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Calcaneal fractures

  1. 1. Department of Orthopaedics AFMC, Pune PG SEMINAR CALCANEAL FRACTURES Maj Rohit Vikas Resident
  2. 2. INTRODUCTION Most common tarsal bone to be fractured 1%–2% of all fractures Typically occur because of axial loading
  4. 4. ANATOMY A relatively thin cortex. Traction trabeculae Compression trabeculae “Neutral triangle” Thalamic portion The cortical bone just inferior to the posterior articular facet is condensed to approximately 1 cm Boehler angle is normally 20°–40° Critical Angle of Gissane Thickening of the cortex is also seen in the regions of the sustentaculum tali, medial wall, and critical angle of Gissane.
  5. 5. ANATOMY 4 articulating surfaces, three superior and one anterior. The superior surfaces articulate with the talus. Posterior facet Separated from the middle and anterior facets by a groove that runs posteromedially, known as the calcaneal sulcus . The canal formed between the calcaneal sulcus and the talus is called the sinus tarsi. Middle calcaneal facet Supported by the sustentaculum tali and articulates with the middle facet of the talus. Anterior calcaneal facet Articulates with the anterior talar facet and is supported by the calcaneal beak. The triangular anterior surface of the calcaneus articulates with the cuboid.
  6. 6. ANATOMY The lateral surface Flat and subcutaneous Peroneal tubercle for the attachment of the calcaneofibular ligament centrally. The lateral talocalcaneal ligament attaches antero-superiorly to the peroneal tubercle
  7. 7. ANATOMY Medially, the talus is held to the calcaneus firmly by the interosseous ligament and the thick medial talocalcaneal ligaments . The sustentaculum tali The groove inferior to it transmits the FHL tendon.
  8. 8. ANATOMY The neurovascular bundle runs adjacent to the medial border of the calcaneus. The neurovascular bundle may be injured during trauma or during surgery by the reduction of the sustentacular fragment, which is a key element in the surgical management of calcaneal fractures
  9. 9. MECHANISM OF FRACTURE Primary fracture line Extends obliquely from the posteromedial to the The shear fracture (black) anterolateral calcaneus. Produces a posterolateral segment consisting of tuberosity lateral wall variable portion of the post. articular surface. The anteromedial segment consists of anterior process, medial sustentaculum, the remaining medial aspect of the post articular surface
  10. 10. MECHANISM OF FRACTURE Secondary fracture lines The compression fracture Can extend into the calcaneocuboid joint separating the anterior process into Tongue – red anteromedial and anterolateral Jt depression - blue fragments Can extend medially separating the sustentacular fragment from the anteromedial fragment .
  11. 11. MECHANISM OF FRACTURE Secondary fracture lines – Constant fragment A lateral fragment of the posterior articular surface characterizes joint depression patterns and is produced by extension of a secondary fracture line to the cranial portion of the tuberosity. Because of the strong ligamentous attachments between the talus and the sustentacular fragment, this fragment is “constant”, and usually in a relatively standard position. The location of this fragment and the density of bone in this area are critical for reduction and fixation of calcaneal fractures.
  12. 12. Vascular supply to lateral skin Lateral calcaneal artery, the lateral hindfoot artery, and the lateral tarsal artery contribute to the vascularity of the lateral skin and soft tissues of the foot. The lateral calcaneal artery definitely is responsible for the majority of the blood supply to the corner of the flap in the extensile lateral approach
  14. 14. CLINICAL EVALUATION HISTORY Mechanism of injury Fall from ht RTA Associated Injuries 10% - spinal #, usually Dorsolumbar junction Head injury Other injury in extremities Bilateral Calcaneal fractures COMORBIDITIES Diabetes Peripheral Vascular Disease
  17. 17. X RAYS Lateral Hind foot AP Foot Harris heel view Broden’s Views Ankle AP, Lateral, Mortise Thoracolumbar spine AP, Lateral
  18. 18. X RAYS Lateral Hind foot Confirms diagnosis of calcaneal # Crucial angle of Gissane Tuber angle of Boehler Intraarticular # Loss of ht of post facet Reduced Boehler angle Increased Gissane angle Joint Depression vs Tongue type
  19. 19. X RAYS AP foot Less informative Calcaneocuboid jt involvement
  20. 20. X RAYS Harris Axial View Visualization of jt surface Loss of ht Increased width Angulation of tuberosity fragment May be difficult to obtain due to pain
  21. 21. X RAYS Broden’s View Leg Internal rotated 20° Foot Neutral Beam directed 10/20/30/40° towards head Centered over lateral malleolus Demonstrates articular surface of post facet
  22. 22. X RAYS Broden’s View
  23. 23. X RAYS Casanova's fracture Lover’s Fracture Jumper’s Fracture
  24. 24. X RAYS
  25. 25. X RAYS Classification of Essex-Lopresti
  26. 26. X RAYS Classification of Essex-Lopresti
  27. 27. CT SCAN Coronal CT image s Shear fracture line (arrow) separating the anteromedial or sustentacular fragment (S) and the posterolateral or tuberosity fragment (T). The articulation of the posterior facet with the talus is maintained medially and is more angulated laterally. Coronal images reveal Articular surface of the post facet, Sustentaculum, Shape of the heel, Position of the peroneal and FHL tendons.
  28. 28. CT SCAN Sagittal image of the same patient Depression of the tuberosity fragment (T)
  29. 29. CT SCAN Transverse (axial) images Calcaneocuboid joint, Anteroinferior aspect of the post facet Sustentaculum.
  30. 30. CT SCAN Axial (a) and coronal (b) CT scans of a calcaneal fracture, identifying the lateral joint fragment (LJF), the sustentacular fragment (SF), and the tuberosity or body fragment (TF). There is lateral dislocation, impaction, and displacement at the articular surface.
  34. 34. INTRA-ARTICULAR FRACTURES Primary and secondary fracture lines, primary same for both types Secondary Fracture line determines type
  35. 35. INTRA-ARTICULAR FRACTURES Sanders classification Type I - Nondisplaced Types II and III - have two or three fragments, respectively, which are then subdivided, depending on the medial or lateral position of the primary fracture line. Type IV - severely comminuted
  38. 38. EXTRA ARTICULAR FRACTURES Vertical Tuberosity # Medial Process # Anterior Avulsion # at EDB Process # attachment
  39. 39. ANTERIOR PROCESS FRACTURE Forced inversion or forced abduction & dorsiflexion Best seen on oblique views Usually treated with protected weight bearing. If involving more than 25% of calcaneocuboid articular surface are treated with ORIF Complication includes non-union.
  41. 41. CALCANEAL BODY FRACTURE Due to axial loading Associated with injuries to appendicular and axial skeleton Better prognosis than intraarticular fractures Usually managed conservatively and heal normally
  42. 42. SUSTANTICULUM TALI FRACTURE Due to axial loading and inversion Usually treated conservatively with non-weight bearing or fixed by screw Associated with FHL tendon injury Nonunion is common.
  43. 43. CALCANEAL TUBEROSITY FRACTURE Commonly occur in elderly porotic patients due to avulsion of tendo achillis Initial immobilization in slight equinus position followed by urgent ORIF
  45. 45. MEDIAL PROCESS FRACTURE Abductor hallucis, flexor digitorum and plantar fascia attach to medial process of calcaneus Due to fall from height Treated with ORIF.
  47. 47. HISTORICAL TREATMENT 1908, Cotton and Wilson ORIF of a calcaneal fracture contra-indicated Recommended closed treatment with use of a medially placed sandbag, a laterally placed felt pad, and a hammer to reduce the lateral wall and “reimpact” the fracture. 1920s Abandoned the treatment of acute fractures altogether and had turned instead to the treatment of healed malunions
  48. 48. HISTORICAL TREATMENT 1931, Böhler Advocated open reduction Technical problems associated with operative treatment Infection, malunion, and nonunion, and the possible need for amputation 1935, Conn Delayed primary triple arthrodesis 1943, Gallie Subtalar arthrodesis as definitive treatment but only for fractures that had healed. This technique became standard for healed, malunited calcaneal fractures.
  49. 49. HISTORICAL TREATMENT 1948, Palmer Dissatisfied with both nonoperative and late treatment Described the operative treatment of acute displaced intra-articular calcaneal #s Standard lateral Kocher approach to reduce the joint Holding up the fragment with bone graft He stated that his patients did well and that many returned to work. 1952, Essex-Lopresti Reported similar findings. Tongue or Joint-depression fragment. Tongue-type # were reduced with percutaneous leverage Joint-depression # necessitated formal ORIF.
  50. 50. HISTORICAL TREATMENT In the last twenty years Better anesthesia, Antibiotics, AO/ASIF principles of internal fixation, Computed tomography Fluoroscopy Good outcomes with use of operative intervention Treatment remains challenging
  51. 51. NON OPERATIVE TREATMENT Specific indications for nonoperative treatment Undisplaced/ minimally displaced Extra articular # Nondisplaced Intra articular # (Sander’s Type I) Anterior Process # with < 25% involvement of Calcaneocuboid jt. Severe peripheral vascular disease Insulin-dependent diabetes Other medical problems that contraindicate an operation. Elderly, household ambulators Specific situations in which nonoperative treatment may be required because an injury precludes early operative intervention Severe open fracture Life-threatening injury Soft-tissue compromise Blistering Massive, prolonged edema
  52. 52. NON OPERATIVE TREATMENT Early range-of-motion exercises Non-weight-bearing for approx 03 months The foot is placed in a boot, locked in neutral flexion to prevent equinus contracture. Elastic compression stocking to minimize dependent edema.
  53. 53. NON OPERATIVE TREATMENT Reserved for nondisplaced (Sanders type-I) fractures. Displaced intra-articular fracture Nonop treatment offers little chance of a return to normal function because a calcaneal malunion will develop. Reduction of the articular surface never is obtained Heel remains shortened and widened Talus remains dorsiflexed in the ankle mortise Lateral wall causes impingement and binding of the peroneal tendons.
  54. 54. OPERATIVE TREATMENT Displaced Intra articular # involving post facet (Sander’s II, III) Anterior Process # with > 25% calcaneocuboid jt involvement Displaced # of calcaneal tuberosity Fracture-Dislocation calcaneum Selected Open fractures Open type I Delayed ORIF Open Type II with Medial wound Delayed ORIF Open Type II with Non medial wound External Fixation/ Percuatneous Fixation Open Type III A External Fixation/ Percuatneous Fixation
  55. 55. OPERATIVE OPTIONS ORIF Closed Reduction/ Int. Fixation ─ Percutaneous ─ Arthroscopic assisted External Fixation Primary Fusion
  56. 56. ORIF Should be performed within the first 03 wks after the injury, before early consolidation of the fracture. Should not be attempted until after swelling in the foot and ankle has markedly decreased. Wrinkle test Methods to reduce edema Elevation Jones dressing with a posterior splint If the swelling is decreasing, a boot locked in neutral flexion Elastic compression stocking Use of a foot pump Pre op 2D CT Scan
  57. 57. ORIF 24-year old man Sanders type 2, Tongue-type fracture Displaced. Böhler’s angle = 8 degrees. No medical contraindications for surgery.
  58. 58. ORIF The axial view Large “constant” sustentacular fragment. The fracture splits the middle of the posterior facet, and it is displaced. The “constant” fragment is the stable medial calcaneal building block which allows lag fixation. This image shows no varus or valgus of the hindfoot.
  59. 59. ORIF CT Scan -The coronal view Split extending into the posterior facet, which is displaced. Loss of height Comminution.
  60. 60. ORIF CT Scan – The axial view “Constant” fragment Intraarticular incongruency of the posterior facet. This view allows assessment of the anteromedial (sustentaculum tali) fragment, its integrity and its dimension. This fracture is a Sanders type 2 fracture which is on the simple end of the calcaneal fracture spectrum.
  61. 61. ORIF Typical positions of the five standard fragments that need reduction. Step-by-step process for the reduction maneuver. Generally, one begins by identifying the “constant” fragment, i.e. the sustentacular fragment (4), which remains attached to the talus and does not displace. The reconstruction builds on this stable fragment and therefore one begins the reconstruction anteriorly and medially with this fragment and works simultaneously on the posterior (2) and lateral (3) articular fragments. Often necessary to apply traction to fragment 2 to restore the 3D shape of the os calcis. Once these are in place, one closes the lateral wall like a door, which is the final step of the reconstruction. Fragments are maintained temporarily with K-wires. The final step is the fixation.
  62. 62. ORIF Lateral decubitus / prone position Fluoroscopy Exsanguination Tourniquet inflated to 350 mm of Hg Extensile right-angled lateral incision Minimizes peroneal tendinitis Reduces devascularization of the anterior skin flap Preserves the sural nerve Seligson's lateral extensile approach
  63. 63. ORIF Standard extended lateral approach. The # line at the level of the angle of Gissane identified Usually, there is a small lateral wall fragment which should be preserved and reflected plantarwards. Thin lateral wall is lifted gently and retracted inferiorly to expose the articular # fragments buried within the body of the calcaneus. Haematoma evacuated
  64. 64. ORIF Reduction - Joystick placement Fracture lines are visualized and identified. Next, a Schanz screw is inserted into the posterior (or tuberosity) fragment (2) from lateral to medial, going through both cortices. It will serve as a joystick to aid in the reduction.
  65. 65. ORIF Reduction of the tuberosity fragment The next step is the reduction of the tuberosity fragment (2) to the “constant” medial sustentacular fragment (4). Once the fragment is reduced, it is held in position with 2 K- wires which are introduced in an anteroposterior superior direction from the posterior inferior aspect of the tuberosity. They are directed superiorly and anteriorly into the “constant” medial fragment (4)
  66. 66. ORIF Elevation of the lateral articular surface With the tuberosity (2) reduced to the “constant” piece (4), while ensuring that there is no varus of the hindfoot, one reduces now the lateral articular piece (3). It needs to be elevated in order to successfully reconstruct the articular surface, the posterior facet.
  67. 67. ORIF Preliminary Fixation Once reduced, it is supported with K-wires, which are introduced from the lateral side into the “constant” medial fragment. Keep in mind that K wires does not occupy the place judged best for the insertion of the subchondral lag screw(s) which will stabilize the articular surface. While the reduction and fixation proceeds, one must be careful at every step to make certain that the hindfoot remains in neutral, or in slight valgus, in the axial view. Varus of the hindfoot must be avoided.
  68. 68. ORIF Physiologic valgus With the patient in the lateral position, and working from the lateral side, there is a tendency for the hindfoot to fall into varus. Throughout the surgical maneuvers, the surgeon must check continuously that the hindfoot remains in valgus. By continuously checking and using K-wires as reduction tools and temporary fixation, physiologic valgus is maintained until the final reduction and fixation is obtained.
  69. 69. ORIF Fixation – Subchondral Lag screw Once the reduction of the articular surface is achieved, it is maintained with a subchondral lag screw which runs from lateral anteromedially into the “constant” medial subchondral fragment. Thus, when drilling the hole for the lag screw, the drill bit must be directed carefully in these three directions: a) Lateral to medial b) Posterior to anterior c) Cephalad to caudad In this way, the threaded portions of the screw will be directed into the strong medial sustentacular cortical bone.
  70. 70. ORIF Fixation – Subchondral Lag screw On the medial side is the neurovascular bundle which ends up frequently at the tip of the subchondral lag screw. If one allows the drill bit, or the screw, to protrude too far medially, one can damage the neurovascular bundle or FHL tendon.
  71. 71. ORIF Bone Deficiency The articular surface of the os calcis is impacted by the talus into the underlying cancellous bone. Once the articular fragments are disimpacted and elevated, varying degrees of void result. Studies show that bone graft is not necessary, yet some surgeons fill the void with bone substitute materials, and other surgeons choose to ignore the void and use locking plate fixation to maintain reductions.
  72. 72. ORIF Plate choice Depends upon the severity of calcaneal fracture type and the bone quality. Simple fracture patterns in good bone require simple lateral plating while complex fracture patterns with comminuted pieces may require adaptable plates or locking plates. This image shows a simple fracture reduced with multiple K- wires and lag screw in place, beneath the subchondral joint. A one-third tubular plate may be all that is required for a simple fracture in good bone.
  73. 73. ORIF Bone Substitute Calcium sulfate bone substitute filling the large void which is commonplace after fracture reduction. This bone substitute will be bioabsorbed over time. In the early phase (0-2 weeks) it may act to support bony anatomy before early soft callus replaces the filled void.
  74. 74. ORIF Post op CT The coronal view shows the joint surface to be reduced, height restored and surgical hardware is not into the joint. The cast is for temporary postoperative splinting.
  75. 75. ORIF Bone Substitute This drawing shows a similar situation, albeit fixation with a different calcaneal plate.
  76. 76. ORIF Lateral plate placement The distal corner of the soft-tissue incision for the lateral extended calcaneal approach is vulnerable to wound breakdown. Most calcaneal plates have at least some of their fixation points at this crucial apical wound.
  77. 77. ORIF Lateral plate placement This image shows the typical problem at the distal corner of the lateral extended calcaneal approach where a screw and plate are right beneath where the wound typically breaks down. This calcaneal incision has between 5 and 15 % incidence of wound breakdown regardless of where hardware is placed.
  78. 78. ORIF Lateral plate placement
  79. 79. ORIF Extremely comminuted # Fixation This is extremely difficult surgery. Decision making is controversial. Some surgeons favor primary fusion while others favor primary ORIF with later reconstruction, if required.
  80. 80. ORIF Post op CT This case shows final CT scans postoperatively with axial and coronal slices. The axial shows the lag screw going deeply into the sustentaculum tali, parallel to the subchondral surface, with the surface reduced. There is no varus malalignment.
  81. 81. ORIF Closure Two-level closure over a hemovac drain is standard. Subcutaneous - Absorbable stitch. Soft-tissue closure should be carefully performed so that there is advancement of the flap. There should be no excessive tension on the distal corner of the incision. Skin - Interrupted Allgöwer- Donati stitch. Skin should be apposed and not strangulated
  82. 82. ORIF
  83. 83. MINIMALLY INVASIVE FIXATION Especially for tongue type # Closed Reduction and Percutaneous Pinning Implant 6.5 mm Cannulated Screw Steinmann Pin
  84. 84. PRIMARY ARTHRODESIS Only for patients who have a Sanders type- IV highly comminuted intra-articular fracture. After restoration of the calcaneal body and the joint surface, the remaining cartilage is removed from both surfaces of the posterior facet and an autologous bone graft is used to perform an arthrodesis. Typically, a 6.5 to 8.0-mm cannulated cancellous-bone lag screw placed from the posterior tuberosity into the talar dome to stabilize the fusion. Non-weight-bearing BK cast for 03 months
  86. 86. COMPLICATIONS Compartment Syndrome Wound Dehiscence Calcaneal Osteomyelitis Problems Related to the Peroneal Tendons Tendinitis Dislocations Neurological Complications Nerve entrapment Cutaneous nerve injury RDS Malpositioning Of Tuberosity Of Superolateral fragment Calcaneal Malunion Arthritis Chronic Ankle pain Heel Exostoses Heel Pad pain
  87. 87. NEUROLOGICAL COMPLICATIONS Cutaneous Nerve Injury Most common neural problem associated with operative treatment Sural nerve is most commonly injured (Lateral approach) Calcaneal branch of the posterior tibial nerve (Medial approach) A neuroma or complete loss of sensation in the affected region Nonoperative treatment is advised. When a neuroma is painful, resection with burial of the stump into deep tissue. Nerve Entrapment Entrapment or compression of the posterior tibial nerve After nonoperative treatment, due to a malunited fracture. Pain in the medial aspect of the heel Paresthesias in the distribution of the posterior tibial nerve. A trial injection of a local anesthetic into the tarsal tunnel can assist in making the diagnosis. Electrodiagnostic studies Operative decompression of the posterior tibial nerve and its branches may provide relief.
  88. 88. NEUROLOGICAL COMPLICATIONS Reflex Sympathetic Dystrophy Occur regardless of the method of treatment Pain that is disproportionate to the extent of the injury Cold, clammy skin, Purplish discoloration Inability to tolerate anyone touching the foot Tibial nerve block does not relieve the symptoms Lumbar sympathetic block, thermogram, or bone scan may be performed to obtain a diagnosis. Intensive therapy such as massage, motion and manipulation, or weight-bearing if the fracture has healed. Multiple lumbar sympathetic nerve blocks and counseling. Unless a specific stimulus (for example, a prominent screw or a neuroma) is found to be causing the underlying pain, additional operative treatment should be avoided
  93. 93. LITERATURE REVIEW Displaced Intra-Articular Calcaneal Fractures Effect of operative treatment compared with nonoperative treatment on rate of union, complications, and functional outcome after intra-articular calcaneal # Among 20 relevant articles: 4 RCTs: O'Farrell 1993 Parmar 1993 Thordarson 1996 Buckley 2002 2 systematic reviews Randle 2000 Bridgman 2000 1 abstract of economic analysis study Brauer 2004 OTA Meeting Bajammal et al, JOT 2005
  94. 94. LITERATURE REVIEW Displaced Intra-Articular Calcaneal Fractures Effect of operative treatment compared with nonoperative treatment on rate of union, complications, and functional outcome after intra-articular calcaneal # Evidence from RCTs with methodological limitations revealed: No significant difference in pain and functional outcome between the two groups Operative treatment maybe superior to nonoperative treatment concerning return to work and the ability to wear the same shoes. Bajammal et al, JOT 2005
  95. 95. LITERATURE REVIEW Displaced Intra-Articular Calcaneal Fractures a. Potential benefit of operative treatment in women younger males higher Böhler angle light workload single, simple displaced intra-articular fracture. b. Potential benefit of nonoperative treatment in: 50 years or older Males heavy workload (Buckley et al, 2002 JBJS Am),
  96. 96. LITERATURE REVIEW Displaced Intra-Articular Calcaneal Fractures Variables Predicting Late Subtalar Fusion Amount of initial injury involved with the calcaneal # is the primary prognostic determinant of long-term patient outcome. A distinct patient group with a displaced intra-articular calcaneal who are at high risk of subtalar fusion, These include: Male Heavy labor work Böhler angle less than 0° (10 times) Sanders-type IV calcaneal fractures (5.5 times ) Initial treatment was nonoperative (6 times) Initial ORIF of patients with displaced intra-articular calcaneal # minimized the likelihood that subtalar fusion would be required. Csizy, Marcel; Buckley, Richard
  97. 97. LITERATURE REVIEW Bilateral Calcaneal Fractures Operative versus nonoperative treatment Pts sustaining bilateral calcaneal # are very similar to those in whom the injury is confined to one side. Neither objective nor subjective functional outcomes are significantly improved following operative intervention. However, careful operative pt selection will minimize complications and lessen need for late subtalar arthrodesis. Dr. R. Buckley