calcaneal fractures

1. 29TH Aug 2015
SITOCON

2. “The man who breaks his heel bone is done”
---Cotton (1912)
“The results of crush fractures of the os calcis
are rotten”
---Bankart (1942)

4. Calcaneal fractures
- 2% of all fractures
- 60-75% of them are
displaced intraarticular fractures
- 10% have associated spine fractures
- 26% have other extremity injuries
-90% occur in young men(21 to 45 yrs)

5. Posterior Facet
Anterior and
Middle Facets

8. Mechanism of Injury
•High energy
─ MVA
─ fall from a height
•Lateral process of talus acts
as wedge
•Impaction fracture

9. CLINICAL FEATURES
C/O pain swelling not able to bear weight
On Examination–
>marked swelling
>ecchymosis
blisters
>tenderness & movements restricted
>other foot and spine also should examined

10. Initial Evaluation
• Thorough primary,
secondary, tertiary survey
• Bilateral injuries
spine injuries
other extremity fractures
can occur in 10 – 15%
• Routine Lumbar spine films

11. Exam
• Note condition of skin
• Open fractures
• Fracture Blisters
• Threatened skin (pressure
from displaced fracture fragments)
• Neurovascular exam

12. RADIOGRAPHIC EXAMINATION
Xrays ---foot
a)AP
b)AXIAL
c)LATERAL
d)BRODEN’S VIEW
OTHER X-RAYS--- >ANKLE JOINT
>OPPOSITE FOOT
>DORSOLUMBAR SPINE
C.T SCAN ----for pathoanatomy of intra-articular
fracture

13. Displaced Posterior Facet
Flattened Bohler’s Angle
Bohler’s Angle
Xray measurements
Bohler’s angle
• Normal 25-40 degrees
• Severity (lower Bohler’s
angle) correlates with
outcome

14. Xray Measurements
• Critical Angle of Gissane
• Normal 120-145 degrees
• Change in angle indicates change in relationship between
posterior, medial, and anterior facets
F
Critical Angle of Gissane

15. 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

16. Broden’s View
Helpful intra-op
• Posterior facet
• Check intraarticular
displacement
• Positioning
A. 20° IR view (mortise)
B. 10°- 40° plantar

17. Broden’s View
• Posterior facet

18. CT Scan and 3D
Axial Coronal Sagital

19. Pathoanatomy
•
• Primary
fracture line
• Constant
fragment

20. Pathoanatomy
1
2
3
• Secondary
fracture lines
• Extend posteriorly
through tuberosity or
into anterior process
• Create 3 +
parts

21. Essex-Lopresti
• Described two distinct fracture patterns
Joint-Depression Tongue-Type
Posterior Tuberosity NOT
attached to Posterior Facet
Posterior Tuberosity attached
to Posterior Facet

22. Not amenable to
Essex-Lopresti
percutaneous reduction
technique
ESSEX-LOPRESTI CLASSIFICTION
JOINT DEPRESSION TYPE

23. Essex-Lopresti Classification:
Tongue Type
B
May be amenable to
Essex-Lopresti
percutaneous
reduction technique

24. 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

25. Sander’s

26. Sanders Classification
A B C
A B C
Sanders R, Fortin P, DiPasquale A, et al. Operative treatment in 120 displaced intra-articular calcaneal fractures.
Results using a prognostic computed tomographic scan classification. Clin Orthop 1993;290:87– 95

27. Classification
• Intra-articular fractures 60-75%
• Extra-articular fractures 25-30%
Anterior process fractures.
 Avulsion fractures of the tuberosity.
Medial process fractures.
Sustentaculum tali
and body fractures.

28. Anterior process fracture
•Inversion “sprain”
•Frequently missed
•Most are small: treat like
sprain
•Large/displaced: ORIF

29. Tuberosity Fracture:
•Fall/MVA
•Usually non-operative
(displacement)
─ Swelling control
─ Early ROM

30. Tuberosity avulsion fractures
•Achilles avulsion
•Wound problems
•Surgical urgency
─ Lag screws or
tension band

31. Sustentaculum Fracture:
•Most small/ nondisplaced:
─ Non-operative
•Large/ displaced
─ ORIF (med. approach)
─ Buttress plate

32. Goals of Treatment
•Restore Anatomy
•Restore Function

33. OPERATIVE vs. NON-OP TREATMENT
 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. Treatment : Non-Operative
• Non- / minimally displaced fractures (<2mm intra-
articular displacement)
• Patients with significant risk factors for complications
with operative treatment
• NWB X 12 weeks
• Early ROM of ankle, hindfoot and midfoot
• Prevent equinus contracture (splint or Fx Brace)

35. Non-op Treatment: Complications
Malunion

36. Timing of Surgery
• Wrinkle Test
• when the patient
dorsiflexes and everts the
foot
• If skin wrinkling is seen
no edema is present,
the test is positive
patient is ready for
surgery

37. Indications for ORIF
• Displaced intra-articular fractures
• Displaced fractures of calcaneal tuberosity
• Fracture-dislocations of calcaneus
• Selected open fractures of calcaneus

38. Operative Treatment via Extended Lateral
Approach: Contraindications
•Diabetes (relative)
•Vascular insufficiency
•Smoker (relative)
•Severe swelling
•Open fractures (relative)
•Neuropathic
•Non-compliant pt.
•In-experienced
surgeon

39. Positioning

40. Approaches
Extensile Lateral (ELA)
Most common
Sinus Tarsi
For selected fractures and situations
s

41. ORIF: Extended Lateral Approach
•
• “No touch” technique • Lateral wall removed
Full thickness skin incision with periosteal flap
Watch sural nerve at proximal and distal extent of incision
Lateral wall must be removed before reduction
is able to be performed anteriorly

42. ORIF: Extended Lateral Approach
• Schanz pin to
manipulate tuberosity
• Clean out fracture
• Disimpact
sustentacular fragment

43. ORIF: Extended Lateral Approach
•Use K-wires
•Reduce post. facet to
sustentaculum- ant.
process

44. ORIF: Lateral Approach
•Provisionally reduce
tuberosity fragment to
sustentacular complex
•Pin with K-wires through
stab incisions in posterio-
inferior heel

45. ORIF: Extended Lateral Approach
•Fine tune tuberosity
reduction to
sustentacular complex
-- Restore height and
length
-- Restore valgus
-- Medial translation
•Pin reduced
tuberosity

46. Bone Graft
•No benefit with bone
grafting
•Bone graft substitute (i.e.
Norian SRS) may allow for
earlier weight-bearing

47. Fixation Options

48. ORIF: Extended Lateral Approach
•Replace lateral wall
•Apply plate and screws
•Recheck radiographs
• Alignment
• Subtalar-/ CC joint
• Hardware position
• Screw length

49. •Check peroneal tendons
•Drain
•Layered closure
1. Periosteum/SQ one layer
2. Skin
•Atraumatic technique
•Advance flap toward apex
•Allgower-Donati sutures
•Splint in neutral

50. Operative Treatment
Complications
• Wound problems
• Apical wound necrosis
• Infection

51. Sinus Tarsi Approach
•Incision from tip of
fibula across sinus tarsi
to anterior process
•Retract sural nerve and
peroneal tendons
plantar
Branch of Sural Nerve
For fractures with wound problems
prohibiting extended lateral approach

52. ST Approach (“Ollier’s”)
•Reduce anterior
process
•Mobilize and reduce
tuberosity
•Reduce Subtalar
joint

53. ST Approach
•Arthroscope (placed
through the incision)
can be helpful to
assure anatomic
joint reduction

54. ST Approach: Fixation
•Small screw/ small plate to
span angle of Gissane
•Medial Wall Screw
•“Articular Support Screw”
•Lateral Column Screw

55. Surgery: Percutaneous
•Essex-Lopresti
maneuver
•Tongue type fractures
Essex-Lopresti, Clin Orthop, 290: 3-16, 1993

56. •
Surgery: Percutaneous
Essex-Lopresti, Clin Orthop, 290: 3-16, 1993

57. Open Fractures
• Up to 10% in some series
• Most commonly medial wound
• Staged management –ext fixation/K wires
& skin cover medially
• High rate (29%) of soft tissue complications

58. Open Fractures
C D
Indirect reduction and percutaneous stabilization

59. Complications
 Malunion
 Varus
 Shortened foot
 Peroneal impingement
 Shoewear problems

60. Complications
•Stiffness
─ Prevention (early ROM)
•Subtalar arthritis
─ NSAIDs
─ Subtalar fusion

61. Ilizarov
•Minimally invasive
•Indirect reduction
•Learning curve
•Immediate weightbearing

62. CALCANAIL

63. CALCANAIL

64. Surgery: Primary Fusion
•Articular
comminution
•Severe cartilage
injury
•ORIF calcaneus,
debride cartilage,
and fuse

65. Postoperative Care
• Elevate, splint
• Sutures out at 2-3 wks.
• Fracture boot to prevent
equinus contracture
• Early motion ankle and foot
• NWB for 12 weeks

66. SUMMARY
•High energy injuries
•Risk for long term morbidity
•ORIF can give good, reproducible results if
complications are avoided
•Individualize treatment