1. Department of Orthopaedics AFMC, Pune PG SEMINAR CALCANEAL FRACTURES Maj Rohit Vikas Resident
2. INTRODUCTIONMost common tarsal bone to be fractured1%–2% of all fracturesTypically occur because of axial loading
3. CALCANEAL FRACTURES RELEVANT ANATOMY
4. ANATOMYA relatively thin cortex.Traction trabeculaeCompression trabeculae“Neutral triangle”Thalamic portionThe cortical bone just inferior to theposterior articular facet is condensed toapproximately 1 cmBoehler angle is normally 20°–40°Critical Angle of GissaneThickening of the cortex is also seen in theregions of the sustentaculum tali, medialwall, and critical angle of Gissane.
5. ANATOMY4 articulating surfaces, three superior and one anterior.The superior surfaces articulate with the talus.Posterior facetSeparated from the middle and anterior facets by a groove thatruns posteromedially, known as the calcaneal sulcus . The canalformed between the calcaneal sulcus and the talus is calledthe sinus tarsi.Middle calcaneal facetSupported by the sustentaculum tali and articulates with themiddle facet of the talus.Anterior calcaneal facetArticulates with the anterior talar facet and is supported by thecalcaneal beak.The triangular anterior surface of the calcaneus articulateswith the cuboid.
6. ANATOMYThe lateral surfaceFlat and subcutaneousPeroneal tubercle for the attachment of thecalcaneofibular ligament centrally.The lateral talocalcaneal ligament attachesantero-superiorly to the peroneal tubercle
7. ANATOMYMedially, the talus is held to the calcaneusfirmly by the interosseous ligament and thethick medial talocalcaneal ligaments .The sustentaculum taliThe groove inferior to it transmits the FHLtendon.
8. ANATOMYThe neurovascular bundleruns adjacent to the medialborder of the calcaneus.The neurovascular bundlemay be injured during traumaor during surgery by thereduction of thesustentacular fragment,which is a key element in thesurgical management ofcalcaneal fractures
9. MECHANISM OF FRACTUREPrimary fracture lineExtends obliquely from the posteromedial to the The shear fracture (black)anterolateral calcaneus.Produces a posterolateral segment consisting of tuberosity lateral wall variable portion of the post. articular surface.The anteromedial segment consists of anterior process, medial sustentaculum, the remaining medial aspect of the post articular surface
10. MECHANISM OF FRACTURESecondary fracture lines The compression fractureCan extend into the calcaneocuboid joint separating the anterior process into Tongue – red anteromedial and anterolateral Jt depression - blue fragmentsCan extend medially separating the sustentacular fragment from the anteromedial fragment .
11. MECHANISM OF FRACTURESecondary fracture lines – ConstantfragmentA lateral fragment of the posteriorarticular surface characterizes jointdepression patterns and is produced byextension of a secondary fracture line tothe cranial portion of the tuberosity.Because of the strong ligamentousattachments between the talus and thesustentacular fragment, this fragment is“constant”, and usually in a relativelystandard position.The location of this fragment and thedensity of bone in this area are critical forreduction and fixation of calcanealfractures.
12. Vascular supply to lateral skinLateral calcaneal artery, the lateralhindfoot artery, and the lateral tarsalartery contribute to the vascularity of thelateral skin and soft tissues of the foot.The lateral calcaneal artery definitely isresponsible for the majority of the bloodsupply to the corner of the flap in theextensile lateral approach
13. CALCANEAL FRACTURES CLINICAL EVALUATION
14. CLINICAL EVALUATIONHISTORYMechanism of injury Fall from ht RTAAssociated Injuries 10% - spinal #, usually Dorsolumbar junction Head injury Other injury in extremities Bilateral Calcaneal fracturesCOMORBIDITIES Diabetes Peripheral Vascular Disease
17. X RAYSLateral Hind footAP FootHarris heel viewBroden’s ViewsAnkle AP, Lateral, MortiseThoracolumbar spine AP, Lateral
18. X RAYSLateral Hind footConfirms diagnosis of calcaneal #Crucial angle of GissaneTuber angle of BoehlerIntraarticular # Loss of ht of post facet Reduced Boehler angle Increased Gissane angleJoint Depression vs Tongue type
19. X RAYSAP footLess informativeCalcaneocuboid jt involvement
20. X RAYSHarris Axial ViewVisualization of jt surfaceLoss of htIncreased widthAngulation of tuberosity fragmentMay be difficult to obtain due to pain
21. X RAYSBroden’s ViewLeg Internal rotated 20°Foot NeutralBeam directed 10/20/30/40° towards headCentered over lateral malleolusDemonstrates articular surface of post facet
22. X RAYSBroden’s View
23. X RAYSCasanovas fractureLover’s FractureJumper’s Fracture
24. X RAYS
25. X RAYSClassification of Essex-Lopresti
26. X RAYSClassification of Essex-Lopresti
27. CT SCAN Coronal CT image s Shear fracture line (arrow) separating the anteromedial or sustentacular fragment (S) and the posterolateral or tuberosity fragment (T). The articulation of the posterior facet with the talus is maintained medially and is more angulated laterally.Coronal images reveal Articular surface of the post facet, Sustentaculum, Shape of the heel, Position of the peroneal and FHL tendons.
28. CT SCANSagittal image of the same patientDepression of the tuberosity fragment (T)
29. CT SCANTransverse (axial) images Calcaneocuboid joint, Anteroinferior aspect of the post facet Sustentaculum.
30. CT SCANAxial (a) and coronal (b) CT scans of a calcaneal fracture, identifying the lateral jointfragment (LJF), the sustentacular fragment (SF), and the tuberosity or body fragment(TF). There is lateral dislocation, impaction, and displacement at the articular surface.
31. CALCANEAL FRACTURES CLASSIFICATION
32. CLASSIFICATION INTRA ARTICULAR # EXTRA ARTICULAR # 70 – 75% 25 – 30%Essex Lopresti Classification # that does not involve post facet JOINT DEPRESSION TYPE TONGUE TYPE ANTERIOR PROCESS # MID CALCANEAL # BODY SUSTANTICULUM TALI PERONEAL TUBERCLE LATERAL PROCESSSander’s Classification POSTERIOR CALCANEAL # TUBEROSITY # MEDIAL CALCANEAL TUBERCLE #
33. CALCANEAL FRACTURESINTRA-ARTICULAR FRACTURES
34. INTRA-ARTICULAR FRACTURESPrimary and secondary fracture lines, primary same for both types Secondary Fracture line determines type
35. INTRA-ARTICULAR FRACTURESSanders classificationType I - NondisplacedTypes II and III - have two or threefragments, respectively, which are thensubdivided, depending on the medial orlateral position of the primary fracture line.Type IV - severely comminuted
36. INTRA-ARTICULAR FRACTURES
37. CALCANEAL FRACTURESEXTRA-ARTICULAR FRACTURES
38. EXTRA ARTICULAR FRACTURES Vertical Tuberosity # Medial Process #Anterior Avulsion # at EDBProcess # attachment
39. ANTERIOR PROCESS FRACTUREForced inversion or forced abduction &dorsiflexionBest seen on oblique viewsUsually treated with protected weight bearing.If involving more than 25% of calcaneocuboidarticular surface are treated with ORIFComplication includes non-union.
40. ANTERIOR PROCESS FRACTURE
41. CALCANEAL BODY FRACTUREDue to axial loadingAssociated with injuries to appendicular andaxial skeletonBetter prognosis than intraarticular fracturesUsually managed conservatively and healnormally
42. SUSTANTICULUM TALI FRACTUREDue to axial loading and inversionUsually treated conservatively with non-weightbearing or fixed by screwAssociated with FHL tendon injuryNonunion is common.
43. CALCANEAL TUBEROSITY FRACTURECommonly occur in elderly poroticpatients due to avulsion of tendo achillisInitial immobilization in slight equinusposition followed by urgent ORIF
44. TUBEROSITY FRACTURE
45. MEDIAL PROCESS FRACTUREAbductor hallucis, flexor digitorum and plantarfascia attach to medial process of calcaneusDue to fall from heightTreated with ORIF.
46. CALCANEAL FRACTURES TREATMENT
47. HISTORICAL TREATMENT1908, Cotton and Wilson ORIF of a calcaneal fracture contra-indicated Recommended closed treatment with use of a medially placed sandbag, a laterally placed felt pad, and a hammer to reduce the lateral wall and “reimpact” the fracture.1920s Abandoned the treatment of acute fractures altogether and had turned instead to the treatment of healed malunions
48. HISTORICAL TREATMENT1931, Böhler Advocated open reduction Technical problems associated with operative treatment Infection, malunion, and nonunion, and the possible need for amputation1935, Conn Delayed primary triple arthrodesis1943, Gallie Subtalar arthrodesis as definitive treatment but only for fractures that had healed. This technique became standard for healed, malunited calcaneal fractures.
49. HISTORICAL TREATMENT1948, Palmer Dissatisfied with both nonoperative and late treatment Described the operative treatment of acute displaced intra-articular calcaneal #s Standard lateral Kocher approach to reduce the joint Holding up the fragment with bone graft He stated that his patients did well and that many returned to work.1952, Essex-Lopresti Reported similar findings. Tongue or Joint-depression fragment. Tongue-type # were reduced with percutaneous leverage Joint-depression # necessitated formal ORIF.
50. HISTORICAL TREATMENTIn the last twenty years Better anesthesia, Antibiotics, AO/ASIF principles of internal fixation, Computed tomography FluoroscopyGood outcomes with use of operative interventionTreatment remains challenging
51. NON OPERATIVE TREATMENTSpecific indications for nonoperative treatment Undisplaced/ minimally displaced Extra articular # Nondisplaced Intra articular # (Sander’s Type I) Anterior Process # with < 25% involvement of Calcaneocuboid jt. Severe peripheral vascular disease Insulin-dependent diabetes Other medical problems that contraindicate an operation. Elderly, household ambulatorsSpecific situations in which nonoperative treatment may be required because aninjury precludes early operative intervention Severe open fracture Life-threatening injury Soft-tissue compromise Blistering Massive, prolonged edema
52. NON OPERATIVE TREATMENTEarly range-of-motion exercisesNon-weight-bearing for approx 03 monthsThe foot is placed in a boot, locked in neutral flexion to prevent equinuscontracture.Elastic compression stocking to minimize dependent edema.
53. NON OPERATIVE TREATMENTReserved for nondisplaced (Sanders type-I) fractures.Displaced intra-articular fracture Nonop treatment offers little chance of a return to normal function because a calcaneal malunion will develop. Reduction of the articular surface never is obtained Heel remains shortened and widened Talus remains dorsiflexed in the ankle mortise Lateral wall causes impingement and binding of the peroneal tendons.
54. OPERATIVE TREATMENTDisplaced Intra articular # involving post facet (Sander’s II, III)Anterior Process # with > 25% calcaneocuboid jt involvementDisplaced # of calcaneal tuberosityFracture-Dislocation calcaneumSelected Open fractures Open type I Delayed ORIF Open Type II with Medial wound Delayed ORIF Open Type II with Non medial wound External Fixation/ Percuatneous Fixation Open Type III A External Fixation/ Percuatneous Fixation
56. ORIFShould be performed within the first 03 wks after the injury, before earlyconsolidation of the fracture.Should not be attempted until after swelling in the foot and ankle hasmarkedly decreased.Wrinkle testMethods to reduce edema Elevation Jones dressing with a posterior splint If the swelling is decreasing, a boot locked in neutral flexion Elastic compression stocking Use of a foot pumpPre op 2D CT Scan
57. ORIF 24-year old man Sanders type 2, Tongue-type fracture Displaced. Böhler’s angle = 8 degrees. No medical contraindications for surgery.
58. ORIF The axial view Large “constant” sustentacular fragment. The fracture splits the middle of the posterior facet, and it is displaced. The “constant” fragment is the stable medial calcaneal building block which allows lag fixation. This image shows no varus or valgus of the hindfoot.
59. ORIF CT Scan -The coronal view Split extending into the posterior facet, which is displaced. Loss of height Comminution.
60. ORIF CT Scan – The axial view “Constant” fragment Intraarticular incongruency of the posterior facet. This view allows assessment of the anteromedial (sustentaculum tali) fragment, its integrity and its dimension. This fracture is a Sanders type 2 fracture which is on the simple end of the calcaneal fracture spectrum.
61. ORIFTypical positions of the five standard fragments thatneed reduction.Step-by-step process for the reduction maneuver.Generally, one begins by identifying the “constant”fragment, i.e. the sustentacular fragment (4), whichremains attached to the talus and does not displace.The reconstruction builds on this stable fragment andtherefore one begins the reconstruction anteriorly andmedially with this fragment and works simultaneouslyon the posterior (2) and lateral (3) articular fragments.Often necessary to apply traction to fragment 2 torestore the 3D shape of the os calcis.Once these are in place, one closes the lateral wall likea door, which is the final step of the reconstruction.Fragments are maintained temporarily with K-wires.The final step is the fixation.
62. ORIFLateral decubitus / prone positionFluoroscopyExsanguinationTourniquet inflated to 350 mm of HgExtensile right-angled lateral incision Minimizes peroneal tendinitis Reduces devascularization of the anterior skin flap Preserves the sural nerve Seligsons lateral extensile approach
63. ORIFStandard extended lateral approach. The # line at the level of the angle of Gissane identified Usually, there is a small lateral wall fragment which should be preserved and reflected plantarwards. Thin lateral wall is lifted gently and retracted inferiorly to expose the articular # fragments buried within the body of the calcaneus. Haematoma evacuated
64. ORIFReduction - Joystick placement Fracture lines are visualized and identified. Next, a Schanz screw is inserted into the posterior (or tuberosity) fragment (2) from lateral to medial, going through both cortices. It will serve as a joystick to aid in the reduction.
65. ORIFReduction of the tuberosity fragment The next step is the reduction of the tuberosity fragment (2) to the “constant” medial sustentacular fragment (4). Once the fragment is reduced, it is held in position with 2 K- wires which are introduced in an anteroposterior superior direction from the posterior inferior aspect of the tuberosity. They are directed superiorly and anteriorly into the “constant” medial fragment (4)
66. ORIFElevation of the lateral articular surface With the tuberosity (2) reduced to the “constant” piece (4), while ensuring that there is no varus of the hindfoot, one reduces now the lateral articular piece (3). It needs to be elevated in order to successfully reconstruct the articular surface, the posterior facet.
67. ORIFPreliminary Fixation Once reduced, it is supported with K-wires, which are introduced from the lateral side into the “constant” medial fragment. Keep in mind that K wires does not occupy the place judged best for the insertion of the subchondral lag screw(s) which will stabilize the articular surface. While the reduction and fixation proceeds, one must be careful at every step to make certain that the hindfoot remains in neutral, or in slight valgus, in the axial view. Varus of the hindfoot must be avoided.
68. ORIFPhysiologic valgus With the patient in the lateral position, and working from the lateral side, there is a tendency for the hindfoot to fall into varus. Throughout the surgical maneuvers, the surgeon must check continuously that the hindfoot remains in valgus. By continuously checking and using K-wires as reduction tools and temporary fixation, physiologic valgus is maintained until the final reduction and fixation is obtained.
69. ORIFFixation – Subchondral Lag screw Once the reduction of the articular surface is achieved, it is maintained with a subchondral lag screw which runs from lateral anteromedially into the “constant” medial subchondral fragment. Thus, when drilling the hole for the lag screw, the drill bit must be directed carefully in these three directions: a) Lateral to medial b) Posterior to anterior c) Cephalad to caudad In this way, the threaded portions of the screw will be directed into the strong medial sustentacular cortical bone.
70. ORIFFixation – Subchondral Lag screw On the medial side is the neurovascular bundle which ends up frequently at the tip of the subchondral lag screw. If one allows the drill bit, or the screw, to protrude too far medially, one can damage the neurovascular bundle or FHL tendon.
71. ORIFBone Deficiency The articular surface of the os calcis is impacted by the talus into the underlying cancellous bone. Once the articular fragments are disimpacted and elevated, varying degrees of void result. Studies show that bone graft is not necessary, yet some surgeons fill the void with bone substitute materials, and other surgeons choose to ignore the void and use locking plate fixation to maintain reductions.
72. ORIFPlate choice Depends upon the severity of calcaneal fracture type and the bone quality. Simple fracture patterns in good bone require simple lateral plating while complex fracture patterns with comminuted pieces may require adaptable plates or locking plates. This image shows a simple fracture reduced with multiple K- wires and lag screw in place, beneath the subchondral joint. A one-third tubular plate may be all that is required for a simple fracture in good bone.
73. ORIFBone Substitute Calcium sulfate bone substitute filling the large void which is commonplace after fracture reduction. This bone substitute will be bioabsorbed over time. In the early phase (0-2 weeks) it may act to support bony anatomy before early soft callus replaces the filled void.
74. ORIFPost op CT The coronal view shows the joint surface to be reduced, height restored and surgical hardware is not into the joint. The cast is for temporary postoperative splinting.
75. ORIFBone Substitute This drawing shows a similar situation, albeit fixation with a different calcaneal plate.
76. ORIFLateral plate placement The distal corner of the soft-tissue incision for the lateral extended calcaneal approach is vulnerable to wound breakdown. Most calcaneal plates have at least some of their fixation points at this crucial apical wound.
77. ORIFLateral plate placement This image shows the typical problem at the distal corner of the lateral extended calcaneal approach where a screw and plate are right beneath where the wound typically breaks down. This calcaneal incision has between 5 and 15 % incidence of wound breakdown regardless of where hardware is placed.
78. ORIFLateral plate placement
79. ORIFExtremely comminuted # Fixation This is extremely difficult surgery. Decision making is controversial. Some surgeons favor primary fusion while others favor primary ORIF with later reconstruction, if required.
80. ORIFPost op CT This case shows final CT scans postoperatively with axial and coronal slices. The axial shows the lag screw going deeply into the sustentaculum tali, parallel to the subchondral surface, with the surface reduced. There is no varus malalignment.
81. ORIFClosure Two-level closure over a hemovac drain is standard. Subcutaneous - Absorbable stitch. Soft-tissue closure should be carefully performed so that there is advancement of the flap. There should be no excessive tension on the distal corner of the incision. Skin - Interrupted Allgöwer- Donati stitch. Skin should be apposed and not strangulated
83. MINIMALLY INVASIVE FIXATIONEspecially for tongue type #Closed Reduction and Percutaneous PinningImplant 6.5 mm Cannulated Screw Steinmann Pin
84. PRIMARY ARTHRODESISOnly for patients who have a Sanders type-IV highly comminuted intra-articularfracture.After restoration of the calcaneal body andthe joint surface, the remaining cartilage isremoved from both surfaces of the posteriorfacet and an autologous bone graft is usedto perform an arthrodesis.Typically, a 6.5 to 8.0-mm cannulatedcancellous-bone lag screw placed from theposterior tuberosity into the talar dome tostabilize the fusion.Non-weight-bearing BK cast for 03 months
85. CALCANEAL FRACTURES COMPLICATIONS
86. COMPLICATIONSCompartment SyndromeWound DehiscenceCalcaneal OsteomyelitisProblems Related to the Peroneal Tendons Tendinitis DislocationsNeurological Complications Nerve entrapment Cutaneous nerve injury RDSMalpositioning Of Tuberosity Of Superolateral fragmentCalcaneal MalunionArthritisChronic Ankle painHeel ExostosesHeel Pad pain
87. NEUROLOGICAL COMPLICATIONSCutaneous Nerve InjuryMost common neural problem associated with operative treatment Sural nerve is most commonly injured (Lateral approach) Calcaneal branch of the posterior tibial nerve (Medial approach)A neuroma or complete loss of sensation in the affected regionNonoperative treatment is advised.When a neuroma is painful, resection with burial of the stump into deep tissue.Nerve EntrapmentEntrapment or compression of the posterior tibial nerveAfter nonoperative treatment, due to a malunited fracture.Pain in the medial aspect of the heelParesthesias in the distribution of the posterior tibial nerve.A trial injection of a local anesthetic into the tarsal tunnel can assist in making the diagnosis.Electrodiagnostic studiesOperative decompression of the posterior tibial nerve and its branches may provide relief.
88. NEUROLOGICAL COMPLICATIONSReflex Sympathetic DystrophyOccur regardless of the method of treatment Pain that is disproportionate to the extent of the injury Cold, clammy skin, Purplish discoloration Inability to tolerate anyone touching the footTibial nerve block does not relieve the symptomsLumbar sympathetic block, thermogram, or bone scan may be performed to obtain a diagnosis.Intensive therapy such as massage, motion and manipulation, or weight-bearing if the fracturehas healed.Multiple lumbar sympathetic nerve blocks and counseling.Unless a specific stimulus (for example, a prominent screw or a neuroma) is found to be causingthe underlying pain, additional operative treatment should be avoided
89. CALCANEAL FRACTURES RECENT ADVANCES
90. CALCANEAL PLATES
91. CALCANEAL NAILS
92. CALCANEAL FRACTURES REVIEW OF LITERATURE
93. LITERATURE REVIEW Displaced Intra-Articular Calcaneal FracturesEffect of operative treatment compared with nonoperative treatment on rate ofunion, complications, and functional outcome after intra-articular calcaneal #Among 20 relevant articles:4 RCTs: OFarrell 1993 Parmar 1993 Thordarson 1996 Buckley 20022 systematic reviews Randle 2000 Bridgman 20001 abstract of economic analysis study Brauer 2004 OTA Meeting Bajammal et al, JOT 2005
94. LITERATURE REVIEW Displaced Intra-Articular Calcaneal FracturesEffect of operative treatment compared with nonoperative treatment on rate ofunion, complications, and functional outcome after intra-articular calcaneal #Evidence from RCTs with methodological limitations revealed:No significant difference in pain and functional outcome between the two groupsOperative treatment maybe superior to nonoperative treatment concerning returnto work and the ability to wear the same shoes. Bajammal et al, JOT 2005
95. LITERATURE REVIEW Displaced Intra-Articular Calcaneal Fracturesa. Potential benefit of operative treatment in women younger males higher Böhler angle light workload single, simple displaced intra-articular fracture.b. Potential benefit of nonoperative treatment in: 50 years or older Males heavy workload (Buckley et al, 2002 JBJS Am),
96. LITERATURE REVIEW Displaced Intra-Articular Calcaneal FracturesVariables Predicting Late Subtalar FusionAmount of initial injury involved with the calcaneal # is the primary prognosticdeterminant of long-term patient outcome.A distinct patient group with a displaced intra-articular calcaneal who are athigh risk of subtalar fusion, These include: Male Heavy labor work Böhler angle less than 0° (10 times) Sanders-type IV calcaneal fractures (5.5 times ) Initial treatment was nonoperative (6 times)Initial ORIF of patients with displaced intra-articular calcaneal # minimizedthe likelihood that subtalar fusion would be required. Csizy, Marcel; Buckley, Richard
97. LITERATURE REVIEW Bilateral Calcaneal FracturesOperative versus nonoperative treatmentPts sustaining bilateral calcaneal # are very similar to those in whom the injury isconfined to one side.Neither objective nor subjective functional outcomes are significantly improvedfollowing operative intervention.However, careful operative pt selection will minimize complications and lessenneed for late subtalar arthrodesis. Dr. R. Buckley