calcaneal fracture

1. Extern conference
Ext. Boonpitak Thanadsillapakul RA 5502088

2. Patient profile
- 45 years old, male
- He Works as employee.
- He lives in Kham Thale so district, Nakhon Ratchasima province.
- Buddhism

3. Chief complaint
- Fall from height (about 2.5 m) 3 hours PTA
- Date of event: 22/9/60, 12.00 a.m.
- Scene: Ban Cho Ho, Nakhon Ratchasima
- He was sent to MNRH hospital by his wife.

4. Primary survey
- Air way and c-spine protection
- Can talk, not tender along c-spine, no limitation of neck ROM
- Breathing and ventilation
- Clear breath sound equal BL, CCT negative
- Circulation and hemorrhagic control
- BP 142/82 mmHg, HR 95 bpm, no external bleeding
- Disability
- E4V5M6, pupil 2.5 mm RTLBE
- Expose
- No external wound

5. Resuscitation
- Air way and c-spine protection
- No need
- Breathing and ventilation
- No need
- Circulation and hemorrhagic control
- No need
- Disability
- No need
- Expose
- No need

6. Secondary survey
- Allergy
- Denied food and drug allergy
- Medication
- Amlodipine(5 mg/tab) 2 tabs po od pc
- Past history
- Underlying disease: Essential hypertension
- Last meal
- 00.30 p.m.

7. Secondary survey
- Event
- 3 hours PTA, he was fallen from stairs(about 2.5 m), his heel was crashed to
the floor, he denied any head injury, he can remember the event
- After event, he complaint his heels were pain. He cannot bear his weight by
his heels. He denied any pain at his ankle, knee, hip, spine

8. Phyical examination
- Vital sign: BP 142/82, HR 95, RR 18, T 37.3
- GA: Alert, good consciousness
- HEENT: no pale conjunctivae, anicteric sclerae
- Chest: no dyspnea, normal breath sound, no adventitious sound equal BL
- CVS: full, regular pulse, normal s1s2, no murmur
- Abdomen: soft, not tender
- Skin: no external wound

9. Phyical examination
- Orthopedic exam: not tender along spine, knee, hip
- swelling, tenderness at bilateral calcaneal area, limited active ROM of bilateral
ankle
- dP,pT 2+/2+
- Cap. Refill < 2 sec
- Intact sensation

10. Plain film: Lateral
- Displaced intra-
articular fracture
involve posterior
facet of right
calcaneus
- Soft tissue swelling
- Angle of Bohler 13

11. Plain film: Lateral
- Displaced intra-
articular fracture
involve posterior facet
of right calcaneus
- Soft tissue swelling
- Angle of Gissane 127

12. Plain film: AP
- Displaced intra-articular
fracture extend to
calcaneocuboid joint

13. Plain film: Axial

14. Management at ER
- Immobilization with posterior short leg slab
- Pain control

15. Plain film: Lateral
- Angle of Bohler 16
- Angle of Gissane 121

16. Plain film: Axial

17. CT scan Rt. Calcaneus with 3D reconstruction
Right Calcaneus fracture Sander class IV

18. CT scan Rt. Calcaneus with 3D reconstruction

19. Post op. for ORIF with screw fixation

20. Calcaneus fracture

21. Outline
- Anatomy
- Epidemiology
- Mechanism of injury
- Sign and symptom
- Imaging and others diagnostic tool
- Classification
- Treatment and outcome
- Complication

22. Calcaneus Bone

23. Calcaneus Bone

24. Epidemiology
- 2 percent of all fracture
- 60 to 75 percent of these fracture were intra-articular fracture.
- 90 percent of these fracture were men between 21 to 45 years of age
- Most common from high energy motor vehicle crash or fall from height.
- Associated injury were Talar neck, Tibial pilon, tibial plateau, Lumbar spine
8th edition Rockwood and green’s fractures in adults, p. 2639-2688, 2015

25. Mechanism of injury
Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg. 1952;39:395–419

26. Sign and symptom
- Skin Blister >> from shear stress on the skin
- Swelling and ecchymosis
- Skin necrosis >> secondary from displaced tongue fracture
- Sign and symptom of Compartment syndrome
8th edition Rockwood and green’s fractures in adults, p. 2639-2688, 2015

27. Sign and symptom
- Open fracture
8th edition Rockwood and green’s fractures in adults, p. 2639-2688, 2015

28. Imaging and other diagnostic studies

29. Plain film
- Plain film lateral >> normal: 20 to 40 degree of Bohler angle, 95 to 105 degree of Gissane
Bohler L. Diagnosis, pathology and treatment of fractures of the os calcis. J Bone Joint Surg. 1931;13:75–89

30. Double density sign
- Bohler and gissane angle may normal >> only lateral half of posterior facet is
fractured and displaced >> splitted articular surface
Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2000;82A:225–250.

31. Plain film
- Plain film AP >> Fracture line extend to Calcaneocuboid joint
8th edition Rockwood and green’s fractures in adults, p. 2639-2688, 2015

32. Plain film
- Plain film Harris axial view >> visualize joint surface, loss of height, tuberosity fragment
8th edition Rockwood and green’s fractures in adults, p. 2639-2688, 2015

33. CT scan
- Indication: intraarticular fracture
8th edition Rockwood and green’s fractures in adults, p. 2639-2688, 2015

34. Classification: Extra VS Intra-articular
- Extra-articular
- Avulsion fracture: calcaneal tuberosity, anterior process by bifurcate
ligament, sustentaulum tali
- Intra-articular

35. Classification: Based on Plain film
Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg. 1952;39:395–419

36. Classification: Based on CT scan
- Type I: non displaced posterior facet
- Type II: one fracture line in posterior
facet (two fragments)
Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic
computed tomography scan classification. Clin Orthop. 1993;87–95

37. Classification: Based on CT scan
- Type III: two fracture line in posterior
facet (three fragments)
- Type IV: comminuted with three or
more fracture line in posterior facet
(four of more fragments)
Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic
computed tomography scan classification. Clin Orthop. 1993;87–95c

38. Treatment: non operative

39. Treatment: non operative
- Initiate with supportive splint >> dissipation of fracture hematoma
- Convert to cast immobilization with ankle lock in neutral flexion >> prevent equinus
contracture
- Early subtalar and ankle joint ROM
- Non weight bearing 10-12 weeks or until clinical and radiological union.

40. Treatment: operative
- Indication: contraindication of non operative

41. Outcome: Non operative VS operative

42. Crosby et al.,Computerized tomography scanning of acute intra-articular fractures of the calcaneus. A new classification system. The journal
of Bone and joint surgery, 1990
Crosby et al.

43. Crosby et al.
- In their series, there were 13 type I, 10 type II, and 7 type III fractures regarding to Crosby
classification.
- 30 patients was treated by closed technique and followed up 36 months(mean)
- Primary outome was subtalar motion.
- Good outcome in all type I fracture, but poor in most type II and III
- Crosby suggest operative treatment in these fracture.
Crosby et al.,Computerized tomography scanning of acute intra-articular fractures of the calcaneus. A new classification system. The journal
of Bone and joint surgery, 1990

44. Kitaoka et al.
Kitaoka et al., Displaced intra-articular fractures of the calcaneus treated non-operatively. Clinical results and analysis of motion and ground
reaction and temporal forces. The journal of Bone and joint surgery, 1994

45. Kitaoka et al.
Kitaoka et al., Displaced intra-articular fractures of the calcaneus treated non-operatively. Clinical results and analysis of motion and ground
reaction and temporal forces. The journal of Bone and joint surgery, 1994
- Fractures in 16 patients treated non operatively and use gait analysis to evaluate outcome.
- They were followed up 6 years(mean)
- Most patients show altered gait pattern
- Kitaoka confirm non-operative treatment led to at least some persist functional
impairment.

46. In contrast..

47. Griffin et al. Operative Versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised
controlled trial. BMJ 2014. 24th july 2014
Griffin et al.

48. Griffin et al.
Griffin et al. Operative Versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised
controlled trial. BMJ 2014. 24th july 2014
- 151 patients with acute displaced intra-articular calcaneal fractures randomly allocated to
operative (n=73) or non-operative (n=78) treatment. >> 22 tertiary hospital in UK
- The primary outcome measure was patient reported Kerr-Atkins score for pain and
function (scale 0-100, 100 being the best possible score) at two years after injury.
- They concluded that no statistical difference between operative and non-operative
treatment.

49. Griffin et al.
Griffin et al. Operative Versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised
controlled trial. BMJ 2014. 24th july 2014

50. Griffin et al.
Griffin et al. Operative Versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised
controlled trial. BMJ 2014. 24th july 2014

51. Griffin et al.
Griffin et al. Operative Versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised
controlled trial. BMJ 2014. 24th july 2014

52. Sanjay et al. Review Article: Operative versus non-operative treatment for displae intra-artiular calaneal fracture: a meta-analysis of
randomised controlled trials. Journal of Orthopedic surgery, 2016
Sanjay et al.

53. - 8 randomised controlled trials that compared operative and non-operative treatment for
displaced intra-articular calcaneal fractures.
- The primary outcome measure was pre-injury work.
- The secondary outcome were problem in wearing shoes, AOFAS score, SF36
- They concluded that operative treatment result in not only a higher rate of return to pre-
injury work, but also higher rate of complication
Sanjay et al.
Sanjay et al. Review Article: Operative versus non-operative treatment for displae intra-artiular calaneal fracture: a meta-analysis of
randomised controlled trials. Journal of Orthopedic surgery, 2016

54. Sanjay et al. Review Article: Operative versus non-operative treatment for displae intra-artiular calaneal fracture: a meta-analysis of
randomised controlled trials. Journal of Orthopedic surgery, 2016
Sanjay et al.

55. Sanjay et al. Review Article: Operative versus non-operative treatment for displae intra-artiular calaneal fracture: a meta-analysis of
randomised controlled trials. Journal of Orthopedic surgery, 2016
Sanjay et al.

56. Complication
- Wound complication >> Osteomyelytis, wound dehiscence
- Risk factor: smoking, DM, open fracture, High BMI
- Post-traumatic subtalar, calcaneocuboid arthritis >> anatomical reduction is
needed
- Malunion
- Ankle/foot pad pain
- Nerve injury/entrapment >> posterior tibial n. >> heel and plantar numbness

57. Peroneal Tenosynovitis and stenosis
- Impingement >> lateral wall subluxes peroneal tendons against the distal tip of
fibular >> Adhesion and scarring
- Management: Nsaids, Stretching and strengthening exercise

58. Peroneal subluxation/dislocation
- Typical in joint depression type, fracture dislocation
- SPR injury >> result in ankle pain, instability

59. Subtalar arthritis
- Inadequate anatomical reduction
- Extensive damage at time of injury
- Intraoperative complication
- Management: Nsaids, lace up style ankle brace

60. Nerve entrapment
- Posterior tibial nerve are commonly involved.
- Secondary to soft tissue scarring
- Fracture fragment, bony exostosis >> Impingement
- Medial sided heel pain, night pain, heel and plantar numbness

61. Algorithm for treatment of calcaneal fracture
8th edition Rockwood and green’s fractures in adults, p. 2639-2688, 2015

62. Extra-Artiular
8th edition Rockwood and green’s fractures in adults, p. 2639-2688, 2015

63. Intra-articular
8th edition Rockwood and green’s fractures in adults, p. 2639-2688, 2015

64. Reference
- 8th edition Rockwood and green’s fractures in adults, p. 2639-2688, 2015
- Essex-Lopresti P. The mechanism, reduction technique, and results in
fractures of the os calcis. Br J Surg. 1952;39:395–419
- Bohler L. Diagnosis, pathology and treatment of fractures of the os calcis. J
Bone Joint Surg. 1931;13:75–89
- Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint
Surg Am. 2000;82A:225–250.
- Sanders R, Fortin P, DiPasquale T, et al. Operative treatment in 120 displaced
intraarticular calcaneal fractures. Results using a prognostic computed
tomography scan classification. Clin Orthop. 1993;87–95

65. Reference
- Sanjay et al. Review Article: Operative versus non-operative treatment for
displae intra-artiular calaneal fracture: a meta-analysis of randomised
controlled trials. Journal of Orthopedic surgery, 2016
- Kitaoka et al., Displaced intra-articular fractures of the calcaneus treated non-
operatively. Clinical results and analysis of motion and ground reaction and
temporal forces. The journal of Bone and joint surgery, 1994
- Griffin et al. Operative Versus non-operative treatment for closed, displaced,
intra-articular fractures of the calcaneus: randomised controlled trial. BMJ
2014. 24th july 2014

66. Reference
- Crosby et al.,Computerized tomography scanning of acute intra-articular
fractures of the calcaneus. A new classification system. The journal of Bone
and joint surgery, 1990
- Gray’s anatomy for medical student, 2nd edition
- Orthobullets.com

67. Thank you