Calcaneal fractures

Fractures of the calcaneus

Ahmad F. Ja’far

Orthopaedic resident

JUH

Introduction

• Approximately 2% of all fractures.

• Most frequent tarsal bone fracture

• Challenging fracture for orthopedists

• 90% occur in males between 21-45 years of age.

• Although not all these fractures have bad results, the results of treatment of calcaneus fractures over the years have not been good.

Relevant Anatomy• Largest tarsal bone.• Dense cancellous bone

covered with a very thin cortical bone.

• Articular surfaces-ant half• Post half/ tuberosity• Plantar fascia

Functions:

• Lever arm powered by gastrocnemius

• Foundation for body wt.

• Supports/ maintains lat. column of foot

• Articular surface for cuboid• Ant./middle/post articular

facet for talus• Post articular facet

– Is the calcaneal portion of the subtalar joint

– Is the largest and is convex in shape

– Is separated by the tarsal sinus and the tarsal ligament from the middle and anterior facets

• Interosseous ligament• Sinus tarsi

Post.

Middle

Ant.

Ant.Post.

Middle

CC

Sustentaculum tali:

• Projects medially and supports the neck of talus.

• FHL passes beneath it .

• Deltoid and talocalcanealligament connect it to the talus

• Clinical significance :

contained in the anteromedialfragment, which remains "constant" due to medial talocalcaneal and interosseous ligaments

Ant.

process

Tuberosity

Sinus tarsi

Lateral Aspect

Classification

• Intra-articular fractures 60-75%

• Extra-articular fractures 25-30% and include :

Anterior process fractures.

Beak or avulsion fractures of the tuberosity.

Medial process fractures.

Sustentaculum tali and body fractures.

Anterior process fracture

• Inversion “sprain”

• Frequently missed

• Most are small: treat like sprain

• Large/displaced: ORIF

Tuberosity body fracture

• Fall/MVA

• Usually non-operative

─ Swelling control

─ Early ROM

─ PWB

Tuberosity avulsion fractures

• Achilles avulsion

• Wound problems

• Surgical urgency

─ Lag screws or tension band

Sustentacular fracture

• May alter ST jt. mechanics

• Most small/ nondisplaced:

─ Non-operative

• Large/ displaced

─ ORIF (med. approach)

─ Buttress plate

“Intra-articular” fractures

Mechanism of injury• High energy: Axial load

─ MVA, fall Lateral process of talus acts as wedge

• Oblique shear1ry # line 2 fragments:

-- Superomedial (constant) fragment.

-- Superolateral fragment>(intra-articular aspect through post facet)

2ry # line dectates whetherthere is joint depression or tongue-type fracture

z

Mechanism of injury

• Secondary fracture line runs in one of two planes

• beneath the facet exiting posteriorly in tongue-type fracture

• behind the posterior facet in joint depression fractures

Mechanism of injury

IMAGING: plain films

Standard Views

1. Lateral

2. Broden’s

3. Axial

• Scan other regions

- Lumbar spine?

- Contra lateral side?

- Knees?

Lateral view

• Bohler’s angle

• 20-40

• Gissane’s angle

• 95-105

Broden’s view

• Positioning

– 20° IR view (mortise)

– 10°-40° plantar flex

Demonstrating the articular surface of the posterior facet.

Axial Harris view

• Very difficult to obtain in the acute setting

• 45° axial of heel

• 2nd toe in line w/ tibia

• Assess varus/valgus

-- Normal »10° valgus --

• Joint displacement

• Tuberosity angulation

• Heel width.

Imaging: CT

Coronal Axial Sagittal

Classifications (intra-articular)

• Several used- None are ideal

• Most commonly used

─ Essex-Lopresti

─ Sanders

Classifications

• Essex-Lopresti

• Sanders:

• Based on CT findings

• Coronal plane

• # joint fragments

• 2 = type II

• 3 = type III

• 4 or more = type IV

• Predictive of results

Sander’s

Sander’s

Associated injuries

– Extension into the calcaneocuboid joint occurs in 63%

– Vertebral injuries in 10%

– Contralateral calcaneus in 10%

– Compartment syndrome 2-10%

Principles of treatment1) No reduction, with elevation of the foot, compression

dressing, and early ROM.2) Closed reduction, with elevation of the foot,

compression dressing, and early ROM.

3) Percutaneous reduction (Essex-Lopresti) .

4) ORIF as popularized by Palmer and McReynolds .

5) Primary arthrodesis.

• Medial approaches, lateral approaches, or dual approaches

TREATMENT: historical

• <1850: bandages/elevation

• 1850: Clark: traction

• 1931: Bohler: closed red./cast

• 1952: Essex-Lopresti: perQ fixation

• 1993+: Benirschke/Letournel/Sanders:

– Extensile lateral approach & plating

Management of intra-articularcalcaneal fractures

• Conservative

• Operative.

Formal ORIF

Minimally invasive techniques

Ex. Fixation.

Fusion

Conservative

• Admit to hospital

• Ice packs applied with or without compression

• Elevation.

• Below knee lightweight cast / functional brace for a 4–6 week period

• Non-weight bearing for a further 2 w

Operative treatment:Rationale

• Restore anatomy

─ Shape and alignment of hindfoot

─ Articular congruency

• Return to function & prevent arthritis

• Typically, restoring articular anatomy gives improved results if complications are avoided

• Prospective, randomized, controlled multicenter trial(level II)

• 82 patients …Follow-up at 1year and 8-12 years

• Primary out come at one 1 year no difference

• 8-12 years Better VAS score for pain and function (p = 0.07) and the physical component of the SF-36 (p = 0.06) in the operative group.

• The prevalence of radiographically evident posttraumatic subtalar arthritis was lower in the operative group (risk reduction, 41%).

Canadian Calcaneus Registry, R. Buckley et al., JBJS, 2002

• The following did better with surgery:

• Women

• Age <29 years

• Non-Work-Comp

• Bohler angle <10˚

• Comminuted fracture

• Large initial joint step off

Difficulties with ORIF

Difficult exposure

Complex 3D-shape of the bone

Ever-changing fixation devices

Open fractures

Osteopenic bone disease.

Increased incidence of wound complications in patients with DM, HTN, or PVD, and tobacco chewers and smokers

Indications for ORIF

• Displaced intra-articular fractures involving the posterior facet.

• Anterior process of the calcaneus fractures with more than 25% involvement of the calcaneocuboidarticulation.

• Displaced fractures of the calcaneal tuberosity.

• Fracture-dislocations of the calcaneus.

• Selected open fractures of the calcaneus

Rel. Contraindications

• Diabetes• Vascular insufficiency• Smoker• Severe swelling

• Open fractures

• Elderly

• Neuropathic

• Non-compliant pt.

• In-experienced surgeon

• Lymphedema.

• Immune compromise

Folk et al., JOT, 1999

• Diabetes

• Vascular insufficiency

• Smoker

• Wound problems: these factors have additive effects. If

all 3, >90%.

Operative treatment: contraindications

• Open Fractures

– Mostly medial wounds, varied severity

– All treated with I&D/ IV abx

– Grade II-III: 48% infections

– Grade IIIB: 77% infections & 46% BKAs

Heier KA, Infante AF, Walling AK, et al.J Bone Joint Surg Am 2003, 85-A: 2276-82

Preparing Soft Tissues

• Elevation• Compression stocking• Cast boot• Care of blisters• ORIF @ 10-17 days• + Wrinkle test

ORIF via Extensile Lateral Approach

Non touch technique

• Schanz pin to

manipulate tuberosity

• Clean out fracture

• Disimpact sustentacular

fragment

• Reduce tuberosity (body) fragment to sustentaculum

Tuberosity Reduction

Restore Joint Surface +/- graft

Lag screw below post facet

≥2 screws in each major fragment

Fixation Options

• Replace lateral wall

• Apply plate

• Recheck Xrays

Drain and deep closure

Post op care

• Elevate, splint

• Sutures out @ 3 wks.

• Fracture boot

• Early motion

• NWB for 8-12 weeks

• Improvement up to 2 yrs

Other Surgical Options

• Closed Reduction/ Int. Fixation

–Percutaneous

–Arthroscopic assisted

• Ilizarov

• Primary Fusion.

Surgery: percutaneous

• Fewer wound problems

• More difficult reductions?

• Ex. Essex-Lopresti

maneuver (Tongue type)

Ilizarov

• Minimally invasive

• Indirect reduction

• Learning curve

• Immediate weightbearing

Primary Fusion

• Sanders type IV or severe cartilage injury

• ORIF calcaneus, debride cartilage, and fuse ST joint

• 69 patients(75 displaced intra-articular fractures)• 36 fractures initial ORIF +fusion• 39 fractures conservative –later fusion• Follow-up 63 months

• First group : fewer postoperative wound complications and had significantly higher Maryland Foot Scores (90.8 compared with 79.1; p < 0.0001) and American Orthopaedic Foot and Ankle Society ankle-hindfoot scores (87.1 compared with 73.8; p < 0.0001) than did Group B.

Complications Malunion

Varus hindfoot

Shortened foot = short lever arm

Peronealimpingement/ dislocation

Shoewear problems

Valgus>varus with surgical

Complications

• Stiffness─ Prevention (early ROM)

• Subtalar arthritis

• 5-20% of calcaneal fractures may require subtalar arthrodesis─ NSAIDs

─ Subtalar fusion

Complications

• Peroneal tendon problems

─Tendonitis- NSAIDs, therapy

─Entrapped-release tendons, exostectomy

─Dislocated-open reduction

Complications

Wound problems

•Apical wound necrosis– Stop ROM

– Leave sutures in

• Infection– Antibiotics

– I&D

– Soft tissue coverage?

Take home message

Thank you

• Complex injuries ,, patient education

• Don’t miss other injuries.

• Pay attention to soft tissue envelope.

• Functional impairment up to 5 years.

• Much controversies (classification, management, op

techniques…etc)

• ORIF is a good option for displaced intra-articular fractures

in selected group of pateints (on the long term)