fractures · 2018-05-18 · fracture • delayed treatment results in full thickness necrosis •...
TRANSCRIPT
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CALCANEUS
FRACTURES
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No disclosures relevant to this topic
Acknowledgement: some clinical pictures were obtained from the OTA fracture lecture series and AO fracture lecture series
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• 2% of all fractures
• Most commonly
fractured tarsal bone
• 60% of tarsal fractures
• 75% are displaced
intra-articular fractures
INCIDENCE
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CALCANEUS FRACTURES
Fall or mva
Look for associated injury
75% are intraarticular
Caring for skin is paramount
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CALCANEUS FRACTURES
High incidence of associated injuries (50%)
spine (10%)
extremity (25%)
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CALCANEAL FRACTURES
• High risk for disability
• Chronic pain
• Gait disturbance
• Inability to work
• Optimal treatment remains controversial
• Must consider patient, injury, and surgeon factors
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CALCANEUS FRACTURES
History and functional level are important when choosing treatment
most calcaneus fractures will heal
surgery is to prevent malunion and disability associated with it
some will tolerate a malunion better than others
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CALCANEUS FRACTURES
• Detailed History
• Important to determine appropriate treatment
• Pre-injury level of function
• Recreational activity
• Occupation
• Heavy manual labor?
• Habits
• Smoker?
• Comorbidities
Comorbidities
Diabetes
Vascular disease
Smoking
Neuropathy
Age?
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MECHANISM OF INJURY
Figures A-C: Joint depression fracture. Note the slight posterior vector of force leading to separation of the posterior facet in Figure B and CFigures D-E: Tongue-type. Secondary fracture line results from a purely axial force
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PHYSICAL EXAM
• Note condition of skin
• Fracture Blisters?
• Threatened skin?
• Open wound?
• Detailed neurovascular
exam
• Assess for associated
injuries
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INITIAL MANAGEMENT
• Bulky splint in neutral dorsiflexion
• Period of soft tissue rest
• If considering lateral extensile
approach…
• PATIENCE!
• Await return of skin wrinkling
• May take 2-3 weeks
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IMAGING
• Foot series
• AP, Lateral, Oblique
• Ankle series
• Mortise
• Axial (Harris) view
• Contralateral views
• Broden’s view (intraop)
• CT scan
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LATERAL VIEW
• Assess
• Posterior facet
• Middle facet
• Calcaneocuboid joint
• Calcaneal length and height
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AXIAL (HARRIS) VIEW
• 45° axial of heel
• 2nd toe in line w/ tibia
• Normal 10° valgus
• Assesses tuber alignment
• Varus/valgus
• Translation
• Width
• Can be difficult to obtain as dorsiflexion of ankle may be difficult in injured foot
• Intraoperatively used to assess:
• medial wall reduction
• screw placement / length
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CT SCAN
Done in 3 planes
Gives 3D picture of fragments
Helpful with surgical planning and
prognosis
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CALCANEUS FRACTURES
Classification systems
Essex-lopresti– based on plain xray
Joint depression
Tongue type
Sanders classification—based on ct scan
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SURGICAL INDICATIONS
CALCANEUS FRACTURES
Intra-articular displacement
Distortion of height, width, and
alignment of heel
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SURGICAL INDICATIONS
CALCANEUS FRACTURES
Condition of soft tissues is
critical for wound healing
May require a several
week delay
Meticulous care of soft
tissues intra-operatively
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EMERGENT CONDITIONS
• Threatened skin
• Displaced tongue
fragment or avulsion
fracture
• Delayed treatment
results in full thickness
necrosis
• Treat with provisional or
definitive percutaneous
fixation
Gardner MJ, Nork SE, Barei DP, Kramer PA, Sangeorzan BJ, Benirschke SK. Secondary Soft Tissue Compromise in tongue-type calcaneal fractures. J Orthop Trauma. 2008 Aug;22(7):439-45
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BASIC SET-UP
CALCANEUS FRACTURES
Lateral incision (axillary roll, bean bag)
Thigh tourniquet
Possible bone graft
fluoroscopy
Prep & drape to above knee (& hip if iliac bone graft)
Pre-op antibiotics
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IMPLANT CONSIDERATIONS
CALCANEUS FRACTURES
Small fragment set
Small cannulated screws
3.5mm reconstruction plates
Locked calcaneal plates
Cervical H plate
2.7 mm cortical screws & plates (mini frag)
Extra k-wires
Schanz screw & T-handlechuck
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SURGICAL TECHNIQUE
CALCANEUS FRACTURES
Meticulous soft tissue handling
K wires serve as retractors
Schanz screw can serve as handle to correct deformity and reduce medial wall
Sequence: reduce medial wall, reduce anterior fragments, reduce joint, place hardware
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CALCANEUS FRACTURE
Lateral position
Xray/fluoro: axial view of
calcaneus
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CALCANEUS FRACTURE—POST OP
Drain under the flap, leave for 1-2
days
Tension free closure with nylon:
simple/mattress/Allgower-donati
Splint until wound is dry and stable
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CALCANEUS FRACTURES
Other options for operative
treatment
Percutaneous/limited open
Sinus tarsi approach
Primary fusion
2 stage primary fusion
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CALCANEUS FRACTURE
Postoperative care
Bulky cotton dressing and splint
Drain for open procedures
Elevation
Leave sutures in for at least 3 wks
Immobilize until skin stable
NWB for 3 months
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COMPLICATIONS—CALCANEUS FRACTURE
• Wound edge necrosis
• Most common complication
• Up to 25%
• Deep infection
• 1-4% closed fractures
• 19% open fractures
• Symptomatic hardware
• Stiffness
• Post-traumatic arthrosis
• Peroneal tendonosis
• Neuritis
• Heel pad pain
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CALCANEUS FRACTURE
After care
Rolling knee scooter
ROM exercises as soon as skin stable
PT once weightbearing
Prepare patient for long recovery
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CALCANEAL FRACTURE
Summary
High energy injury, look for associated injuries
Many result in long term morbidity and impairment
This can be decreased with operative treatment provided
complications avoided
Patient selection and management of comorbidities is essential for
good outcomes
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THANKYOU