriorly from most superior portion of the posterior facet. FOIA Furthermore, while fixation of the tension band on the tuber calcanei was challenging, the simple test set-up does not mimic the properties of in vivo Achilles tendons. 1993 Nov;(296):8-13. official website and that any information you provide is encrypted Orthop. Although suture anchors were not included in the test protocol, they may also be used to augment screw fixation for bony fragments (Khazen et al., 2007; Yoshida et al., 2016). 19, 978983. doi:10.1053/j.jfas.2014.09.038, Yu, G.-r., Pang, Q.-j., Yu, X., Chen, D.-w., Yang, Y.-f., Li, B., et al. Gardner MJ, Nork SE, Barei DP, Kramer PA, Sangeorzan BJ, Benirschke SK. Surgical Management for Avulsion Fracture of the Calcaneal Tuberosity. Andermahr et al. Li YP, Zhao QA, Shi FM, Xu HP, Dong P, Tang HL, Tang X. Zhongguo Gu Shang. Conclusions: 1953;35(1):3345. The size of the triangular fragment was 2.0 3.2 4.2mm. mostly avulsion type fractures: anterior process, sustentaculum tali, calcaneal tuberosity. The most important feature of this In: Rockwood CA, Green DP, Bucholz RW, editors. Fractures of the calcaneal tuberosity can result in either an open beak-type fracture or an avulsion fracture 52, 181 (Fig. 2009 Dec;22(12):942-3. -Decreased calcaneal height & shortening in vertical axis (increases ant. Careers. When such large screws cannot be applied, 4.0-mm screws also allow reasonable fixation strength. Treatment usually requires osteosynthesis. Bone Substitute First or Screws First? 5, 196202. FIGURE 6. A power analysis was performed in previous tests using a power of 80% and a significance level of 5%, which showed that the sample size was adequate. Fixation of calcaneal avulsion fractures using screws with and without suture anchors: a biomechanical investigation. Bookshelf Type III fractures are infrabursal avulsions from the middle third of the posterior tuberosity. Screw-to-bone ratio. Mitchell PM, ONeill DE, Branch E, Mir HR, Sanders RW, Collinge CA. The beak fracture is a rare calcaneal fracture subtype of the posterior calcaneal tuberosity (Warrick and Bremner, 1953; Carnero-Martn de Soto et al., 2019). HHS Vulnerability Disclosure, Help Means were 787 184N in Group A, 638N 147N in Group B, and 651N 113N in Group C. No significant difference was found for the maximum load (Figure 5). More markers were attached to the fixation device as reference points (Figure 1). Unable to load your collection due to an error, Unable to load your delegates due to an error. Axial viewThis view is difficult to interpret because the displaced tuberosity hides the injury as it is in the plane of displacement. (A) In type III fracture, only the superficial fibers are involved with the avulsed fracture fragment (. type II: "beak" fracture with oblique fracture line running posteriorly from just behind Bohler's angle. (2008) described three different fracture types based on the extent to which the tendon insertion is affected at the tuber calcanei. Bethesda, MD 20894, Web Policies However, lack of biomechanical understanding of the ideal fixation technique persists. For type II fractures, the literature recommends open reduction and fixation using 4.5- or 6.5-mm partially threaded screws (Banerjee et al., 2012; Gitajn et al., 2015). muscle strength) -Widening of calcaneal shaft through displacement of its LATERAL margin (impinges peroneal) -VARUS deformation of calcaneal tuberosity. Types IV and V(60%) involve the subtalar joint. Specimens in groups D and E were not able to bear the 200 and 300N tensions and, therefore, could not progress to load-to-failure tests. The site is secure. 2009;15(2):5861. Patients will present with pain and swelling, with the inability to bear weight.Bilateral fractures of the calcaneus occur approximately 10% of the time. The next load level was 10200N for 1,000 cycles, and the third load level was 10300N for 1,000 load repeats: a static ultimate strength test was performed after cyclic testing. (B) Cracks and bursts of the fracture can occur when the screw size is not appropriate. Type I (20%) the fracture line may be through the tuberosity, the sustentaculum tali, or the anterior process of the calcaneus. MP: manuscript revision and data processing. 2021 Jan-Feb;60(1):218-220. doi: 10.1053/j.jfas.2020.09.001. Means for cyclic testing at 300N were 0.7 0.6mm in Group A, 3.1 2.3mm in Group B, and 1.4 1.1mm in Group C. There was a significant difference between groups A and B with p = 0.006. Executive Editors. FIGURE 9. doi:10.1053/j.jfas.2018.09.002, Elfar, J. J., Menorca, R. M. G., Reed, J. D., and Stanbury, S. (2014). All fibers within the Achilles tendon are involved in both type I and II fractures. Thirty-three patients who sustained extra-articular calcaneal avulsion fractures from 2002 to 2011 were retrospectively identified. RM is president of the International Bone and Research Association. Connect with peers, learn from experts. Philadelphia: Lippincott Williams & Wilkins; 2006. pp. In these and in revision cases, plate fixation may be an option. (A) To avoid burst of the fracture caused by oversized screws, a 1:2 screw-to-bone ratio is recommended. A beak fracture was simulated in synthetic bones and assigned to five different groups of fixation: A) Note that in the tongue-type fracture the fracture exits posteriorly, splitting the posterior portion into two. The distinction lies in that the avulsion fracture pulls the entire Achilles tendon from its insertion. One specimen failed by fracture at the level of the caudal screw. Careful selection of screw sizes is vital and screw size is limited by the dimensions of the fragment. FIGURE 2. Avulsion fractures of the calcaneal tuberosity, although relatively uncommon, occur more frequently in patients with osteoporosis and in the elderly. Biotechnol. (C and D) Postoperative x-ray after 12months demonstrating osseous healing in lateral and ap views. 15, 533. doi:10.1186/s13018-020-02009-6, Gitajn, I. L., Abousayed, M., Toussaint, R. J., Vrahas, M., and Kwon, J. Y. Few injuries are more devastating or have more long-term impact on a patients life. In (A) Fixation device for synthetic bone specimens to the material testing machine. A Biomechanical Comparison of Two Operative Techniques for Tibial-Head Depression Fractures. In addition, in cases where the fragment does not adapt well, conversion to open exposure and fixation may become necessary. Department of Orthopedics, Balgrist University Hospital, Switzerland. However, it is difficult to fix the bone fragment rigidly, because the avulsed bone fragment is small and thin, and the bone quality of the calcaneal body in the elderly is poor. (A) Beak fracture characterized by a solid bone part in a 61-year-old female patient. Harnroongroj T, Chuckpaiwong B, Angthong C, Nanakorn P, Sudjai N, Harnroongroj T. Biehl WC 3rd, Morgan JM, Wagner FW Jr, Gabriel R. Clin Orthop Relat Res. In Group A, four specimens developed an anterior fracture at the screw ends. The calcaneal beak fracture is a rare avulsion fracture of the tuber calcanei characterized by a solid bony fragment at the Achilles tendon insertion. Trauma 33 (Suppl. Avulsion Fracture of the Calcaneal Tuberosity Treated Using a Side-Locking Loop Suture (SLLS) Technique through Bone Tunnels. Load vectors may also be different under real-life conditions. Treatment is nonoperative versus operative based on fracture displacement and alignment, associated soft tissue injury, and patient risk factors. However, screw revision may be more difficult due to the challenge of finding the screw head under the bone level. The .gov means its official. 2022 Aug 4;10:896790. doi: 10.3389/fbioe.2022.896790. Type I: simple extra-articular avulsion,, The involved fibers of the Achilles tendon according to the fracture type. Computed tomographyIf there is time before skin compromise, a CT will be helpful to discern the exact amount of joint displacement. AO Surgery Reference. FIGURE 3. However, lack of biomechanical understanding of the ideal fixation technique persists. Epub 2021 Dec 31. Most anterior process fractures of the calcaneus can be treated non-surgically. 2) Whenever the fragment size does not allow one of the screws mentioned earlier, two 4.0-mm partially threaded screws are a good alternative. Parameters measured were peak-to-peak displacement for 100, 200, and 300N in mm, stiffness (N/mm) and plastic deformation (mm), total displacement (mm), load-to-failure (N), and mode of failure (anterior fracture, caudal screw cut-out and cranial screw pull-out, caudal screw cut-out, caudal and cranial screw pull-out, pull-out of the fracture-fragment from the caudal screw, pull-out of the fracture fragment from both screws, fracture of the fracture-fragment at the caudal screw, fracture of the fracture fragment at the site of the cranial screws, and plastic deformation of the plate). In Group C, modes of failure were different to the ones described for groups A and B. Injury. 2021 Feb 15;16:275-280. doi: 10.2147/CIA.S291497. -, Beavis RC, Rourke K, Court-Brown C. Avulsion fracture of the calcaneal tuberosity: a case report and literature review. Important outcome. The advantage of the percutaneous operative technique is the very low risk of soft tissue trauma compared to open techniques. Before Composite Bone Models in Orthopaedic Surgery Research and Education. The beak fracture is a rare calcaneal fracture subtype of the posterior calcaneal tuberosity (Warrick and Bremner, 1953; Carnero-Martn de Soto et al., 2019). As anticipated, large 6.5-mm screw diameters provide the best biomechanical fixation. Creative Commons Attribution License (CC BY). To avoid an iatrogenic burst of the bony fragment through the use of inadequate screws, we recommend a screw-bone ratio of roughly 1:2 (Figure 7). The greater the impact, the greater the damage to the calcaneus. 2015 Feb 5;20:106. doi: 10.11604/pamj.2015.20.106.5709. The https:// ensures that you are connecting to the Fractures of the Calcaneum. Combined Lag Screw and Cerclage Wire Fixation for Calcaneal Tuberosity Avulsion Fractures. -, Lui TH. *Correspondence: Martin C. Jordan, [email protected], Innovations to improve screw fixation in traumatology and orthopedic surgery, Front. Methods: Thirty (2015). sharing sensitive information, make sure youre on a federal * Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis, 1951-52. Foot Ankle Int. For 200N, means were 1.1 0.6mm in Group A, 3.0 1.8mm in Group B, and 0.7 0.1mm in Group C. At this level, statistical differences could be seen between groups A and B with p = 0.002 and between groups B and C with p < 0.001. Management of Calcaneal Tuberosity Fractures. Injury. See this image and copyright information in PMC. The 2.3- and 2.8-mm plating groups showed a high drop-out rate at 100N tension force and failed under higher tension levels of 200N. The fracture fixation using 4.0-mm partial threaded screws showed a significantly higher repair strength and was able to withhold cyclic loading up to 300N. The lowest peak-to-peak displacement and the highest load-to-failure and stiffness were provided by fracture fixation using 6.5-mm partial threaded cannulated screws or 5.0-mm headless cannulated compression screws. They result from an axial load and may demonstrate varying severity, type and location of fracture type.The type of fracture is determined by position of the foot, direction and magnitude of the force and the quality of the bone. Non normally distributed data were analyzed using the KruskalWallis test and DunnBonferroni correction. 772,395) attached to the fragment (EPO-X-Y, Roxolid, Germany and staples). J Orthop Trauma. 2022 Aug 4;10:896790. doi: 10.3389/fbioe.2022.896790. No potential conflict of interest relevant to this article was reported. Rockwood and Green's fractures in adults. Foot Ankle Surg. Disclaimer, National Library of Medicine MeSH and transmitted securely. If the fracture fragment is not interfering with the function of the calcaneal cuboid joint, non Fig. Foot Ankle Int. Calcaneal Avulsion Fractures. [Article in German] Authors P Schreinlechner, W Calcaneus / injuries* 55, 891893. (B) Boxplots show the high fixation strength of 6.5-mm partial threaded cannulated screw screws. eCollection 2018. J. Orthop. J Bone Joint Surg Br. Description of Extreme tongue-type (beak) fracture of the calcaneus body. HHS Vulnerability Disclosure, Help In contrast, the stability of plate fixation was disappointing. We see first an example of a joint depression and in the lower image a tongue type. Surg. J. AO Davos Courses 2022. Federal government websites often end in .gov or .mil. This site needs JavaScript to work properly. Two subjects required below knee amputation. The integrated software (Correlate Professional, 2018; GOM) captured marker displacement. Neuropathic calcaneal tuberosity avulsion fractures. Reposition was achieved by a pointed reduction clamp and temporarily fixed by k-wires. (B) Optical measuring machine. None of the plates was able to tolerate loads above 100N. In terms of overall stability, the best results were observed with 6.5-mm cannulated partially threaded screws, followed by 5.0 headless cannulated compression screws and 4.0-mm cannulated partially threaded screws, respectively. Fractures of the calcaneum, with an atlas illustrating the various types of fracture. J. Dec 416, 2022, Revised distal humerus module is now online, with displacement of more than a few millimeters posteriorly, present or impending posterior soft-tissue compromise. doi:10.4055/cios.2012.4.2.134, Mitchell, P. M., O'Neill, D. E., Branch, E., Mir, H. R., Sanders, R. W., and Collinge, C. A. Warrick CK, Bremner AE. Kline AJ, Anderson RB, Davis WH, Jones CP, Cohen BE. Four specimens sustained a cut-out of the caudal screw and a pull-out of the cranial screw. Conclusions: Combined hindfoot injuries; Further reading 3; Open fractures, Compartment syndrome, Infections 3; Body. Breakout of the fragment happens when plates are used. (B) X-ray after urgent reduction and screw fixation. Avulsion injuries: an update on radiologic findings. Type I (20%) 60-75% of injuries are intra-articular fractures, no significant increase in infection rates, peak incidence in women in seventh decade of life, violent contaction of the triceps surae with forced dorsiflexion, strong concentric contaction of the triceps surae with knee in full extension, intrinsic tightness of the gastrocnemius and achilles tendon, peripheral neuropathy leading to decreased pain sensation and proprioception resulting in recurrent microtrauma, increased physical activity in the setting of relative energy deficiency, primary fracture line results from oblique shear and leads to the following, includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments, dictate whether there is joint depression or tongue-type fracture, strong contraction of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus, more common in osteopenic/osteoporotic bone, inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament, superolateral fragment contains the articular facets, superior articular surface contains three facets that articulate with the talus, the flexor hallucis longus tendon is medial to the posterior facet and inferior to the medial facet and can be injured with errant drills/screws that are too long, between the middle and posterior facets lies the, projects medially and supports the neck of talus, connects the dorsal aspect of the anterior process to the cuboid and navicular, calcaneal tuberosity (Achilles tendon avulsion), the primary fracture line runs obliquely through the posterior facet forming two fragments, the secondary fracture line runs in one of two planes, the axial plane beneath the facet exiting posteriorly in, when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly, behind the posterior facet in joint depression fractures, based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet, One fracture line in the posterior facet (, Two fracture lines in the posterior facet (, based on fracture morphology of the calcaneus tuberosity, tenting, ecchymosis, or lack of skin blanching with tuberosity fractures, neccessitates urgent sugical reduction and fixation to avoid posterior heel skin necrosis, must be debrided and epithelialized prior to surgical intervention, lack of heel cord continuity in avulsion fractures, lack of posterior heel skin blanching with tenting fractures, assess for compartment syndrome secondary to swelling, presence of Langer's lines and skin wrinkles suggests skin is appropriate for surgical intervention, decreased ankle plantarflexion strength with avulsion fractures, assess for neuologic compromise due to swelling, severe peripheral vascular disease may preclude surgical treatment due to poor wound healing potential, useful for evaluation of intraoperative reduction of posterior facet, with ankle in neutral dorsiflexion and ~45 degrees internal rotation, take x-rays at 40, 30, 20, and 10 degrees cephalad from neutral, visualizes tuberosity fragment widening, shortening, and varus positioning, place the foot in maximal dorsiflexion and angle the x-ray beam 45 degrees, demonstrates lateral wall extrusion causing fibular impingement, indicates partial separation of facet from sustentaculum, angle between line from highest point of anterior process to highest point of posterior facet + line tangential to superior edge of tuberosity, represents collapse of the posterior facet, angle between line along lateral margin of posterior facet + line anterior to beak of calcaneus, demonstrates posterior and middle facet displacement, demonstrates calcaneocuboid joint involvement, used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis, cast immobilization with nonweightbearing for 10 to 12 weeks, anterior process fracture involving <25% of calcaneocuboid joint, comorbidities that preclude good surgical outcome (smoker, diabetes, PVD), avoids the high wound complications seen with these fractures, minimally displaced tuberosity fractures (<1 cm of displacement) without threatened soft-tissue envelope in elderly patients with reduced function or physical capacity, begin early range of motion exercises once swelling allows, early reduction prevents skin sloughing and need for subsequent flap coverage, ideal in patients with sever peripheral vascular disease or severe soft-tissue compromise, lag screws from posterior superior tuberosity directed inferior and distal, require urgent reduction and fixation to avoid skin necrosis (disastrous consequence), open reduction allows for sufficient debridement of contaminated tissue, inability to participate in closed treatment, large extra-articular > 2 mm displacement, posterior facet displacement >2 to 3 mm, flattening of Bohler angle, or varus malalignment of the tuberosity, anterior process fracture with >25% involvement of calcaneocuboid joint, wait 10-14 days until swelling and blisters resolve and wrinkle sign present 10-14 days, no benefit to early surgery due to significant soft tissue swelling, displaced tuberosity fractures with posterior skin compromise should be addressed urgently, number of intra-articular fragments and the, surgical treatment decreases the risk of post-traumatic arthritis, age > 50 (similar outcomes with surgical and nonsurgical treatment), initial Bhler's angle <0 (these injuries do poorly regardless of treatment), lower Bhler angles suggest greater energy absorbed, open fractures (significant soft tissue injury and engery absorbed), bilateral calcaneal fractures (significant gait problems following bilateral injuries), factors associated with most likely need for a secondary subtalar fusion, male worker's compensation patient who participates in heavy labor work with an initial Bhler angle less than 0 degrees, standard short-leg cast for calcaneal stress fractures, standard short-leg cast applied with mild equinus, windowed over posterior heel to allow for frequent skin checks, requires close follow-up to determine if pull of gastrocnemius-soleus dispaces fracture, weekly cast changes are necessary due to high incidence of skin complications, high incidence of vascular insufficiency and diabetes in this population, ideal for poor soft tissue coverage or patients with peripheral vascular disease, Steinmann pin placed into the fracture site anteromedially-to-posterolateral to leverage fragments into place, additional K-wires and Steinmann pins are placed from posterior-to-anterior and lateral-to-medial to secure remaining bone fragments, calcaneal transfixin pin can be used to distract fracture, percutaneus tamps and elevators can be used to raise the articular surface, pins are cut flush with the skin and removed 8-10 weeks post-op, can be combined with distracting external fixator, pins placed in calcaneal tuberosity, cuboid, and distal tibia, restor calcaneal height, width, and alignment, can be combined with percutaneous cannulated screws, extensile lateral L-shaped incision is most popular, vertical portion inbetween posterio fibula and achilles tendon, horizontal portion in line with 5th metatarsal base, a more inferior incision protects the sural nerve, provides access to the calcaneocuboid and subtalar joints, full-thickness skin, soft tissue, and periosteal flaps are developed, lateral calcaneal branch of peroneal artery, superior flap contains the calcaneofibular ligaments and peroneal tendon sheath, sural nerve and peroneal tendons are retracted superiorly, fracture opened and medial wall reduced going medial to lateral, reduction confirmed indirectly via fluoroscopy, tuberosity reduction is done under direct visualization, manual traction, Schanz pins, and minidistractors, height and length of tuberosity is recreated, definitive fixation with plates and screws, restore Bhler's angle and calcaneal height, minimally invasive incision that minimizes soft tissue dissesction, reduces wound complications associated with extensile lateral incision, allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall, same incision can be utilized for secondary subtalar arthrodesis or peroneal tendon debridement, patient placed in lateral decubitus position, incision made in line with the tip of the fibula and the base of the 4th metatarsal, extensor digitorum brevis retracted cephalad to expose sinus tarsi and posterior facet, Schanz pin inserted percutaneously in posteroinferior tuberosity going from lateral to medial, provides distraction and aids with reduction, fibrous debris and fat removed from sinus tarsi, small elevator or lamina spreader placed under posterior facet fragment to aid in reduction, K-wires inserted for provisional fixation aimed towards the sustentaculum, two screw are placed lateral-to-medial to engage sustentaculum and support facet, one large fully threaded screw from posterior-to-anterior to support axial length of calcaneus, low-profile plate is applied underneath a well developed soft tissue envelope with screws engaging anterolateral and tuberosity fragments, nonweight bearing for 6-8 weeks post-op with ankle range-of-motion exercises beginning 2 weeks post-op, manipulate the heel to increase the calcaneal varus deformity, manipulate the heel to correct the varus deformity with a valgus reduction, stabilize the reduction with percutaneous K-wires or open fixation as described above, arthroscopic-assisted reduction and internal fixation, improved visualization of articular surface and carilage lesions, increased swelling from fluid extravasation, can be combined with sinus tarsi approach, patient positioned in lateral decubitus position, fluoroscopy unit positioned posterior and oblique to patient, anterolateral and posterolateral portals are used to visualize posterior facet, loose bodies and cartilage fragments are removed with a shaver, Freer elevator is introduced into one of the portal sites and used to elevate the posterior facet, Schanz pin to control tuberosity fragment, cannulated screws from the posterior aspect of the calcaneal tuberosity to the anterior aspect of the calcaneus, lateral-to-medial screws placed in sustentaculum, buttress screw from the posterior aspect of the calcaneal tuberosity to the subchondral bone of the posterior facet, posterior approach for calcaneal tuberosity fractures, fracture fragment is mobilized and debrided, plantar flexion of foot aids with reduction, presence of gastrocnemius tightness may preclude reduction, Strayer procedure may be performed to aid in reduction, figure-of-8 tension-band wire passed around ends of K-wires or cannulated screws, Krackow sutures passing through bone tunnels, restricted weight bearing for 6 weeks followed by progression of weight bearing an additional 6 weeks, performed in highly comminuted Sanders IV intraarticular fractures, high rate of secondary fusion after ORIF with these injuries, avoids added treatment costs and decreases time off from work, can be performed through an extensile lateral or sinus tarsi approach, fracture reduction is perfromed in a similar fashion as ORIF, articular cartilage of the subtalar joint denuded to bleeding subchondral bone, cannulated compression screws are placed from the posterio calcaneal tuberosity to the talar dome, lateral fixation plate applied to hold reduction, increased risk in smokers, diabetics, and open injuries, may consider nonoperative treatment in these patients, tongue type fractures at high risk (>20%) for posterior skin necrosis, should be splinted in 30 degrees of planarflexion to relieve soft tissue tension, keep all hardware away from the corner of the incision, delayed wound healing is the most common complication, can be addressed with ankle bracing (gauntlet type), NSAIDs, injections, and physical therapy, may require bone block subtalar arthrodesis to address loss of calcaneal height, important when there are symptoms of anterior ankle impingement, Lateral impingement with peroneal irritation, at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment), loss of height, widening, and lateral impingement, distraction bone block subtalar arthrodesis, incongruous subtalar joint/post-traumatic DJD, results from posterior talar collapse into the posterior calcaneus, Lateral exostosis with no subtalar arthritis, Lateral exostosis with subtalar arthritis, Lateral exostosis, subtalar arthritis, and varus malunion, increased due to mechanism (fall from height), smoking, and early surgery, lateral soft tissue trauma increases the rate of complication, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Nonunion and Malunion, Distal Radial Ulnar Joint (DRUJ) Injuries. 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