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. A 28 year-old-male presents with the injury pattern seen in Figure A. She has pain throughout the day that worsens with prolonged weight-bearing. The flexor hallucis longus tendon lies underneath the sustentaculum and if screw placement to the sustentacular fragment is too long, this could affect the flexor hallucis longus tendon, causing fixed flexion of the big toe. Dr. Ebraheims educational animated video describes fracture of the calcaneus - heel bone. Fragment typically does not move due to its attachment to the Achilles tendon, Fragment has the flexor hallucis longus wrap inferiorly around it, Fragment typically does not move due to its attachment to the navicular, Fragment typically displaces superior and laterally, Fragment has the tibialis posterior wrap inferiorly around it, avulsion injury of the bifurcate ligament, in-situ arthrodesis with preserved calcaneal height, Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws, Type in at least one full word to see suggestions list, 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope, 29th Orthopaedic Trauma - What We Need to Know in 2017, Panel Discussion Lower Extremity 3 - (NYT #37 - S6-5 - 2017). Copyright 2022 Lineage Medical, Inc. All rights reserved. When this occurs, the heel can widen, shorten, and become . Diagnosis is made radiographically with foot radiographs with CT scan often being required for surgical planning. Lateral calcaneal branch of the anterior tibial artery, Lateral calcaneal branch of the peroneal artery, Lateral malleolar branch of the peroneal artery, Lateral malleolar branch of the dorsalis pedis artery, Lateral malleolar branch of the anterior tibial artery. He obtains good pain relief with a steroid injection into the sinus tarsi. Sanders type II & type III calcaneal fractures will benefit from surgery of reduction and fixation. Men do worse with calcaneal fractures than women. 8600 Rockville Pike Operative Compared with Nonoperative Treatment of Displaced Intra-Articular Calcaneal Fractures. Personalized approach for complex bilateral calcaneal osteomyelitis and defect reconstruction with bilateral abductor digiti minimi flaps. Tracking tools monitor your progress and help you learn more efficiently by decreasing redundancy in the future. 2022 Sep 29;22(1):170. doi: 10.1186/s12880-022-00898-z. Treatment of calcaneal fractures has to be tailored to the individual pathoanatomy. This procedure improves which of the following issues? Of the options listed below, what is the most appropriate next step in management? Medially, it articulates with the navicular nad lateral cuneiform. 58. In this episode, we review the high-yield topic of Visceral Blunt Trauma from the Knee & Sports section. Appropriate initial management of calcaneal fractures involves assessment for concomitant trauma (polytrauma), and the vertebral column, in particular, the lumbar spine, is known to be especially vulnerable to simultaneous injury when the os calcis has been fractured. Treatment of Fracture of the Calcaneus via Bone Axial X-Ray Image-Based Minimally Invasive Approach. These fractures often occur because of repetitive, long-term stress on the bone, such as from jogging. The https:// ensures that you are connecting to the The way it occurs is often similar to that of an ankle sprain, where the foot is flexed in an . The Orthobullets Podcast In this episode, we review the high-yield topic of Calcaneus Fractures from the Trauma section. (SBQ12FA.56) A calcaneal spur, or commonly known as a heel spur, occurs when a bony outgrowth forms on the heel bone. The primary fracture line divides the calcaneus into two main fragments. Stress fracture of the calcaneus may be misdiagnosed as plantar fasciitis. For most of the displaced, intraarticular fractures, this can be achieved by less invasive reduction and fixation via a sinus tarsi approach, which may be extended along the "lateral utility" line for calcaneocuboid joint involvement or calcaneal fracture-dislocations. In this episode, we review the high-yield topic of Avascular Necrosis of the Shoulder from the Shoulder & Elbow section. (OBQ04.163) Treatment of calcaneal fractures has to be tailored to the individual pathoanatomy. (OBQ12.83) Orthobullets Team Trauma . All of the following would be indications for a subtalar distraction arthrodesis using a bone graft instead of an in-situ subtalar arthrodesis EXCEPT: Presence of a collapsed subtalar joint from AVN, Presence of full ankle dorsiflexion with no tibiotalar impingement. What is the most likely etiology of this finding? Fractures of the calcaneus could be open or closed. Specific approaches are used for rare calcaneal fracture variants. (OBQ07.269) He is treated with immediate open reduction internal fixation to prevent which of the following complications? In this episode, we review the high-yield topic of Congenital Vertical Talus from the Pediatrics section. Calcaneal fractures usually occur after a high-energy accident, such as in a motor vehicle crash or a fall from a great height. Type VI Highly comminuted May require primary subtalar arthrodesis. A 47-year-old male sustained a comminuted calcaneus fracture in a motorcyle accident. Tongue-type fracture may benefit from closed reduction and percutaneous fixation or open reduction and internal fixation. Feng Y, Shui X, Wang J, Cai L, Yu Y, Ying X, Kong J, Hong J. BMC Musculoskelet Disord. He subsequently develops the post-traumatic condition shown in Figure A. For joint depression fracture, wait for swelling to go down before surgery. A decrease in this angle indicates the collapse of the posterior facet. In this episode, we review the high-yield topic of Elbow Stiffness and Contractures from the Shoulder & Elbow section. Tethering of the flexor hallucis longus by fracture fragments. For most of the displaced, intraarticular fractures, this can be achieved by less invasive reduction and fixation via a sinus tarsi approach, which . He has completed a course of plantar fascia and Achilles tendon stretching with no significant improvement in his symptoms. There is a negative Tinel's sign at the tibial nerve. official website and that any information you provide is encrypted Because of this calcaneal fractures tend to come with other problems that vary with the extent of the injury. Careers. This is usually related to the amount of force that was used to cause the . (OBQ10.19) Three months after the injury the patient complains of shoewear problems secondary to clawing of the lesser toes. Diagnosis is made radiographically with foot radiographs with CT scan often being required for surgical planning. This resulted in 590 articles. ORIF The axial view Large "constant" sustentacular fragment. Calcaneus fractures are the most common fractured tarsal bone and are associated with a high degree of morbidity and disability. The "constant" fragment is the stable medial calcaneal building block which allows lag fixation. Extensile lateral versus sinus tarsi approach for displaced, intra-articular calcaneal fractures: a meta-analysis. (OBQ10.208) A 26-year-old male sustains a comminuted, intra-articular calcaneus fracture and subsequently undergoes operative intervention as shown in Figure A. Postoperatively in the recovery room, he presents with an isolated, fixed flexed great toe. Nosewicz T, Knupp M, Barg A, Maas M, Bolliger L, Goslings JC, Hintermann B. Yu, Sarah M., and Joseph S. Yu. The extensile approach has delayed wound healing in about 20% of cases. It's important to see your healthcare provider right away if you have a . He notes the pain is worse with jumping and long distance running. Which of the following MRI images (Figures B to F) would you expect to find in this patient? Calcaneus (Heel Bone) Fractures. He is a nonsmoker. 2-Open fractures of the calcaneus--May lead to amputation & there is a high risk of infection. Joint depression type usually needs open reduction.Some surgeons advocate conservative treatment of the calcaneus.Subtalar distraction arthrodesis plus insertion of a bony block and rigid internal fixationThe lateral calcaneal artery provides blood supply to the lateral flap associated with the calcaneal extensile approach. Ankle Fractures. type B: fracture of the mid calcaneus . Male worker's compensation patient who participates in heavy labor work with an initial Bhler angle less than 0 degrees, Female worker's compensation patient who participates in heavy labor work with an initial Bhler angle >15 degrees, Male non-worker's compensation patient who participates in heavy labor work with an initial Bhler angle less than 0 degrees, Male worker's compensation patient who participates in heavy labor work with an initial Bhler angle >15 degrees, Female non-worker's compensation patient who participates in heavy labor work with an initial Bhler less than 0 degrees. (OBQ04.261) Radiographs show significant loss of calcaneal height and an incongruous subtalar joint. In this episode, we review the high-yield topic of Marfan's Syndrome from the Pediatrics section. Team Orthobullets (D) Trauma . A 47-year-old male presents with a one month history of heel pain after starting marathon training. Calcaneus fractures in children younger than 10 years of age, are usually extra-articular. Type I-- Nondisplaced/Non-operative treatmentType II--Two-part fracture of the posterior facet. . (OBQ09.73) Copyright 2022 Lineage Medical, Inc. All rights reserved. PMC Tarsal fractures account for 2% of all fractures. A 55-year-old male sustained a Sanders IV intra-articular calcaneus fracture two years ago that was treated nonoperatively. 2022 Jul 1;2022:3012589. doi: 10.1155/2022/3012589. Peak guides you to the most relevant content based on your learning needs and helps you engage with content more effectively with tools like highlighting and personal notes. Positive squeeze test could mean there is a stress fracture of the calcaneus.Get an MRI if x-ray is negative Will see a fracture in T1 as a linear streak or a band of low signal intensity in the posterior calcaneal tuberosity. identify constant anteromedial fragment and build off of it with kwires. He is treated nonoperatively. He presents with intact skin, moderate swelling and ecchymosis about the right heel, and global tenderness of the hindfoot. A 42-year-old male sustains the closed injury shown in Figure A. Online ahead of print. 2022 Jul 4;7(2):65-70. doi: 10.1515/iss-2022-0010. "Calcaneal avulsion fractures: an often forgotten diagnosis." American Journal of . What additional treatment modality is appropriate at this time? 4-Peroneal tendon irritation and impingement from the lateral wall. Avulsion fracture of the calcaneus is an emergency. In this episode, we review the high-yield topic of Meniscus from the Knee & Sports section. sharing sensitive information, make sure youre on a federal All of the following are prognostic of a superior outcome with operative treatment EXCEPT: (OBQ05.168) HHS Vulnerability Disclosure, Help 2022 Aug 2;7(3):24730114221115678. doi: 10.1177/24730114221115678. Decreased risk of development of clinically significant subtalar arthritis, Decreased long-term subjective and functional outcomes, Greater difficulty with shoe wear but increased likelihood of returning to work post-operatively, Worse radiographic indices at long-term follow-up. Axial and frontal X-ray fluoroscopy technique of the sustentaculum tali can improve the accuracy of sustentacular screw placement. In this episode, we review the high-yield topic of Lateral Patellar Compression Syndrome from the Knee & Sports section. A calcaneal stress fracture is one or more small breaks in your heel bone (calcaneus). Calcaneal Fracture ORIF with Lateral Approach, Plate Fixation, and Locking Screws, Leg Compartment Release - Single Incision Approach, Leg Compartment Release - Two Incision Approach, Arm Compartment Release - Lateral Approach, Arm Compartment Release - Anteromedial Approach, Shoulder Hemiarthroplasty for Proximal Humerus Fracture, Humerus Shaft ORIF with Posterior Approach, Humerus Shaft Fracture ORIF with Anterolateral Approach, Olecranon Fracture ORIF with Tension Band, Olecranon Fracture ORIF with Plate Fixation, Radial Head Fracture (Mason Type 2) ORIF T-Plate and Kocher Approach, Coronoid Fx - Open Reduction Internal Fixation with Screws, Distal Radius Extra-articular Fracture ORIF with Volar Appr, Distal Radius Intraarticular Fracture ORIF with Dorsal Approach, Distal Radius Fracture Spanning External Fixator, Distal Radius Fracture Non-Spanning External Fixator, Femoral Neck Fracture Closed Reduction and Percutaneous Pinning, Femoral Neck FX ORIF with Cannulated Screws, Femoral Neck Fracture ORIF with Dynamic Hip Screw, Femoral Neck Fracture Cemented Bipolar Hemiarthroplasty, Intertrochanteric Fracture ORIF with Cephalomedullary Nail, Femoral Shaft Fracture Antegrade Intramedullary Nailing, Femoral Shaft Fracture Retrograde Intramedullary Nailing, Subtrochanteric Femoral Osteotomy with Biplanar Correction, Distal Femur Fracture ORIF with Single Lateral Plate, Patella Fracture ORIF with Tension Band and K Wires, Tibial Plateau Fracture External Fixation, Bicondylar Tibial Plateau ORIF with Lateral Locking Plate, Tibial Plafond Fracture External Fixation, Tibial Plafond Fracture ORIF with Anterolateral Approach and Plate Fixation, Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleol, Ankle Isolated Lateral Malleolus Fracture ORIF with Lag Screw, RETIRE Transtibial Below the Knee Amputation (BKA), differential diagnosis and physical exam tests, interpret radiographs (AP/Lat/Oblique and Harris/Broden views), describes accepted indications and contraindications for surgical intervention, remove splint and place in short-leg cast boot non-weight bearing, remove cast and place in CAM boot non-weight bearing, begin range of motion exercises to ankle and foot, advance weight-bearing status in CAM boot, order radiographs (AP/Lat/Oblique and Harris/Broden views), describe complications of surgery including, wound breakdown (10-25%, worse in diabetics, smokers, open fractures), iatrogenic injury to peroneal tendons, sural nerve, saphenous vein, lateral impingement with peroneal irritation, iatrogenic injury to FHL from lateral to medial screws, identify fracture pattern based on xrays (AP/Lat/Oblique and Harris/Broden views) and CT scan, analyze direction and number of fracture lines (Sanders classification), evaluate joint depression, articular comminution, Bohlers angle, and angle of Gissane, if severe articular comminution may need to concurrently fuse subtalar joint, if tongue-type with mild displacement and shortening can perform closed reduction with percutaneous pinning, goal is to restore calcaneus height, width, alignment, and articular surface, describe the steps of the procedure verbally to the attending prior to the start of the case, describe potential complications and steps to avoid them, Calcaneus Plating System (Stryker Veriax Calcaneus System), c-arm in from contralateral side end of bed at ~20 to get Harris heel view, patient lateral decubitus on beanbag with feet at end of bed, place sheets between ipsilateral and contralateral extremities to make elevated flat working surface ~1 in height, make sure body and legs are taped down (need flat surface to work on), can alternatively place patient supine with table tilted away from surgeon, thigh tourniquet placed high on thigh with webril underneath, extend incision down posterior fibula and bend around lateral maleolus over the peroneal tubercle, curve distally to a point 4 cm inferior and 2.5 cm anterior to lateral malleolus, follow the course of the peroneal tendons, be careful to avoid sural nerve and short saphenous vein that run posterior to the lateral malleolus, incise the deep fascia to uncover the peroneal tendons, incise the inferior peroneal retinaculum over peroneus brevis, must repair at end of case to prevent dislocation, mobilize peroneal tendons and retract them anteriorly over the lateral malleolus, locate the posterior talocalcaneal joint capsule and incise it transversly, inverting the foot will expose the articular surface, to expose lateral surface of calcaneus perform subperiosteal dissection inferiorly, if necessary and there is no infection may divide tendons by Z-plasty and repair at end of case, incise and elevate the periosteum below the tendons, subperiostally elevate tissues (including tendons) superiorly and inferiorly off the lateral surface of the calcaneus, bend kwires with driver into two 90 angles as fixed internal retractors for subcutaneous and skin retraction, delineate fracture lines with knife and clean out using freer, curettes, and rongeur, identify lateral wall that is often broken off, remove piece, clean and mark orientation for later use, and place in saline on back table, next find constant anteromedial fragment and build off of it, check to see how remaining fragments fit together, break apart fragments with curved osteotome and lever to regain calcaneus height, identify if there is a central void of comminution due to bone loss, remove fragments if needed and temporarily pin into place with multiple kwires, check Bohlers angle and angle of Gissane with fluoro, use kwires through bottom of calcaneus to pin constant fragment to remaining fragments, drill large Shantz pin into posteroinferior aspect of calcaneus perpendicular to bone to gain traction through fragment, use bolt cutter to remove sharp end, T-handle to apply traction through pin and distract fragments, build periphery of calcanues and later fill in central void with allograft chips, tamp in gently, use blue handle of lap around forefoot to pull foot into dorsiflexion for heel view, use a 3.5mm lag screw to join largest pieces lateral to medial (2.7mm drill, 3.5mm screws), be careful of iatrogenic injury to FHL from long screws, use bone chips allograft, then place lat wall fragment back into place, first place bicortical nonlocking screws into the anterior and posterior aspects of plate to compress plate down to bone, if performing simultaneous fusion of subtalar joint, place threaded guidepins for 8.0mm cannulated screws x2 through posterior facet of subtalar joint, check on fluoro Lat for placement into talar body, measure, drill calcaneus cortex, just into talar body, can use fully threaded (if significant comminution of subtalar joint) or partially threaded screws (for compression), exchange screws that are too long medially to avoid tendon irritation (FHL) and damage, irrigate wounds thoroughly and deflate tourniquet, cauterize any bleeders carefully, watching out for saphenous vein, hemovac drain deep exiting superolateral from incision, skin closure with 3-0 nylon horizontal mattress or Allgower-Donati stitch to reduce skin tension (diabetics, smokers), dress the incision(gauze, webril) followed by postmold splint with extra padding under heel for immobilization, appropriately orders and interprets basic imaging studies, schedule follow up appointment in 2 weeks. 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