Fractures of the Calcaneus

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1 Fractures of the Calcaneus Anthony T. Sorkin, M.D. Rockford Orthopedic Trauma Service Rajeev Garapati, MD Illinois Bone and Joint Institute Assistant Clinical Professor University of Illinois at Chicago

2 INTRODUCTION the man who breaks his heel bone is done. - Cotton and Henderson, 1916 results of crush fractures of the os calcis are rotten. - Bankhart, 1942

3 INTRODUCTION High potential for disability Pain Gait disturbance Unable to work Best treatment method controversial

4 Soft Tissue Very thin skin Almost no subcutaneous tissue

5 EXTRA-ARTICULAR FRACTURES Anterior process fracture Tuberosity (body) fracture Tuberosity avulsion Sustentacular fracture

$non-displaced fractures are treated$ non-operatively Larger and/or

6 EXTRA-ARTICULAR FRACTURES Small, or non-displaced fractures are treated non-operatively Larger and/or displaced fragments may require open procedure

7 TUBEROSITY AVULSION The exception to the extra-articular rule Achilles avulsion Wound problems Surgical urgency Lag screws or tension band

8 INTRA-ARTICULAR FRACTURES

9 MECHANISM OF INJURY High energy: MVA, fall Lateral process of talus acts as wedge Impaction fracture

10 PATHOANATOMY Primary fracture line Constant fragment

$PATHOANATOMY Secondary fracture line Extends$

11 PATHOANATOMY Secondary fracture line Extends posteriorly through tuberosity Creates 3+ parts 2 3 1

12 PATHOANATOMY Articular incongruity Hindfoot varus Shape of foot Wide Loss of height/short Peroneal impingement Heel pad crush

13 CLINICAL PROBLEMS Stiffness Loss of normal gait Walk on lateral border- varus hindfoot Shoewear problems- wide heel Arthritic pain- mainly subtalar joint Peroneals- subluxation or entrapment Heel pad pain

14 IMAGING: Plain Films Standard Views 1. Lateral 2. Broden s 3. Axial (Harris)

15 LATERAL VIEW Bohler s Angle Gissane s Angle Normal Normal

16 IMAGING: CT Scan ST joint Heel width/ shortening Lateral wall blowout Peroneal impingement or dislocation CORONAL

17 SANDERS CLASSIFICATION Based on CT findings # joint fragments 2 = type II 3 = type III 4 or more = type IV Subtype: L M fx position Predictive of results

18 NON-OP TREATMENT: Injury maybe

19 NON-OP TREATMENT Malunion But bad things can happen

20 NON-OP TREATMENT: Complications Malunion Varus hindfoot Locks midfoot Medializes foundation for stance Shortened foot = short lever arm Peroneal impingement/ dislocation Shoewear problems

21 NON-OP TREATMENT: Complications Malunion treatment Orthosis/ custom shoe Lateral wall exostectomy Peroneal tenolysis Subtalar fusion +/- bone block Sliding wedge osteotomy

22 OPERATIVE TREATMENT: Natural History Early studies recommending non-op treatment: Old ORIF techniques No CT classification No assessment of fracture reduction

23 OPERATIVE TREATMENT: Natural History Initial results were poor (wound problems) Newer ORIF techniques improved results Anatomic reduction for good result Fracture severity correlates with results Learning curve

function & prevent arthritis Typically, restoring

24 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

25 OPERATIVE TREATMENT: Relative Contraindications Diabetes Vascular insufficiency Smoker Severe swelling Open fractures Elderly Neuropathic Non-compliant pt. In-experienced surgeon

26 TREATMENT: A Rational Approach? Many treatment methods attempted Best method remains controversial Open vs Percutaneous? Assess each case individually Injury/ patient/ surgeon Risks vs. benefits

27 Surgical Tips: Preparing Soft Tissues Elevation Compression stocking Cast boot days + Wrinkle test

28 ORIF via Extensile Lateral Approach Benirschke/Sangeorzan, Clin Orthop, 292: 128, 1993 Letournel, Clin Orthop, 290: 60, 1993 Sanders et al., Clin Orthop, 290, 87, 1993

29 Surgical Tips: Positioning Lateral decubitus L incision

30 Surgical Tips: Exposure No touch technique Lateral wall removed

$tuberosity Clean out fracture Disimpact sustentacular$

31 Surgical Tips: Restore Joint Surface Schanz pin to manipulate tuberosity Clean out fracture Disimpact sustentacular fragment

32 This image cannot currently be displayed. Reduce Body

33 Surgical Tips: Tuberosity Reduction Pin reduced tuberosity Assess radiographically

34 Surgical Tips: Wound Closure Full-thickness sutures tied towards apex

35 Surgical Tips: Drain and Deep Closure

36 Surgical Tips: Skin Closure & Splint Nylon

37 OPERATIVE TREATMENT: Wound problems Apical wound necrosis Stop ROM Leave sutures in Infection Antibiotics I&D Soft tissue coverage? Complications

38 Percutaneous Internal Fixation Fewer wound problems More difficult reductions? Ex. Essex-Lopresti maneuver

39 Percutaneous Internal Fixation Essex-Lopresti, Clin Orthop, 290: 3-16, 1993

40 Percutaneous Internal Fixation GIII open fracture

41 Percutaneous Internal Fixation Joint elevated through open wound Percutaneous fixation

42 Percutaneous Internal Fixation

43 Percutaneous Internal Fixation

44 SUMMARY High energy injuries Risk for long term morbidity ORIF can give good, reproducible results if complications are avoided Individualize treatment Longterm outcomes studies are needed comparing treatment alternatives

No disclosures relevant to this topic Acknowledgement: some clinical pictures were obtained from the OTA fracture lecture series and AO fracture

$No disclosures relevant to this topic Acknowledgement: some clinical pictures were obtained from the OTA fracture lecture series and AO fracture$ CALCANEUS FRACTURES No disclosures relevant to this topic Acknowledgement: some clinical pictures were obtained from the OTA fracture lecture series and AO fracture lecture series INCIDENCE 2% of all fractures