29TH Aug 2015SITOCON

“The man who breaks his heel bone is done” ---Cotton (1912)

“The results of crush fractures of the os calcis are rotten” ---Bankart (1942)

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)

Posterior Facet

Anterior andMiddle Facets

Mechanism of Injury

•High energy─ MVA─ fall from a height

•Lateral process of talus acts as wedge•Impaction fracture

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

Initial Evaluation• Thorough primary,

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

Exam• Note condition of skin

• Open fractures• Fracture Blisters• Threatened skin (pressurefrom displaced fracture fragments)

• Neurovascular exam

RADIOGRAPHIC EXAMINATION

Xrays ---foot

a)AP b)AXIAL c)LATERAL d)BRODEN’S VIEW OTHER X-RAYS--- >ANKLE JOINT >OPPOSITE FOOT >DORSOLUMBAR SPINEC.T SCAN ----for pathoanatomy of intra-articular fracture

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

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

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

Broden’s View

Helpful intra-op• Posterior facet • Check intraarticular

displacement• Positioning

A. 20° IR view (mortise)

B. 10°- 40° plantar

Broden’s View

• Posterior facet

CT Scan and 3D

Axial Coronal Sagital

Pathoanatomy

• • Primary

fracture line

• Constant fragment

Pathoanatomy

1 2 3

• Secondary fracture lines

• Extend posteriorly through tuberosity or into anterior process

• Create 3 + parts

Essex-Lopresti• Described two distinct fracture patterns

Joint-Depression Tongue-Type

Posterior Tuberosity NOT attached to Posterior Facet

Posterior Tuberosity attached to Posterior Facet

Not amenable to Essex-Loprestipercutaneous reduction technique

ESSEX-LOPRESTI CLASSIFICTIONJOINT DEPRESSION TYPE

Essex-Lopresti Classification:Tongue Type

B

May be amenable to Essex-Lopresti percutaneousreduction technique

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

Sander’s

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

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.

Anterior process fracture• Inversion “sprain”• Frequently missed• Most are small: treat like

sprain• Large/displaced: ORIF

Tuberosity Fracture:

•Fall/MVA•Usually non-operative (displacement)

─ Swelling control─ Early ROM

Tuberosity avulsion fractures• Achilles avulsion• Wound problems• Surgical urgency

─ Lag screws or tension band

Sustentaculum Fracture:

•Most small/ nondisplaced: ─ Non-operative

•Large/ displaced─ ORIF (med. approach)─ Buttress plate

Goals of Treatment

• Restore Anatomy

• Restore Function

OPERATIVE vs. NON-OP TREATMENT

Canadian Calcaneus RegistryR. 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

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)

Non-op Treatment: Complications

Malunion

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

Indications for ORIF• Displaced intra-articular fractures

• Displaced fractures of calcaneal tuberosity

• Fracture-dislocations of calcaneus

• Selected open fractures of calcaneus

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

Positioning

Approaches Extensile Lateral (ELA)

Most commonSinus TarsiFor selected fractures and situations

s

ORIF: Extended Lateral Approach

• • “No touch” technique

• Lateral wall removed

Full thickness skin incision with periosteal flapWatch sural nerve at proximal and distal extent of incision

Lateral wall must be removed before reduction is able to be performed anteriorly

ORIF: Extended Lateral Approach

• Schanz pin to manipulate tuberosity• Clean out fracture • Disimpact sustentacular fragment

ORIF: Extended Lateral Approach

•Use K-wires•Reduce post. facet to sustentaculum- ant. process

ORIF: Lateral Approach•Provisionally reduce tuberosity fragment to sustentacular complex

•Pin with K-wires through stab incisions in posterio-inferior heel

ORIF: Extended Lateral Approach

•Fine tune tuberosity reduction to sustentacular complex

-- Restore height and length

-- Restore valgus-- Medial translation

•Pin reduced tuberosity

Bone Graft•No benefit with bone grafting

•Bone graft substitute (i.e. Norian SRS) may allow for earlier weight-bearing

Fixation Options

ORIF: Extended Lateral Approach

•Replace lateral wall •Apply plate and screws

•Recheck radiographs• Alignment• Subtalar-/ CC joint• Hardware position• Screw length

•Check peroneal tendons•Drain•Layered closure

1. Periosteum/SQ one layer2. Skin • Atraumatic technique• Advance flap toward apex• Allgower-Donati sutures

•Splint in neutral

Operative TreatmentComplications• Wound problems

• Apical wound necrosis

• Infection

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

ST Approach (“Ollier’s”)

•Reduce anterior process

•Mobilize and reduce tuberosity

•Reduce Subtalar joint

ST Approach

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

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ST Approach: Fixation•Small screw/ small plate to span angle of Gissane

•Medial Wall Screw

•“Articular Support Screw”

•Lateral Column Screw

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Surgery: Percutaneous

•Essex-Lopresti maneuver•Tongue type fractures

Essex-Lopresti, Clin Orthop, 290: 3-16, 1993

•

Surgery: Percutaneous

Essex-Lopresti, Clin Orthop, 290: 3-16, 1993

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

Open Fractures

C D

Indirect reduction and percutaneous stabilization

Complications Malunion

Varus

Shortened foot

Peroneal impingement

Shoewear problems

Complications• Stiffness

─ Prevention (early ROM)

• Subtalar arthritis

─ NSAIDs─ Subtalar fusion

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

CALCANAIL

CALCANAIL

Surgery: Primary Fusion

•Articular comminution

•Severe cartilage injury

•ORIF calcaneus, debride cartilage, and fuse

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

SUMMARY• High energy injuries

• Risk for long term morbidity

• ORIF can give good, reproducible results if complications are avoided

• Individualize treatment

Thank you