Acta Orthopæ dica Belgica, Vol. 79 - 6 - 2013
Management of intra-articular calcaneal fractures
during the past years has ranged from the nihilistic
approach of no active treatment to open reduction
and internal fixation or even to early subtalar
arthrodesis. Operative treatment presents the surgeon
with many challenges. Good results require atraumatic
exposure, anatomic reduction, rigid fixation and early
We describe the use of a temporary external fixator as
an intraoperative aid in the open reduction and inter-
nal fixation of intra-articular calcaneal fractures. We
propose this operative strategy as an option for the
treatment of calcaneal fractures. The controlled
distractive force provides numerous benefits. These
include improved exposure of the subtalar joint, cor-
rection of angulation and maintenance of temporary
stability prior to definitive fixation. We have found
this technique applicable and easily reproducible.
Keywords : calcaneal fractures ; external fixator ; ORIF.
Surgical management of calcaneal fractures is
difficult and often requires a steep learning curve to
achieve consistent results. They usually occur in
young individuals with intensive labour occupations
and are associated with major complications (11).
A better understanding of the comminution of the
joint surface has been possible with computed to-
Non-operative treatment often leads to broaden-
ing of the heel, muscle imbalance, loss of motion,
peroneal impingement, impaired gait, intractable
pain, and early development of subtalar osteo-
Open reduction and internal fixation methods
have been associated with partial skin flap necrosis,
deep infection, delay of rehabilitation and some-
times catastrophic failure (7).
We describe a technique of open reduction and
internal fixation through an extended lateral ap-
proach utilizing a temporary external fixator intra-
operatively. The fixator allows ample access and
easy reduction of the articular fragments. Preopera-
tive management includes limb elevation and
computed tomography scan (Fig 1). Surgery is
performed 10-14 days after injury to allow swelling
No benefits or funds were received in support of this study.
The authors report no conflict of interests.
Acta Orthop. Belg., 2013, 79, 738-741
Temporary external fixation facilitates open reduction and internal fixation
of intra-articular calcaneal fractures
Tarek A. ElgAmAl, Andy E. TAnAgho, Rupert D. FErdinAnd
From Dumfries and Galloway Royal Infirmary, Dumfries, United Kingdom
n Tarek A. ElGamal, Clinical Fellow, Trauma and Ortho-
n Andy E. Tanagho, Specialty Doctor, Trauma and Ortho-
n Rupert D. Ferdinand, Consultant Orthopaedic Surgeon.
Dumfries and Galloway Royal Infirmary, Dumfries, United
Correspondence : Tarek A. ElGamal, 43 Dalbeattie Road,
Dumfries, Scotland, DG2 7PJ.
E-mail : firstname.lastname@example.org
© 2013, Acta Orthopædica Belgica.
Acta Orthopæ dica Belgica, Vol. 79 - 6 - 2013
TEmporAry ExTErnAl FixATion FAciliTATEs opEn rEducTion And inTErnAl FixATion 739
The calcaneus is approached through a modified
obtuse lateral incision as described by Freeman et
al (4). This approach minimizes the sequelae of
peroneal tendinitis, devascularization of the postero-
lateral skin and preserves the sural nerve (4). Two
straight cuts meet at the lateral side of the heel at an
angle of not less than 100°. The distal arm starts
over the base of the 5th metatarsal and passes directly
posteriorly to meet the proximal arm. The proximal
part of the incision begins in the posterior midline,
at about 12 cm above the level of the sole and passes
in a straight line distally and anteriorly to meet the
distal arm about 2 cm anterior to the line of the heel.
The incision is carried directly through the deep
fascia with no undermining of skin, followed by
subperiosteal dissection of the lateral wall. The flap
elevated includes the peroneal tendons proximally,
sural nerve, posterior peroneal artery and the
detached calcaneofibular ligament (4). It is held
retracted by two Kirschner wires which are passed
obliquely to come underneath the peroneal tendons
and are secured into the lateral malleolus anteriorly
and body of the talus posteriorly. To allow access to
the calcaneocuboid joint, the peroneal tendons
distally need to be separated from the flap and from
each other. The full “inverted J” aspect of the supe-
rior calcaneocuboid joint can be easily visualized in
The first 5 mm Steinmann pin of the external fix-
ator is inserted at the junction of its upper and mid-
dle third of the lateral cortex of the tibia, the second
across the posterior plantar calcaneal fragment from
lateral to medial (taking care to avoid medial neuro-
vascular structures). A unilateral external fixator
frame is applied, followed by locking the frame in
place at the desired tension (Fig. 2)
The fracture line at the level of the angle of
Gissane is identified and the thin lateral wall is lifted
gently and retracted inferiorly to expose the articular
fragments buried within the body of the calcaneus.
The fragments are usually depressed and rotated
inferiorly. The depression of the posterior facet
joint is reduced using a lamina spreader. If inferior
bone is soft or fragmented, a smooth metal instru-
ment such as a metal ruler is used to protect the
inferior fragments from the point loading of the
lamina spreader. The talar articular facet is used as
a reduction reference. A Macdonald retractor is
used to gently palpate the surface of the anterior and
posterior aspects of the subtalar joint. A temporary
1.6 mm Kirschner wire is passed just beneath the
articular surface aiming towards the sustentaculum.
Valgus heel alignment is restored by controlling
the amount and direction of distraction using the
Fig. 1. — Preoperative CT scan showing a Sanders 3AC calca-
Fig. 2. — Temporary external fixator in place and distraction
T. A. ElgAmAl, A. E. TAnAgho, r. d. FErdinAnd
Acta Orthopæ dica Belgica, Vol. 79 - 6 - 2013
multiaxial distractor. The “constant” medial susten-
tacular fragment is then fixed by a 3.5 mm partially
threaded cancellous lag screw. After exposure of
the calcaneocuboid joint, a calcaneal locked plate is
applied from the anterior process to the most poste-
rior aspect of the tuberosity to maintain tuber-
sustentacular alignment. Reduction is then verified
using fluoroscopy (Fig. 3). The external fixator and
half pins are then removed and the wound is closed
Calcaneal fractures are disabling injuries, which
represent more than 2% of all fractures and approx-
imately 60% of all tarsal injuries. The articular
surfaces are displaced in 65% to 70% of cases.
Motor vehicle collisions and falls are the major
causes of these large force compression injuries,
causing widening of the heel, loss of heel height,
and articular surface displacement (2).
The main goal of treatment for displaced frac-
tures of the calcaneus should be the restoration of
the three dimensional structure, with emphasis on
correct alignment in the coronal and axial planes
and the height of the calcaneal body. A correlation
has been shown between restoration of normal
anatomy and satisfactory functional outcome (6,9).
Overall, there is insufficient high quality evidence
relating to current practice to establish whether
surgical or conservative treatment is better for adults
with displaced intra-articular calcaneal fracture.
Evidence from adequately powered randomised,
multi-centre controlled trials, assessing patient-
centred and clinically relevant outcomes is re-
The described technique permits manipulation
and easier reduction of the subtalar joint in open re-
duction and internal fixation. The Böhler calcaneal
traction pin represents one of the earliest uses of this
concept. It has been widely incorporated in various
treatment schemes for calcaneal fractures (1). The
use of temporary external fixator in intra-articular
calcaneal fractures has been useful to obtain expo-
sure of subtalar joint and minimize the amount of
soft tissue dissection incurred from surgery. Intra-
operatively the external fixator is versatile because
it has potential for angular adjustment that can then
be “locked in”.
We found this technique to be safe and useful to
aid in treatment of intra-articular calcaneal frac-
tures. We have had no instance of bone failure at pin
insertion site or soft tissue injury. Although pin sites
represent stress risers, no stress fractures have been
To the best of our knowledge this technique has
not been described before. The external fixator has
been described as definitive method of fixation
rather than a temporary tool to aid open reduction
and internal fixation (5). The advantage over fixed
traction and traction bow is that length, angulation,
and manipulation of the limb for X-ray control are
all easily possible without the need for assistance,
which dramatically reduces operative time.
1. Böhler L. Diagnosis, pathology and treatment of fractures
of the os calcis. J Bone Joint Surg 1931 ; 13-A : 75-88.
2. Bruce J, Sutherland A. Surgical versus conservative inter-
ventions for displaced intra-articular calcaneal fractures.
Cochrane Database Syst Rev 2013 Jan 31 ; 1 : CD008628.
doi : 10.1002/14651858.CD008628.pub2.
3. Eastwood DM, Langkamer VG, Atkins RM. Intra-
articular fractures of the calcaneum. Part II : open reduction
and internal fixation by the extended lateral transcalcaneal
approach. J Bone Joint Surg 1993 ; 75-B : 189-195.
4. Freeman B, Duff S, Allen P Nicholson HD, Atkins RM.
The extended lateral approach to the hindfoot. J Bone Joint
Surg 1998 ; 80-B : 139-142.
5. Magnan B, Bortolazzi R, Marangon A et al. External
fixation for displaced intra-articular fractures of the
calcaneum. J Bone Joint Surg 2006 ; 88-B : 1474-1479.
Fig. 3. — Intraoperative assessment of reduction
Acta Orthopæ dica Belgica, Vol. 79 - 6 - 2013 Download full-text
TEmporAry ExTErnAl FixATion FAciliTATEs opEn rEducTion And inTErnAl FixATion 741
Jahss MH (ed). Disorders of the Foot and Ankle. Second
ed. Saunders, Philadelphia, 1991, pp 2326-2354.
11. Stapleton JJ, Kolodenker G, Zgonis T. Internal and
external fixation approaches to the surgical management of
calcaneal fractures. Clin Podiatr Med Surg 2010 ; 27 : 381-
12. Zeman P, Zeman J, Matejka J, Koudela K. Long-term
results of calcaneal fracture treatment by open reduction
and internal fixation using a calcaneal locking compression
plate from an extended lateral approach. Acta Chir Orthop
Traumatol Cech 2008 ; 75 : 457-464.
13. Zwipp H, Tscherne H, Thermann H, Weber T. Osteo-
synthesis of displaced intraarticular fractures of the
calcaneus. Results in 123 cases. Clin Orthop Relat Res
1993 ; 290 : 76-86.
6. Palmersheim K, Hines B, Olsen BL. Calcaneal fractures :
update on current treatments. Clin Podiatr Med Surg 2012 ;
29 : 205-220.
7. Paul M, Peter R, Hoffmeyer P. Fractures of the calcane-
um : a review of 70 patients. J Bone Joint Surg 2004 ;
86-B : 1142-1145.
8. Sanders R. Displaced intra-articular fractures of the calca-
neus. J Bone Joint Surg 2000 ; 82-A : 225-250.
9. Sanders R, Fortin P, DiPasquale T, Walling A. Opera-
tive treatment in 120 displaced intraarticular calcaneal frac-
tures : results using a prognostic computed tomography
scan classification. Clin Orthop Relat Res 1993 ; 290 : 87-
10. Sanders R, Hansen ST Jr, McReynolds IS. Trauma to the
calcaneus and its tendon : fractures of the calcaneus. In :