Fractures of the Calcaneus

Transcription

1 Fractures of the Calcaneus Diagnosis and Treatment CARL E. HORN, M.D., Sacramento Good lateral, Anthonsen oblique, anterior-posterior, and axial roentgenograms are necessary to define the extent of fractures of the calcaneus. Roentgenograms of the lumbar spine, including the thoracolumbar junction, are recommended whenever a fall has occurred sufficient to fracture the calcaneus. The great majority of calcaneal fractures are compression shearing fractures. Significant disruption of articular surfaces and spreading of the body beneath the fibula are major surgical problems and require careful treatment. In a series of 50 fractures treated by four methods, open reduction with stabilization by bone grafts, followed by active motion at six to eight weeks, gave the best results. SUCCESSFUL TREATMENT of fractures of the calcaneus must begin with a positive attitude. One must not accept the cliche that comminuted calcaneal fractures usually require triple arthrodesis. A careful evaluation of the patient and of the type of fracture is required. Knowledge of the anatomy and function of the three components of the subtalar joint, the calcaneocuboid joint and the talonavicular joint, which sometimes has an associated subluxation, is, of course, essential to a reasonably accurate appraisal of the local problem. Problems in Diagnosis Such an appraisal is frequently difficult due to the problem in obtaining adequate roentgen visualization. Multiple projections, including the lateral, Anthonsen oblique, anterior-posterior and axial roentgenograms are essential for adequate analysis of the initial situation. A description of the posi- Reprint requests to: 5301 F Street, Sacramento tioning involved for the various roentgen projections has been described by a number of observers, including Wilson,'4 Thompson and Friesen,12 and Warrick and Bremner." Wilson pointed out the variation in the lateral roentgen projection between the position of inversion and eversion of the heel. The Anthonsen oblique usually brings out some details not clearly seen in the lateral, as has been noted by Schottstaedt" (See Figures 1 and 2). Good details in the anterior-posterior projection reveal: (1) The amount of lateral spread of the lateral fragments; (2) Whether the calcaneocuboid joint is involved by fracture; (3) Whether there is talonavicular subluxation (See Figure 3). Good detail in the axial view shows the amount of lateral spread of the fractures and also the type CALIFORNIA MEDICINE 209

2 of fractures involving the posterior calcaneal facet and sometimes the sustentaculum tali (Figure 4). Additional fractures are frequently found at open operation despite the most careful preoperative roentgen examinations. Lumbar spine roentgenograms are taken routinely whether or not the patient has any low back complaints. This routine has been of great value in detecting mild compression fractures of the bodies of the lumbar and lower thoracic vertebrae (Figure 5). In addition, establishment of a baseline as to the presence or absence of degenerative disease of the spine, anomalies and the like has been very helpful in the evaluation of subsequent low back complaints which may have medicolegal implications. Warrick and Bremner"3 developed an excellent atlas in color illustrating various types of calcaneal fracture. This atlas, of course, cannot be allinclusive, for an infinite number of variations is possible. In addition, they classified three hundred fractures (Table 1). Figure 6, which was drawn using pictures in the Warrick and Bremner atlas Figure 3.-Anterior-posterior view showing talonavicular subluxation. Figure 1.-Lateral view in case of fracture of calcaneus in 63-year-old man. Figure 2.-Anthonsen oblique view (same patient as in Figure 1) bringing out details not seen in lateral view..- v... Figure 4.-Axial view showing amount of lateral spread. 210 MARCH 1968 * 108 * 3

3 as models, illustrates the various kinds of fractures listed in Table 1. Methods of Treatment Obviously, the great range in the severity of the fractures with absence or presence of involvement of weight-bearing joints demands careful selection of treatment. Group 1 fractures may be treated initially by elevation, compression dressings and ice bags, followed by either active motion or protected weight-bearing in a few days if there are no other injuries. These fractures are usually no problem and frequently the patient may be treated in the office or as an out-patient. Wide divergence of opinion exists as to treatment of Group II fractures. Methods of treatment that have been recommended for Group II calcaneal fractures are as follows: * Conservative treatment as described above for Group I fractures.' * Further comminution followed by molding as advocated by Cotton.5.~~~~~~~~~~~~~~~~~~~~~F N Figur 5,Ltea viwo h pn a hhrclm bajucin suc assol eincue nallma sine sre..iil_ * Various types of pin reduction, traction, and fixation techniques with or without early motion.2'3 * Primary manipulative reduction with skeletal traction followed in five weeks by triple arthrodesis.4 * Primary subtalar arthrodesis.6 * Primary triple arthrodesis.'2 * Total excision of the calcaneus.i0 * Open reduction with pin or screw fixation. * Open reduction with bone grafts.7'8'9 Some light is shed on the problem by a careful consideration of each method of treatment. The goals of treatment should be a painless foot, nor- TABLE 1.-Warrick and Bremner's" Classification of Fractures of the Calcaneus, Showing Incidence of Various Classes in a Series of 300 Cases. Ditsribution of 300 fractures Group I includes: Isolated fracture of the anterior end of the bone. Isolated fracture of the sustentaculum tali... Fracture of the tuberosity (1) "Beak" fracture (2) Vertical fracture Total Group I... Group II includes: A. Fractures with division of the bone into two main fragments only (1 ) Involving but not displacing the posterior articular facet... (2) Involving the posterior articular facet and accompanied by lateral displacement of the main lateral fragment... (3) With diminution of the tuber-joint angle but no involvement of the posterior articular facet.....~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ B. Fracture with division of the bone into two main fragments and secondary compression fractures of the main lateral fragment... Total Group II... Fractures with displacement of the lateral part of the posterior articular facet were divided between Type 1* and Type 2 as follows: Type Type Total Fracture with displacement of the entire posterior articular facet were divided between Type 1 and Type 2 as follows: Type I Type Total Using Palmer's9 classification of Group II fractures, Type 1 is defined as fractures with depression of that portion of the posterior articular facet lying lateral to the primary fracture. Type 2 is the type in which the depressed portion of the posterior articular facet is continuous with the upper part of the main lateral fragment which is split horizontally. CALIFORNIA MEDICINE 211

4 B C J Figure 6.-Various kinds of fractures of the calcaneus. A, fracture of the anterior end of the bone involving the calcaneocuboid joint. B, vertical fracture of the tuiberosity. C, isolated fracture of sustenaculum tali. D, "beak" fracture of the tuberosity. E, fracture involving but not displacing the posterior articular facet. F, fracture with diminution of the tuber-joint angle but no involvement of the posterior articular facet. G, fracture involving the posterior articular facet with lateral displacement of the main lateral fragment. H, fracture with depression of the lateral part of the articilar surface (Type 1). 1, fracture with depression of the lateral part of the articular surface (Type 2). J, fracture with depression of the entire posterior articular surface (Type 1). K, fracture with depression of the entire posterior articular surface (Type 2). 212 MARCH 1968 * 108 * 3

5 mal function of the subtalar, midtarsal and ankle joints, no deformity, and return to the former occupation within a reasonable time. An approximation of these goals requires the following treatment: * Restoration of normal congruity of articular surfaces. * Correction of the widening of the calcaneus beneath the lateral malleolus. * Restoration of the normal tuber joint angle. * Restoration of the height between the malleoli and the plantar surface of the heel pad. * Commencement of active motion as soon as reasonable stability of the fractures has occurred. Open Reduction with Bone Grafts Undoubtedly, some Group II fractures may be treated conservatively with manipulation, casting or Steinman pin traction or fixation, with good results. However, achievement of the goals set forth above has appeared unlikely in Type 1, Group II fractures without open reduction and bone grafting. In addition, most Type 2, Group II fractures appear to be best handled in the same way. Therefore, the technique described by Palmer, with modifications, has been, for me, the treatment of choice. The following are the modifications of the Palmer technique as used by me: * The incision is made to swing across the sinus tarsi from the lateral border of the long extensor tendons to just posterior to the lateral malleolus so as to allow better exposure of the subtalar joint and any projections of the fracture lines into the sustentaculum tali and calcaneocuboid joints. Care must be taken here to avoid the sural nerve. * The peroneal sheaths are not opened but are dissected subperiosteally as an intact band of tendons with their sheaths, periosteum and fibular calcaneal ligament to prevent the tendency of the comminuted lateral wall of the calcaneus to spread out beneath the lateral malleolus after reduction. This lateral spread impinges on the peroneal tendons, squeezing them against the fibula so that ankle and subtalar motion is limited, and is the cause of persistent complaint of pain. * Multiple segments of cortical and cancellous iliac bone, rather than a single block of bone, are firmly placed in the most appropriate planes to completely fill the defect caused by the impaction and to support the elevated articular surfaces. Experience has shown that recurrence of deformity is usually due to insertion of too little bone. It is obvious that open reduction and bone grafting of calcaneus fractures are major procedures and should be performed only if there is significant displacement, and then by surgeons highly skilled in these methods and in hospitals well set up for these procedures. The records of 47 patients with 50 fresh fractures of the calcaneus have been reviewed. All of the patients had their definitive treatment and most of them their follow-up care by the author. Methods of treatment of the 50 fractures were as follows: *Casting * Bohler type closed reduction with pin fixation... 9 * Open reduction with excision of loose fragments and usually pin fixation * Modified Palmer open reduction and bone grafting The earliest method used in this series was of the Bohler type. Unsatisfactory results frequently occurred, requiring subtalar or triple arthrodesis to relieve subtalar and midtarsal arthritis. However, patients undergoing arthrodesis still had less than an ideal foot with not infrequent complaints of pain over the lateral heel and weakness of the foot and calf despite solid arthrodesis in optimal weight-bearing position. For example: One patient, a 58-year-old man who had fallen about 15 feet onto his right foot about three months previously, had- been treated elsewhere with a cast for seven weeks, and after three months still had complaint of pain in the lateral aspect of the right heel and in the sinus tarsi on walking. Protruding bone from the lateral border of the calcaneus and subtalar arthrodesis was excised, and films taken five months following operation showed clearly the residual shortening in length and height of the tuberosity, with resultant poor structure of the hind-foot. The patient returned to construction work almost 12 months after injury but was unable to walk backward carrying heavy forms. He still complained of pain over the lateral heel. (See Figures 7 and 8.) Treatment in recent years of all significantly displaced Group II fractures has been by open reduction with bone grafts. Some details of management are as follows: * No operation is done until the skin is free of blisters and abrasions. This usually requires seven CALIFORNIA MEDICINE 213

6 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ :::...I. *Wa<... l ::..:: ,, g,, S:... U... :...'... ~,.: Figure 7.-Lateral and axial roentgenograms (case reported in text). to ten days of elevation and application of ice bags or compresses. * Postoperatively a pressure dressing, consisting a sterile sheet wadding and bias stockingette, is used, with an extra pressure pad beneath the fibula. A long leg cast is applied with the knee in moderate flexion and the ankle in about 10 degrees of equinus. * The cast is removed at two weeks for removal of sutures and a new cast is applied. * The cast is removed at six to eight weeks and active motion begun. * Protected weight-bearing is started at 8 to 12 weeks. At six months postoperatively most patients are pain free or subject to only relatively mild pain or ache on exertion. Ankle motion is excellent with rarely more than 5 degree impairment of full dorsiflexion and plantarflexion. Subtalar motion is usually limited with 25 percent to 50 percent of normal motion being considered very good and more than 50 percent of subtalar motion in both eversion and inversion being considered excellent. One patient was found to have fully normal sub :... Figure 8. (Same patient as in Figure 7.) - Lateral roentgenograms of left and right calcaneus after subtalar arthrodesis of right foot. talar motion, ten years after operation. Most patients have returned to their former occupations with little or no restriction of their activities. However, one roofer did not return to full duties as a roofer for three years. There were no deaths in this series and only two significant complications. In one patient with bilateral comminuted calcaneal fractures, pulmonary embolism developed, but recovery ensued. In one patient a low grade infection necessitated partial sequestrectomy. There has been no drainage from the heel in more than 16 years, but never was any subtalar motion regained. REFERENCES 1. Barnard, Leonard: Non operative treatment of fractures of the calcaneus, J. Bone and Joint Surg., 45-A: , June Bohler, L.: Diagnosis, pathology and treatment of fractures of the os calcis, J. Bone and Joint Surg., 13:75-88, Jan MARCH 1968 * 108 * 3

7 3. Carothers, R. G., and Lyons, J. F.: Early mobilization in the treatment of os calcis fractures, Amer. J. Surg., 83: , Mar Conn, H. R.: The treatment of fractures of the os calcis, J. Bone and Joint Surg., 17: , Apr Cotton, F. J.: Os calcis fracture: Remodeling with mallet, Surg. Clin. N. Amer., 1: , June Hall, Michael C., and Pennal, George F.: Primary subtalar arthrodesis in the treatment of severe fractures of the calcaneum, J. Bone and Joint Surg., 42-B: , May Maxfield, Jack E., and McDermott, F. J.: Experiences with the Palmer open reduction of fractures of the calcaneus, J. Bone and Joint Surg., 37-A: , Jan Maxfield, Jack E.: Treatment of calcaneal fractures by open reduction, J. Bone and Joint Surg., 45-A: , June Palmer, Ivar: The mechanism and treatment of fractures of the calcaneus. Open reduction with the use of cancellous grafts, J. Bone and Joint Surg., 30-A:2-8, Jan Pridie, K. H.: A new method of treatment for severe fractures of the os calcis. A preliminary report, Surg. Gynec. and Obstet., 82: , June Schottstaedt, Edwin R.: Symposium: Treatment of fractures of the calcaneus. Introduction, J. Bone and Joint Surg., 45-A: , June Thompson, Kearns R., and Friesen, Carl M.: Treatment of comminuted fractures of the calcaneus by primary triple arthrodesis, J. Bone and Joint Surg., 41-A: , Dec Warrick, C. K., and Bremner, A. E.: Fractures of the calcaneum, J. Bone and Joint Surg., 35-B:33-45, Feb Wilson, George E.: Fractures of the calcaneus, J. Bone and Joint Surg., 32-A:59-70, Jan c CALIFORNIA MEDICINE 215