Calcaneal fractures: three-dimensional treatment

A series of 22 calcaneal fractures operated over 4 yr is presented. Radiographic evaluation of these fractures using axial, lateral, anteroposterior, and oblique medial projection (Broden's view) with varying tube angulation toward the head and computerized axial tomography in two planes, coronal and transverse, were done. This repeatedly demonstrated intra-articular splitting fractures along the axis of the os calcis through the posterior facet, extending to the calcaneocuboid joint. These fractures were surgically reduced as described by McReynolds with sequential medial and lateral approaches. Intraoperative X-rays demonstrate the three-dimensional nature of this injury. Bohler's angle may be reconstituted with apparent reduction of the posterior facet when projected laterally; however, Broden's and axial views show persistent widening and split of the posterior facet. The 22 patients have been followed from 12 to 46 mo. All have heels of normal width and wear standard shoes. The first two cases, done only medially, have less than anatomic reconstruction of the subtalar joint. Functional results have been encouraging. Of six active duty members so treated, three returned to full duty, a second who was medically retired as a result of other injuries had minimal heel problems, and fifth had a contralateral open pilon fracture which hampers him, and the sixth patient is now 4 mo postbilateral calcaneal fractures with return to duty anticipated. Most of the 22 have some decrease in subtalar motion without apparent gait abnormality. No cases of medial or lateral impingement or tendinitis are present. Fractures of the calcaneus are amendable to open reduction and internal fixation. Sequential medial and anterolateral exposure allow anatomic reconstruction in three dimensions, avoiding pitfalls of two-dimensional analysis and treatment.