Calcaneus Fracture

Calcaneus Fractures

Anthony J Longo M.D. University of Texas Medical Branch

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Introduction „ „ „ „ „ „

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Most frequently fractured tarsal bone Sixty % of all tarsal fractures and 1-2% of all fractures Seventy-five% are intra-articular 10% are Bilateral Seventy % occur in the work place Majority occur in men age 25-45

Introduction „

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Treatment is controversial, with mixed outcomes for both surgical and nonsurgical management. Very severe injury, this was recognized early Initially all were treated nonsurgically. Initial surgical treatment was a primary subtalar fusion

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Second surgical method was closed reduction and pins with plaster Continue to have problems with morning stiffness, subtalar motion and long term running

Anatomy „ „

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Largest tarsal bone Calcaneus has been described as being like an egg Three articular facets Posterior, Middle and Anterior All articulate with the talus

Anatomy „

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Lateral anatomy is important because it is exposed during the most common surgical approach Lateral process of the tuberosity, origin of the plantar fascia Peroneal trochlea View of the posterior facet

Mechanism of injury „

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Essex-Lopresti - described two basic fracture types: joint depressed and tongue type. Axial compression with an oblique primary fracture line. Anterior-lateral superior to posteriormedial inferior Involving some portion of the posterior facet Lateral process acts as a wedge

Mechanism

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Fracture is caused by a shearing force

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The posterior tuberosity is lateral to the mechanical axis of the leg

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This primary fracture line divides the calcaneus into a sustenaculum piece and a tuberosity piece.

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The secondary fracture line determines joint depression versus tongue type

Joint Depression „

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Secondary fracture line runs superior from the primary fracture line and exits behind the posterior facet

Tongue type „

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Secondary fracture line runs posterior to the primary fracture line and exits out the back of the tuberosity

Physical Exam

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Heel appears shorter and wider and at times in a varus position

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Sural nerve injury is common

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High incidence of associated injures

Physical Examination „

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Significant swelling with rapid onset of fracture blisters and ecchymosis to the heel and arch

Associated injuries

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70% of calcaneus fractures have an associated injury

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L spine 10% (3-12%)

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Ipsilateral lower extremity fracture 10%

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Compartment syndrome 10%

Radiographic Evaluation

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Plain films

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Lateral of the foot and ankle

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Harris axial view

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Broden View

Lateral of the Calcaneus

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Bohler angle

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Insertion of a line from posterior tuberosity to the posterior facet and anterior process to the posterior facet

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25-40 degrees

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Crucial angle of Gissane

Broden’s View

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Evaluates reduction of the posterior facet

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IR foot to 45 degrees

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Angle the x-ray beam vertically toward the horizontal in 10 degree increments form 10-40 degrees

Broden’s View

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Harris View „

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Passively dorsiflex the ankle to achieve a tangential radiograph across the plantar aspect of the heel

CT Scan „ „ „ „ „

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Coronal and axial views Commonly saggital reconstructions Three dimensional reconstructions are available Knee flexed at 90 degrees and foot flat on the table Both feet simultaneously

Classification based on Plain Radiographs

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Essex Lopresti 1950

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Rowe in 1963 further subdivided into comminuted and those that were not

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Soeur and Remy – 1975 nonthalamic and thalamic- subdivided in to vertical compression and shearing and compression

Classification based on CT Scans „

Crosby-Fitzgibbons – 1990

– Type I – nondisplaced – Type II – displacement of posterior facet – Type III – comminuted intraarticular fx

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Sanders – 1993

– Type I nondiplaced – Type II 2 intraarticular fragments subtype into A/B/C – Type III 3 intraarticular fragments – Type IV 4 fracture fragments

Sanders Classification „

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choose the coronal CT image that shows the posterior facet in widest profile mark two vertical lines to divide the posterior facet into three equal sections final line marks the vertical border of the sustentaculum

Treatment Options

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Controversial

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Best surgical outcomes are in Sanders type II and tongue type

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Poorer outcome associated with male patients, men, overweight, and workman compensation cases

Surgical Techniques „

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Multiple approaches described including medial, lateral, combined, sinus tarsi, and extensile lateral Extensile lateral approach in the most preferred

Considerations

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Soft tissue swelling

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Initially treat in a bulky Jones splint

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Goal of surgery is anatomic reduction of posterior facet and the calcaneocuboid joint

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Bone grafting, also controversial, some studies show no benefit with lateral plate

Surgical technique „ „ „

Slide 26

Positioning - Unilateral, then lateral decubitus; Bilateral, then prone. No touch technique with the skin, K wires in the talar neck, fibula and cuboid Stieman pin in the posterior tuberosity to indirectly reduce posterior facet

Surgical Technique „

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Anterior calcaneus and posterior facet reduced and held with k wires Low profile plate to hold reduction C-arm with flouroscopic Broden’s view to visualize reduction

Post operative care „ „ „ „ „

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Immobilize for 3 weeks, until wound has healed Early ROM, some recommend out of splint at week one Nonweight bearing 10-12 weeks, trabecula bone formation on plain films Progression to full weight bearing without assistive devices Maximal medical improvement at 18 months

Primary arthrodesis Recommended for some Sanders type IV fractures „ Poor results in type IV with both surgical and nonsurgical treatment „ Sanders et al reported only one good to excellent result in 11 type IV fractures treated with ORIF „

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Primary arthrodesis „ „

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Similar to ORIF, restoration of anatomy Removal of the cartilage for the undersurface of the talus and remnants of the posterior facet. Iliac crest bone grafting versus allograft Fusion with large fully threaded canulated screw from the posterior facet into the talus 16 weeks or longer before complete fusion