BÀI TẬP BỔ TRỢ TIẾNG ANH 8 - I-LEARN SMART WORLD - CẢ NĂM - CÓ FILE NGHE (BẢN...
Calcaneal fractures
1. Fractures of the calcaneus
Ahmad F. Ja’far
Orthopaedic resident
JUH
2. 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.
3. 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
4. • 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
5. Sustentaculum tali:
• Projects medially and supports
the neck of talus.
• FHL passes beneath it .
• Deltoid and talocalcaneal
ligament connect it to the talus
• Clinical significance :
contained in the
anteromedial
fragment, which remains
"constant" due to medial
talocalcaneal and
interosseous ligaments
7. 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.
8. Anterior process fracture
• Inversion “sprain”
• Frequently missed
• Most are small: treat like
sprain
• Large/displaced: ORIF
11. Sustentacular fracture
• May alter ST jt.
mechanics
• Most small/
nondisplaced:
─ Non-operative
• Large/ displaced
─ ORIF (med.
approach)
─ Buttress plate
13. Mechanism of injury
• High energy: Axial load
─ MVA, fall
Lateral process of talus acts as
wedge
• Oblique shear
1ry # line 2 fragments:
-- Superomedial (constant)
fragment.
-- Superolateral fragment>(intra-
articular aspect through post
facet)
2ry # line dectates whether
there is joint depression or tongue-
type fracture
15. • 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
16. IMAGING: plain films
Standard Views
1. Lateral
2. Broden’s
3. Axial
• Scan other
regions
- Lumbar spine?
- Contra lateral side?
- Knees?
19. Broden’s view
• Positioning
– 20° IR view (mortise)
– 10°-40° plantar flex
Demonstrating the
articular surface of the
posterior facet.
20. 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.
26. Associated injuries
– Extension into the calcaneocuboid joint occurs in
63%
– Vertebral injuries in 10%
– Contralateral calcaneus in 10%
– Compartment syndrome 2-10%
27. Principles of treatment
1) 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
30. 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
31. 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
32. • 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%).
33. 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
34. 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
35. Indications for ORIF
• Displaced intra-articular fractures involving the
posterior facet.
• Anterior process of the calcaneus fractures with
more than 25% involvement of the calcaneocuboid
articulation.
• Displaced fractures of the calcaneal tuberosity.
• Fracture-dislocations of the calcaneus.
• Selected open fractures of the calcaneus
54. Primary Fusion
• Sanders type IV or
severe cartilage injury
• ORIF calcaneus, debride
cartilage, and fuse ST
joint
55. • 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.
56. Complications
Malunion
Varus hindfoot
Shortened foot = short
lever arm
Peroneal
impingement/
dislocation
Shoewear problems
Valgus>varus with
surgical
60. 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)
Hinweis der Redaktion
articular surfaces are located on the dorsal aspect of its anterior half
Post half –achilles
The plantar fascia originates from the medial and lateral processes located on the plantar aspect of the tuberosity
Sinus tarsi =interossseous sulcus(calcaneal sulcus)+talar sulcus
Sinus tarsi =calcaneal interosseous sulcus+talar sulcus
Iry # line 2 fragments
2ry # line 3 fragments
only if the entire facet is separated from the sustentaculum and depressed IA fractures show
a loss in the height of the posterior facet
a decrease in the angle of Bohler
an increase in the angle of Gissane
If only the lateral half of the posterior facet is fractured and displaced
a split in the articular surface will be seen as a double density
Bohler's and Gissane's angles may appear normal
The articular surface can be found within the body of the calcaneus, usually rotated plantarly up to 90o in relation to the remainder of the subtalar joint.
====30o semi-coronal
ST joint
Heel width/ shortening
Lateral wall “blowout”
Peroneal impingement or dislocation
Axial—CC joint
Sagit---similar to lat
3 frac lines devides the post facet into …..
Type 1…any fract line non displaced < 2mm irrespective of the number of lines
Type 2.. 2 part fract of post facet
Tyoe 3.. 3 part fract with depression of central fragment
=== Can’t restore articular surface
=== joysticks, small elevators, cannulated screws
=== anatomic reduction of the articular facets; reconstitution of hindfoot height, width, and length realignment of the tuberosity to appropriate axial alignment.
Swedish study JBJS 2013
wrinkle test is done by bringing the foot from the plantarflexed position (A) into dorsiflexion and observing the wrinkles (B) that form on the lateral side of the ankle and foot.
2 cm proximal to the tip of the lateral malleolus, at the lateral edge of the Achilles tendon, and is continued down toward the plantar surface of the heel then curved anteriorly toward the CC joint
full thickness flap is then developed by raising the corner of the incision subperiosteally
Avoid use of retractors earlier will tear the skin away from the periosteum, which could potentially cause late necrosis of the skin.
With continued dissection, the calcaneofibular ligament is encountered and resected from the calcaneus; this will expose the peroneal tendons and their inferior sheath at the level of the peroneal tubercle
Retract distal aspect of peroneal tendons and skin flab by 3 wires(fibula talar neck and cuboid).. Depressed lat fragment is visulaized
The exposed corner of the calcaneal tuberosity is then predrilled and a short Schantz pin is screwed into place. Using the pin, the heel is manipulated and distracted into varus, which disimpacts the fracture and makes the edge of the fragment more visible
