acute calcaneal fractures

36 Journal of the American Academy of Orthopaedic Surgeons

Acute Calcaneal Fractures: Treatment Options and Results

Lance R. Macey, MD, Stephen K. Benirschke, MD, Bruce J. Sangeorzan, MD, and Sigvard T. Hansen, Jr, MD

The calcaneus is the most commonlyfractured tarsal bone. Despite theorthopaedic communitys length ofexperience with this injury, treat-ment remains a source of contro-versy. Historically, the treatment ofacute calcaneal fractures has beenlargely dissatisfying due to the mar-ginal functional results. In 1916 Cot-ton and Henderson, writing on thebasis of their experience with con-servative treatment, stated that theman who breaks his heel bone isdone. This view was reiterated byConn, who in 1926 reported thatcalcaneus fractures are serious anddisabling injuries in which the endresults continue to be incrediblybad. In 1942 Bankarts experiencewas summarized when he wrote,the results of crush fractures of theos calcis are rotten.1

The search for improved resultshas provided a strong impetus forthe development of alternative treat-ment methods. Historically, a widespectrum of treatment options havebeen advocated. Elevation, compres-sion, and early range-of-motionexercises without reduction weresupported by Rowe et al.2 Gissaneand Bohler advocated closed manip-

ulative reduction by means of percu-taneous pins placed in the tibia andcalcaneus, followed by casting.3 Gal-lie4 and Hall and Pennal5 reportedtheir results with primary arthrode-sis as the treatment of choice forseverely comminuted os calcis frac-tures. Recently, open reduction withrigid internal fixation has gainedincreasing support.

The lack of consensus regardingthe most appropriate treatment ofcalcaneal fractures has resulted inpart because the association betweenclassification and treatment has notbeen consistent. Clearly, a meaning-ful classification scheme mustinclude information relative to pat-tern of injury, prognosis, and treat-ment. Several authors have proposedschemes based on fracture configura-tion and the degree of involvementof the posterior facet,1,6-8 but the prog-nostic value of these schemes hasbeen variable. Consequently, there isno single method of classificationthat has gained universal acceptanceor that reliably addresses theseissues.

For the purpose of data collection,we use the classification systemdescribed by Letournel.6 This system

is based on the premise that all dis-placed calcaneal fractures have onefracture line in common, the separa-tion fracture (the primary fractureline). This fracture line runsobliquely anterior to posterior,breaking the calcaneus into twopieces through the sinus tarsi or theposterior facet, and always liesbehind the interosseous ligament.An essential feature of this fractureline is that it creates a fragment (thesustentaculum tali) that remainsattached to the talus by theinterosseous ligament. The simplestdisplaced fractures end with this lineand are considered two-part frac-tures (Fig. 1). These are extremelyrare injuries, as the associatedtrauma usually creates secondaryfracture lines that extend through-out the remainder of the calcaneus.

Dr. Macey is Attending Orthopaedic Surgeon,St. Joseph Hospital and Nashua Memorial Hos-pital, Nashua, NH; and Attending OrthopaedicSurgeon, Parkland Medical Center, London-derry, NH. Dr. Benirschke is Associate Professor,Department of Orthopaedic Surgery, Universityof Washington, Harborview Medical Center,Seattle. Dr. Sangeorzan is Associate Professor,Department of Orthopaedic Surgery, Universityof Washington, Harborview Medical Center. Dr.Hansen is Professor, Department of OrthopaedicSurgery, University of Washington, HarborviewMedical Center.

Reprint requests: Dr. Macey, 29 Riverside Drive,Nashua, NH 03062.

Copyright 1994 by the American Academy ofOrthopaedic Surgeons.

Abstract

The treatment of choice for acute displaced intra-articular calcaneal fracturesremains controversial. The authors present a brief historical review of treatmentoptions and results, coupled with the biomechanical rationale for open reductionand internal fixation. Their current management protocol and surgical techniqueare outlined, along with preliminary functional results at an average follow-up of2.5 years.

J Am Acad Orthop Surg 1994;2:36-43

In a simple three-part fracture,there is an additional fracture linethrough the posterior facet. If thisfracture line involves only the poste-rior facet without extension into thetuberosity, it is considered animpaction fracture or a joint-depres-sion fracture (Fig. 2). In a tongue-typefracture, the fracture line continuesposteriorly to include the posteriorfacet and exits through the posterioraspect of the tuberosity (Fig. 3). In thesimplest fractures, the inferior cortexof the calcaneus remains intact,thereby preserving the general mor-phologic features of the bone.

Complex fractures result in fouror more fragments. These includethe two basic fragments from the pri-mary fracture line and the posteriorfacet fragment in combination withother fragments created by sec-ondary fracture lines that extendthrough the inferior cortex and theanterior process of the calcaneus.These fractures disrupt the wholemorphologic structure of the boneand are associated with severe dis-

ruption of the lateral cortex causedby violent impaction of the posteriorfacet (Fig. 4).

Although we use Letournelsclassification system for descriptivepurposes, we do not consider thissystem comprehensive enough toserve as the only basis for a decisionto proceed with operative interven-tion. We believe an important crite-rion is restoration of biomechanicalfunction.

Biomechanical Rationalefor Open Reduction

An evaluation of normal hindfootfunction provides the most com-pelling evidence in support ofanatomic reduction of calcaneal frac-tures. Because the majority of cal-caneal fractures involve thetalocalcaneal articulation, a goodunderstanding of subtalar joint func-tion is important in comprehendingthe rationale for anatomic reduction.Further support for anatomic

restoration comes from an under-standing of the relationship betweennormal calcaneal morphology andhindfoot function during normalgait.

Subtalar Joint FunctionOne important function of the

subtalar joint is its action as a torqueconverter producing a cushioningeffect on the foot. During normalgait, between the phases of heelstrike and foot flat, the subtalarjoint converts the normal internal

Vol 2, No 1, Jan/Feb 1994 37

Lance R. Macey, MD, et al

Fig. 1 Constant separation fracture line. A, Fracture runs through the sinus tarsi behind theinterosseous ligament. B, Fracture intersects the thalamus (posterior facet). C, Two-fragmentfracture without displacement (exceptional).

A B C

Fig. 2 Three-fragment fractures. A, Impactionof the thalamus; the various fracture lines areseen from above. B, Horizontal impaction ofthe thalamus. C, Possible fracture lines of a ver-tical impaction. D, Vertical impaction of thethalamus.

B

C

D

A

rotation of the tibia into pronation ofthe foot by increasing the talocal-caneal angle (producing hindfootvalgus) and unlocking the trans-verse tarsal joints. This torque con-version results in a softening of thearch, allowing shock absorptionbecause the arch functions as a leafspring (Fig. 5). Between the phasesof foot flat and toe off, normalexternal rotation of the tibia causesconvergence of the talocalcanealangle (producing hindfoot varus),which locks the transverse tarsaljoints and creates a more rigid plat-form for push-off.9,10

The second important function ofthe subtalar joint is to allow the footto adapt to uneven surfaces throughinversion and eversion. Theseactions protect the tibiotalar joint,where motion is normally limited tothe sagittal plane. Without free sub-talar inversion and eversion, thetibiotalar joint is exposed to unusu-ally high stresses out of its normalplane of motion. Long-term studiesof subtalar and triple arthrodeseshave shown that significant degen-

erative changes occur in the anklewhen the subtalar joint is unable tocushion and protect the ankle frommedial and lateral tilt stresses.11

Calcaneal FunctionNormal calcaneal morphology

contributes to three principal func-tions of normal gait, which are vari-ably disrupted dependent on thefracture pattern:

1. The normal calcaneus providesa lever arm to increase the power ofthe gastrosoleus mechanism. Thislever arm is extended through themidfoot and forefoot by normal sub-talar supination with simultaneouslocking of the transverse tarsal artic-ulations. To maximize the efficiencyof its lever-arm function, the calca-neus must provide a fulcrum in themidbody of the talus, and it mustinteract normally with its motor, thegastrosoleus muscle. High-energycalcaneal fractures markedly disruptthese anatomic relationships andhave a profound effect on hindfootfunction. The gastrosoleus muscle isfunctionally weakened when thesubtalar joint is disrupted and thetuberosity of the calcaneus is dis-placed proximally.

2. Normal calcaneal structureprovides a foundation for body


Acute Calcaneal Fractures

Fig. 4 Complex calcaneal fractures comprising four fragments or more. A, Fracture lines onthe upper aspect of the bone. B, Axial view of fracture. C, Lateral view of a complex fracture.

A B C

Fig. 5 The osseous and ligamentous struc-tures of the foot soften the arch when thetibia is internally rotated and locked ontothe dome of the talus. Pronation occurs atthe beginning of the weight-bearing portionof the gait cycle as the foot strikes theground and accepts body weight. The footrotates laterally under and in front of thetalus, and as a result the arch of the footfunctions as a leaf spring.

Fig. 3 Tongue-type fracture verticalimpaction of the thalamus. A, Lateral view.B, Axial view of the tongue.

A

B

weight transmitted through the tibia,ankle, and subtalar joints. The nor-mal vertical-support function of thecalcaneus is dependent on its normalalignment beneath the weight-bear-ing line of the tibia to prevent eccen-tric weight distribution in the foot.Lateral displacement of the calca-neus may result in fibular or per-oneal impingement. In addition,eccentric weight-bearing may causea valgus tilt of the hindfoot, resultingin increased stresses on medial soft-tissue structures (deltoid ligamentand posterior tibialis muscle). Medialdisplacement of the body of the oscalcis results in varus alignment,causing increased compressiveforces on the medial aspect of theankle and increased tension on thelateral soft-tissue structures (lateralligaments and peroneal muscles).This deformity may predispose tolateral ankle sprain and eventuallylead to varus tilting of the talus andsecondary ankle arthrosis. Directvertical collapse of the calcaneusresults in impaction of the talus intothe body of the calcaneus. The talusthen assumes a more dorsiflexedposition in the ankle mortise, whichcan result in anterior ankle impinge-ment, decreased ankle dorsiflexion,and accelerated arthrosis.

3. Normal calcaneal anatomyprovides structural support for themaintenance of normal lateral col-umn length, which affects abductionand adduction of the midfoot andforefoot. In addition, lateral supportindirectly assists in supination of thefoot to provide strong push-off dur-ing gait. When the anterior processof the calcaneus is fractured, oftenthere is shortening and loss of lateralcolumn length. As a result, the mid-foot and forefoot are forced intoabduction through Choparts joint,the naviculocuneiform joint, or Lis-francs joint. Abduction leads toincreased tension on the posteriortibial tendon and may lead to lateralperitalar subluxation or frank dislo-

cation with posterior tibial tendonrupture. As the calcaneus continuesto migrate laterally, there may betalocalcaneal impingement in thesinus tarsi. This degree of malalign-ment causes severe compromise inthe vertical-support function of thecalcaneus.

Criteria and Goals for SurgeryThe important relationships

between the calcaneus and normalhindfoot function underlie the bio-mechanical rationale for the surgicalrestoration of normal calcanealanatomy. Absolute indications foroperative fixation have not beendetermined and will vary amongorthopaedists. The important crite-ria we consider in our decision topursue operative interventioninclude: (1) the degree of distortionin the relationship between the pos-terior facet and the middle and ante-rior facets, which may contribute tothe development of restricted subta-lar motion; (2) the amount of dis-placement within the posterior facet;(3) the amount of lateralization ofthe tuberosity; and (4) the degree ofwidening of the foot and other fac-tors such as displacement of thetuberosity and/or calcaneocuboidjoints.

The goal of surgery should be torestore normal calcaneal morphol-ogy and regain the normal height,width, length, and longitudinal axisof the calcaneus, with stableanatomic reconstruction of all jointsurfaces to allow early motion. Cal-caneal body fractures that do notchange the weight-bearing surfaceof the foot or alter normal hindfootmechanics usually receive closedtreatment. In a simple fracture pat-tern with only a primary fractureline extending through the posteriorfacet, 2 mm of displacement may betolerated and closed reduction canbe used. We believe that fractureswith displacement of 3 mm or moreshould be treated with open reduc-

tion and internal fixation. We believethere is no fracture too comminutedfor reduction, because the salvagefor a severely comminuted, mal-united fracture is usually moredifficult than the initial fracturesurgery.

We try to reconstruct all fractureswithin 10 days from the time ofinjury if soft-tissue conditions arefavorable. Reduction becomes verydifficult after 3 weeks.

Preoperative Evaluationand Treatment

Displaced intra-articular fracturesof the calcaneus are the result ofhigh-energy axial-loading injuries.Consequently, the damage to thesurrounding soft-tissue envelopemay be extensive, resulting insignificant swelling. Fracture-blisterformation is common. To minimizesoft-tissue compromise during thepreoperative period, the foot shouldbe elevated to the level of the heartand immediately splinted with theankle in neutral position. Surgicaltiming is dependent on the condi-tion of the soft tissues. Swellingshould be decreased such that tissueturgor allows skin wrinkling inresponse to gentle pressure. Frac-ture blisters should be debrided andallowed to epithelialize prior to sur-gical reconstruction.

Understanding the fracture pat-tern is dependent on the appropriateradiographic evaluation. Preopera-tive lateral and axial plain films areessential for the preliminary investi-gation of the fracture type. In addi-tion, transverse (parallel to theplantar surface) and coronal (per-pendicular to the posterior facet)computed tomographic (CT) scansshould be obtained to evaluate thefracture pattern and degree of com-minution. The CT scans should beevaluated to determine the degree ofwidening of the heel and the amount

Vol 2, No 1, Jan/Feb 1994 39


of hindfoot varus, calcaneocuboiddisruption, anterior process injury,and posterior facet involvement. Wehave found no real advantage tothree-dimensional CT scans in pre-operative planning.

Operative Technique

The goal of surgery is anatomicreduction of the calcaneus and rigidinternal fixation so that early motioncan proceed. Restoration of the artic-ular surfaces, overall shape, andalignment of the calcaneus is criticalto achieve successful functionalresults.

Historically, the specific surgicalapproach for reduction has been thesource of controversy in the treat-ment of these injuries. The medialapproach has been advocated byMcReynolds.12 The benefits of thisapproach include good visualizationof the sustentaculum tali and theability to control varus and valgusalignment. The disadvantagesinclude poor visualization of theposterior facet and lateral wall andthe lack of exposure of the calca-neocuboid articulation.

The lateral approach to the calca-neus has been favored by Palmer13

and Letournel6 and has beenmodified by Benirschke.14 Thisapproach is our method of choice fortreating displaced intra-articular cal-caneal fractures. The advantagesinclude excellent exposure of thetuberosity, posterior facet, lateralwall, and calcaneocuboid articula-tion. Reduction of the sustentaculumto the tuberosity through the lateralapproach is performed indirectly.

Stephenson15 advocates a com-bined lateral and medial approach todifficult fractures. This methodoffers the advantages of bothapproaches; however it requiressubstantial soft-tissue stripping anddisruption of the calcaneal bloodsupply.

To perform a lateral approach, thepatient is placed on the operatingtable in the true lateral position. Theextremity is exsanguinated, and apneumatic tourniquet is used forhemostasis. After identification ofthe important superficial landmarks,including the fibula, the Achilles ten-don, and the base of the fifthmetatarsal, a J-shaped (left side) orL-shaped (right side) incision ismade laterally (Fig. 6) with care toavoid injury to the sural nerve. Theincision should extend directly tobone plantar to the peroneal tendonsto allow the development of a full-thickness periosteal-cutaneous flap.The calcaneofibular ligament andperoneal tendon sheaths are sharplydissected off the lateral wall of thecalcaneus and maintained within theflap. Progressive dorsally directeddissection results in a full view of thetuberosity, subtalar joint, and ante-rior process. Two small K wires canbe placed into the lateral aspect ofthe talus to serve as soft-tissueretractors of the flap. Distal exten-sion of the incision with dissectionover the peroneal tendons may benecessary to fully visualize the calca-neocuboid joint.

Once adequate exposure has beenobtained, the blown-out portion ofthe lateral wall is removed andmarked to preserve its orientation.The posterior facet is then disim-pacted from the body of the calca-neus and inspected to document theextent of comminution and articularcartilage disruption. If the posteriorfacet is comminuted, it should beanatomically reconstructed on theback table using 0.045-inch K wires.We have found that many intra-articular fractures have associatedextension into the anterior process.In this situation, the first step is toreduce the sustentacular fragment tothe anterior process at the criticalangle of Gissane. This reduction isprovisionally held with 0.045-inch Kwires.

Next, attention is turned to reduc-ing the posterior facet to the anteriorprocesssustentaculum complex.Again, K wires are used for provi-sional fixation. The tuberosity is thenindirectly reduced to the sustentacu-lar complex and the medial wallwith the use of a 4.0- or 5.0-mmSchanz pin introduced laterally intothe tuberosity. The Schanz pin isused to manipulate the tuberosityand secure anatomic alignment inthe varus-valgus planes (Fig. 7). Thisreduction is provisionally held with0.062-inch K wires directed axially.

Alignment and reduction arethen confirmed with intraoperativelateral and axial radiographs. Bonedefects are filled with cancellousgraft. The lateral wall is replaced,and a 3.5- or 2.7-mm reconstructionplate is contoured to span from thetuberosity to the anterior process lat-erally. The plate is fixed with 3.5- or2.7-mm screws. Two additional 3.5-mm thalamic lag screws are placedbeneath the articular surface of theposterior facet to maintain thereduction of the posterior facet to thesustentacular fragment (Fig. 8).Additional fixation of the posteriortuberosity is often necessary if atongue component exists. This isbest accomplished with a small ormedium cervical H plate placedunder the reconstruction plate andextending over the dorsal aspect of



Fig. 6 Surgical approach (dashed line).Sural nerve (solid lines) is shown just aboveit within the elevated periosteal-cutaneousflap.

the tuberosity. All provisionalfixation is then removed. In areas notsuited for screw fixation, such as theanterior process at the critical angleof Gissane, K wires are left in,impacted next to the plate.

The wound is closed over a 18-inchsuction drain brought out dorsolat-

erally through the skin overlying thesinus tarsi. The drain is routinelyremoved 48 hours after the opera-tion. The periosteal-cutaneous flap isclosed as a single layer using 2-0Vicryl in an inverted, interruptedfashion. The skin is closed using a 3-0 nylon horizontal stitch to minimizetension on the edge of the flap.

Postoperative Care

Initially, the leg is splinted with theankle in neutral position for 72 hoursand then placed in a removable alu-minum splint with a sheepskin lin-ing. When the incision is dry (3 to 5days), an active ankle and subtalarrange-of-motion exercise program isbegun. The exercise program alsoincludes passive stretching of alltoes to avoid the development offlexion contractures. Sutures areremoved at 3 weeks, and patientsavoid weight-bearing for 12 weekspostoperatively. Patients are fittedwith support stockings to controledema and are encouraged to con-tinue their use for 6 months. Hard-ware is usually removed at 1 year,depending on symptoms andpatient preference.

Results of Treatment

Literature ReviewIt is difficult to interpret the com-

parative results of various treatmentmodalities advocated in the past.Studies have been done on patientpopulations with different countriesof origin, using numerous fractureclassification systems to describeinjuries treated with various surgicalapproaches. To date, there have beenno prospective studies.

Letournel6 used a lateral approachto gain stable anatomic reductionand fixation in 99 patients withintra-articular calcaneal fractures.His results at 2-year follow-up

were good or very good in 56% ofcases, fair in 33%, and bad in 11%.The patients with good and verygood results had no functional dis-ability or only occasional painwhile walking on uneven surfaces.Forty-seven percent had usefulsubtalar motion following openreduction and internal fixation.There were three infections (3%)and six technical failures (6%).

Sanders et al8 used a combinationof the lateral and modified lateralapproach and correlated their opera-tive results in 120 patients with anew classification system based onthe CT evaluation of associated com-minution at the posterior facet of thecalcaneus. They found that the clini-cal results deteriorated with increas-ing comminution of the posteriorfacet. Seventy-three percent ofpatients with mild to moderate com-minution had excellent or good clin-ical results, while only 9% of patientswith severe comminution of the pos-terior facet had good to excellentresults. Reported complicationsincluded two cases of infection lead-ing to osteomyelitis. Eighteen per-cent of patients developed peronealtendinitis, which responded to plateremoval, and 12 patients had vari-able symptoms related to sural neu-romata.

Tscherne and Zwipp16 used acombination of medial, lateral, andbilateral approaches in their treat-ment of 157 displaced calcanealfractures. They developed a fracture-classification scoring system basedon the number of fracture fragments,the degree of joint involvement andsoft-tissue injury, and the presence ofassociated foot fractures, which theyconsidered predictive of clinical out-come following open reduction andinternal fixation. Using their scoringsystem, they reported an inverse rela-tionship between fracture severityand clinical outcome followingsurgery. Complications includedwound margin necrosis in 8.5% of

Vol 2, No 1, Jan/Feb 1994 41


Fig. 7 A 4.0- or 5.0-mm Schanz pin isplaced laterally in the tuberosity fragment.Vectors of manipulation, all with referenceto the sustentacular fragment, are as fol-lows: 1, restoration of height; 2, valgusalignment; 3, medial translation. Medialwall reduction is indirect.

Fig. 8 Lateral view of reconstruction per-formed with use of a 3.5-mm reconstructionplate extending from the tuberosity to theanterior process, with two separate lagscrews to stabilize the posterior facet.

1

23



cases, hematomas requiring decom-pression in 2.6%, and a deep infectionin 2.0%. These complications devel-oped independent of which opera-tive approach was used.

Authors ResultsWe have yet to fully analyze the

long-term functional results of ourtreatment protocol, but we have con-ducted a preliminary review of over100 displaced intra-articular cal-caneal fractures treated with openreduction and internal fixationthrough a lateral approach. To date,our results have been encouraging,but our preliminary experience hasnot been subjected to rigorous analy-sis. The ongoing functional assess-ment is currently at an averagefollow-up of more than 2 years.Patients are evaluated to determinetheir level of physical activity andlimitations in activities of daily liv-ing. In addition, data on pain-med-ication requirements and workstatus are being collected.

Our most recent surveillanceindicates that the majority ofpatients (65%) are limited only intheir ability to participate in vigor-ous activities and sports. Over 50%of patients are able to walk comfort-ably on any surface. Sixty percentreport no need for medications tocontrol discomfort. Forty percent of

patients have been unable to returnto their previous employment due tofunctional limitations caused by thecalcaneal fracture. Approximately70% of patients have been com-pletely satisfied with their surgicaloutcome to date.

Our preliminary evaluation ofmorbidity reveals that skin loss atthe wound margin is the most com-mon complication and occurs inapproximately 10% of patients. Thisproblem responds well to dailydressing changes on an outpatientbasis. The incidence of superficialwound infection has been less than2%, and deep infection requiringhardware removal has yet to beencountered. Approximately 20% ofpatients have peroneal tendinitisnecessitating hardware removal. Todetermine the longer-term func-tional results and incidence of mor-bidity, we will be conducting arigorous analysis of our data.

Summary

We have found that there is a steeplearning curve associated with thedemanding surgical technique nec-essary for the successful reconstruc-tion of acute calcaneal fractures.Familiarity with the surgical tech-nique and the demand for meticu-lous handling of soft tissues during

this approach are critical factors inachieving a successful result andavoiding postoperative complica-tions. There are a number of pitfallsduring the approach to these frac-tures that can frustrate the inexperi-enced surgeon and lead to poorresults, such as inability to achieveadequate reduction to securefixation.

Although a number of patientsare left with functional limitationsfollowing open reduction andfixation of calcaneal fractures, themajority of limitations are modestwhen compared with the previouslyreported results of conservativetreatment. These improved resultscome from our ability to surgicallyrestore the articular surfaces of thesubtalar joint and overall calcanealmorphology, upon which normalbiomechanics and hindfoot functiondepend. Unfortunately, the disrup-tion of articular cartilage is a variableover which we have no control butwhich clearly has an impact on thefunctional outcome. Although thefinal determination of the treatmentof choice for these difficult fractureswill depend on well-controlled ran-domized clinical trials, we believethat reconstruction of normal cal-caneal anatomy should be the goalwhen treating these potentially dev-astating injuries.

References

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2. Rowe CR, Sakellarides HT, FreemanPA, et al: Fractures of the os calcis: Along-term follow-up study of 146patients. JAMA 1963;184:920-923.

3. Bohler L: Diagnosis, pathology andtreatment of fractures of the os calcis. JBone Joint Surg 1931;13:75-89.

4. Gallie WE: Subastragalar arthrodesis infractures of the os calcis. J Bone Joint Surg1943;25:731-736.

5. Hall MC, Pennal GF: Primary subtalararthrodesis in the treatment of severefractures of the calcaneum. J Bone JointSurg Br 1960;42:336-343.

6. Letournel E: Open reduction and inter-nal fixation of calcaneus fractures, inSpiegel P (ed): Topics in OrthopaedicTrauma. Baltimore: University ParkPress, 1984, pp 173-192.

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9. Wright DG, Desai ME, Henderson BS:Action of the subtalar and ankle jointcomplex during the stance phase ofwalking. J Bone Joint Surg Am 1964;46:361-367.

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11. Angus PD, Cowell HR: Triple arthrode-sis: A critical long-term review. J BoneJoint Surg Br 1986;68:260-265.

12. McReynolds IS: Trauma to the os calcisand heel cord, in Jahss MH: Disorders ofthe Foot. Philadelphia: WB Saunders,1982, vol 2, pp 1497-1542.

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Open reduction with the use of cancel-lous grafts. J Bone Joint Surg Am 1948;30:2-8.

14. Benirschke SK, Sangeorzan B: Extensiveintraarticular fractures of the foot: Sur-gical management of calcaneus frac-tures. Clin Orthop 1993;292:128-134.

15. Stephenson JR: Treatment of displacedintra-articular fractures of the calcaneus

using medial and lateral approaches,internal fixation, and early motion. JBone Joint Surg Am 1987;69:115-130.

16. Tscherne H, Zwipp H: Calcaneal frac-ture, in Tscherne H, Schatzker J (eds):Major Fractures of the Pilon, the Talus andthe Calcaneus: Current Concepts of Treat-ment. Berlin: Springer-Verlag, 1993, pp153-174.

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AbstractBiomechanical Rationale for Open ReductionPreoperative Evaluation and TreatmentOperative TechniquePostoperative CareResults of TreatmentSummaryReferencesJAAOS Home PageTable of ContentsSearchHelp

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