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Fracture dislocation of calcaneum associated with subluxation of Ankle and Talo navicular joint with FHL entrapment– A case report

Raja Mohamed Sharief*, Hisham Mosallami#, Mahmood Abul Fatth#

*Senior Registrar, #Specialist, Department of Orthopaedics,
Al-Adan Hospital, Kuwait.

Address for Correspondence:
Raja Mohammed Sharief,
Department of Orthopaedics,
Al-Adan Hospital, Kuwait
E-Mail: rajariyaz@gmail. com


We report a rare case of complex fracture dislocation of calcaneum associated with subluxation of  ankle and talonavicular joint with entrapment of FHL tendon.17 years old gentleman who sustained the above injury due to a fall from a height is presented .The clinical presentation , mechanism of injury, radiological features , operative reduction and difficulties during surgery are discussed. Post operative CT findings and the necessity for the pre operative CT scan for the surgical planning are emphasized.


J.Orthopaedics 2010;7(2)e13


Calcaneum; Dislocation; Talonavicular joint; FHL


Complex fracture dislocations involving the tarsal bones are rare. Usually they are produced by high energy injuries such as fall from a height. Bony geometry and the strong ligamentous support between the tarsal bones confer more stability preventing isolated mid tarsal joint dislocations with the exception of talonavicular joint and a collective mid tarsal joint(1).

Only a very few cases of isolated dislocation of the calcaneum (2,3) and fracture dislocation of calcaneum (4,6) has been reported. We are presenting this case of rare complex injury of fracture dislocation of calcaneam associated with subluxation of ankle, talo navicular joint and FHL entrapment.

Case Report:

17 yrs old gentleman of British nationality who was on a visit to Kuwait had an accidental fall from the balcony of a house and presented to the hospital with severe pain and swelling of the Left  Ankle and Foot.

Figure 1


He was conscious and oriented but he could not remember how he fell down from the balcony. On examination he had severely deformed and swollen hind and mid foot. The skin over the medial side of the mid foot was stretched and contused with palpable prominent navicular head. The foot was warm with good capillary refilling of the toes. Posterior  Tibial pulse was palpable. Dorsalis pedis pulse was felt by doppler. There was an acute fixed flexion deformity of the big toe which could not be passively extended. There were minor abrasions in both lower limbs and hands. . Plain Xrays of the foot and ankle showed complete lateral dislocation of the calcaneum from the talus and cuboid(Fig.1). The talus subluxed and rotated from the ankle as well as from navicular bone(Fig. 2).Clinical examination and Trauma  X-ray series revealed no other musculo skeletal injuries except for the simple fracture of the 7th rib on the Right side. C.T.Brain,Cervical Spine and U/S abdomen were normal

Figure 3

Figure 4

A trial of closed reduction failed and open reduction was planned. The patient was prepared and taken to operation theater. The Ankle joint  was exposed through Antero medial approach. The talus was reduced in to ankle and talo navicular joint. Attempted reduction of calcaneum in to the sub talar joint was difficult and incongruous. An another small lateral incision was made at sinus tarsi and a bone lever used to reduce the calcaneum through the wound. The difficulty in reduction was due to comminuted bony fragments involving sustentaculam tali and the entrapped FHL tendon. Small pieces of articular fragments were removed from sub talar joint and the wound washed. The reduction was stable. The limb was immobilized in a well padded Below Knee plaster and kept elevated on a Bohler frame.

Figure 5

Post operative X-Rays showed satisfactory reduction(Fig.3).Post operative C.T scan (Fig.4) and the 3D reconstruction films (Fig. 5) showed the comminuted  fracture of anterior process of calcaneum involving sustentaculam tali and the comminuted tip of lateral malleolus which was not well recognized with plain X-Rays pre operatively.

At the time of discharge the  wound was clean.The patient was discharged with POP Cast and advised suture removal after 3 weeks, non weight bearing for 6 weeks and partial weight bearing for another 6 weeks. Patient has left to his native place at UK.


Discussion :

Closed fracture dislocation involving the calcaneum is rare. Only few cases has been reported in the literature(4,6). However a complex fracture dislocation of the calcaneum with subluxation of talus at ankle and navicular bone with the entrapment of FHL tendon has not been reported.  d’Aubigue first described the case of calcaneal dislocation in 1936(5).

Court and Brown et al described the mechanism of injury in calcaneal fracture dislocation. They postulated that the axial loading of an inverted hind foot produces primary sheer type fracture of the antero medial calcaneum with or without associated postero lateral fragment. With continuation of the force, the postero lateral fragment  ruptures the lateral collateral ligament to allow the calcaneum to dislocate(4). With further continuation of the force the talus rotates medially on its long axis to get subluxed from the ankle and talonavicular joint.In our case instead of rupture of the lateral collateral ligament, it got avulsed from the lateral malleolus with multiple chip fracture of the tip of lateral mallelous which was recognized in C.T scan and post reduction Xrays. Naoki Haraguchi et al stressed the importance of special projection views to evaluate the avulsion fractures of the lateral malleolus. Both the anterior talofibular (ATFL) and  the calcaneofibular (CFL) ligaments arise from the anteroinferior aspect of the lateral malleolus, and therefore avulsion fragments are superimposed on the lateral malleolus on standard radiographs, and are difficult to identify accurately.  So, radiographs taken at 15° external rotation with 45° of plantar flexion in projection 1, and at 45° internal rotation in projection 2 were the most useful to asses these injuries(7)However in patients with severe swelling and deformity CT scan may be a better option.

Fracture dislocation of calcaneum with tendinous interposition of FHL preventing closed reduction has been reported by various authors(8,9). FHL  originates from distal 2/3 of posterior fibula, interosseous membrane and adjacent intermuscular septum and its tendon passes through posterior aspect of fibro-osseous tunnel beneath the sustentaculum in an oblique manner, plantar midfoot (knot of Henry);   and gets inserted at the plantar surface of base of distal phalanx of Big Toe.

Fractures involving  disruption of the medial wall at sustentaculam disrupting the integrity of the fibro-osseous tunnel may lead to the interposition FHL at subtalar joint causing irreducible fracture dislocation of calcaneum(8).Fractures involving anterior extremity at sustentaculam may be associated with calcaneocuboid dislocation(10). Sustentaculam tali is a vital load-bearing structure  and any isolated fractures should be fixed  to prevent late hindfoot implications(11). Carr JB presented FHL entrapment in fractures of calcaneum and described the fixed flexed position of hallux as ‘check rein deformity’ and advised for medial approach to release the entrapment(9).In our case we were able to reduce the subtalar joint through lateral approach by relocating the FHL tendon.  


Complex fracture dislocation of calcaneum with FHL entrapment at subtalar joint causing difficulty in reduction at subtalar joint has been presented. The importance  to have a pre operative C.T scan if available for the evaluation of the injury pattern, planning the surgical approach and fixation if needed has been stressed.


Reference :

  1. Piney SJ, Sangeorzan BJ. Fractures of the tarsal bones. Orthop Clin North Am 2001;32:21-32. 

  2. Viswanath SS, Shepard E. Dislocation of the calcanium. Injury 1977; 9:50. 
  3. Rao H. A complete dislocation of the calcaneus: a case report. J Foot Ankle Surg 2005;44(5):401-5.  
  4. Court-Brown CM, Boot DA, Kellam JF. Fracture dislocation of the calcanius. Clin Orthop 1986;213:201-6. 
  5. d’Aubigue MR. Fracture isolee de la petite apophyse du cal-caneum traitee par osteosynthese (Raport de M. Wilmoth). Mem Acad Chir 1936;62:1155.
  6. Julian R. Northover, Stephen A. Milner: Fracture dislocation of the calcaneum: a case report. Injury Extra2006;37:294-296.

  7. Haraguchi N, Kato F, Hayashi H. : New radiographic projections for avulsion fractures of the lateral malleolus.  J Bone Joint Surg Br. 1998; 80(4):684-8.

  8. Anglen JO, Gehrke J.:Irreducible fracture of the calcaneus due to flexor hallucis longus tendon interposition. J Orthop Trauma. 1996;10(4):285-8.

  9. Carr JB: Complications of calcaneus fractures: Entrapment of the flexor hallucis longus. Report of two cases. J Orthop Trauma 1990;4:166-168.

  10. Hagino T, Tonotsuka H, Ochiai S, Hamada Y:    Fracture of the anterior extremity of calcaneus together with calcaneocuboid joint dislocation. Arch Orthop Trauma Surg. 2009 ;129(12):1673-6.

This is a peer reviewed paper 

Please cite as: Raja Mohamed Sharief : Fracture dislocation of calcaneum associated with subluxation of Ankle and Talo navicular joint with FHL entrapment– A case report

J.Orthopaedics 2010;7(2)e13





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