2. “Outcomes in patients with calcaneal fracture have been shown to be
relatively poor, with functional outcome levels similar to patients who
underwent organ transplants or sustained myocardial infarction. “
Campbell’s 14th edition
3. Calcaneal Fracture
• Life changing injury
• Learning curve for operative treatment of this fracture is steep
• Complex challenge for both the patient and surgeon
4. Anatomy
• Largest of the seven articulating
bones that make up the tarsus
• Transfers most of the body weight
from the lower extremity to the
ground
• Has six surfaces
• blood supply - calcaneal
anastomosis - posterior tibial and
fibular arteries
• Innervation - tibial and sural nerves
7. Primary fracture line
• 75% of calcaneal fracture
• Caused by axial load mechanism
• May be associated with lumbar(10%), pelvic, tibial plateu fractures,
contralateral calcaneus(10%)
• Axial load force – shear forces toward medial wall
Lateral edge of the talus
shears the medial
“constant fragment” off
9. Secondary fracture line creates 2 types of
fractures
• If the force causing the fracture
is continued, a secondary
fracture line is created
• If the force is oriented primarily
vertically the facture propagates
anterior to the posterior facet
and exits posteriorly below the
Achilles insertion creating the
TONGUE TYPE
10. JOINT DEPRESSION TYPE
• IF however the axial force also
has an oblique or horizontal
vector the fracture exits more
anteriorly just behind the
posterior facet and this becomes
a free fragment
• This fragment is called
superolateral fragment,
semilunar , or comet fragment
11. 2 Primary types depending on direction of force
and exiting of the fracture either ant or post
• Joint Depression A
• Tongue Type B
13. Radiographic evaluation
• dorsoplantar (AP):
• frx lines will extend into anterior body of calcaneus, deforming articulation,
and severe displacement of calcaneal frx may be assoc w/ talonavicular
subluxation;
• delineates calcaneocuboid joint
• demonstrates amount of lateral spread of calcaneus
• demonstrates subluxation of talonavicular joint;
14. lateral view:
• decrease in Boher’s angle
• incongruity and loss of height of posterior facet
• increase in angle of Gissane
• Demonstrates joint depression & tongue type frx
• lateral x-rays provide minimal information about subtalar joint
• direction of the primary fracture line is typically vertical where as
secondary posterior fracture line is transversely oriented
15. Harris Beath view/
Axial projection
• demonstrates tuberosity, body, sustentaculotalar joint, & posterior
facet of the calcaneus
• amount of widening of the heel
• impingement of lateral frag on peroneal space & lateral malleolus
• degree of overiding of superomedial fragment on psoterolateral fragment, &
degree of comminution & displacement of subtalar fracture fragments
• direction of primary fracture line, lateral comminution of frx
16. Broden's View
• used to better visualize the subtal joint
• pt is supine w/ knee slightly flexed and supported by sandbag
• foot rests on the film cassette with neutral dorsiflexion;
• Technique:
40 deg showing anterior, and 10 deg showing posterior) the foot is kept
in one place, the Tube is moved…
17. Continued
• classification systems based on plain radiographs were of very little or
no prognostic value
• CT scan is an accurate method of scanning the complex calcaneal
fractures
• CT scan analysis has completely changed the treatment and prognosis
of calcaneal fractures.
• Classification systems based on CT scan are more reliable, guide
surgeons in the treatment planning, and carry prognostic value
18. Classification
• More than 40 classification systems
• Classification based on x ray
• Essex-Lopresti system
• Classification based on CT scan
• Sanders classification
19.
20. Treatment
Goals of treatment
• Prevention of swelling and pain
• Correction of anatomy towards normal
• Height – Bohlers angle
• Width
• Axis – realignment of the tuberosity into valgus position
• Impingements – decompression of the sub-fibular space for PTs
• Length
• Restoration of congruency of Post Facet of STJ and reduction of CalCub J
21. Treatment
Factors to be considered in formulating a treatment plan include
• Age of patient
• Health status
• Fracture pattern
22. Open calcaneal fracture
• Up to 39% infection rate
• Antibiotics, urgent irrigation and debridement until wound is clean
• Lateral wound and medial wound (>4cm, cant be closed, not stable
after to 10 days) - reduction through open wound & percutaneous
fixation
• medial wound <4cm and stable wound and closed fracture –standard
ORIF
23. Open reduction technique
• With in 12 to 24hr or delayed 10 to 14 days
• Minimally invasive technique are more appropriate option closer to
time of injury.
• Percutaneous technique - as soon as patient is medically stable
• Sinus tarsi approach – with in the first 10 to 14 days.
• Extensile approach – after 14 days (restoration of calcaneal
architecture can be more difficult)
• Open reduction - more difficult after 3 weeks but possible up to 4 to 5
weeks
25. ELA
Advantages
• Wide exposure
• Easier access to facet fragment
• Ability to decompress lateral fragment
• Exposure of calcaneocuboid joint
• Sufficient area for plate fixation
• More soft tissue dissection is required and a highr incidence of wound
problems occur
27. Sinus Tarsi Approach
Advantages
• Direct visualization of posterior facet
• Lower wound complication
• Incision would be used for an arthrodesis in the future
Disadvantages
• Difficult lateral wall decompression, not enough posterior exposure
• Indirect tuberosity reduction
29. Complications
Wound necrosis, dehiscence, and
infection
• Risk factors include
• Diabetes, smoking, open fracture,
single layer closure, extended time
between injury and surgery, high
body mass index.
30. Minimize infection
• Ways to minimize infection
• Stop smoking in perioperative
period
• Careful retraction of soft tissue
and maintaining full thickness flap
with extensile approach
• Drain under flap
• Two layer closure and closing the
wound from both ends to the
middle
• Suture stay for 2-3 weeks and
motion exercise avoided during
that time.
31. Closed reduction and External fixator application
Calcaneus traction compression with orthopaedic
reduction forceps combined with percutaneous
minimally invasive treatment of intra-articular
calcaneal fractures: An analysis of efficacy
Biomedicine & Pharmacotherapy
32. Complications Continued
• Loss of reduction of major fragments may result from early weight
bearing – NWB TO 6-8 WEEKS
• Malreduction – restoring proper valgus alignment, patients tolerate
varus malrotation poorly
• Sural nerve and peroneal tendon injury
• Sural nerve at proximal and distal extremities of extensile approach
• Give attention to subluxed or dislocated peroneal tendons (28%)
33. Late complications
• Regardless of treatment method,
chronic pain develops in some
patients
• Cause of chronic pain include
• Post-traumatic arthrodesis of
subtalar joint
• Lateral sub-fibular
impingement, crowding of the
peroneal tendons
• Anterior ankle impingement
• Tibial or sural nerve
complications
36. Results
• Controversy over the results of non-operative versus operative treatments
• Essex-Lopresti – 80%of patients younger than 50 years who had “successful
reduction” - satisfactory results
• Modern studies – functions outcomes are equal for both groups but
complication rates are significantly higher in patients treated operatively.
• Similar result between percutaneous fixation vs standard ORIF but
increased patients with percutaneous fixation went back home earlier and
had better range of motion.
• Greater surgeon experience – good and excellent outcomes
38. Calcaneal tuberosity fracture
• Thought to be insufficiency fracture through osteoporotic bone and in
patients with DM
• Violent contracture of triceps sura with forced dorsiflexion, knee in
full extention.
• Classification
39. Continued
• Usually fixed with screw and plates
• Suture anchor can provide greater fixation
• Lengthening of gastrocnemius muscle
• Lateral tension band
• Excision of fragment (small and medium) and fixation of Achilles to
bone
40. TA 26 yo male isolated injury to the foot
Comminuted closed joint depression fracture with large displacement of the
posterior facet and lateral wall extrusion and comminution
41. Post op xrays
• Extended L incision
• Removal of the lateral wall
• Elevation of the posterior facet
• Morselized lateral wall placed in
the void
• In ex fix for 6 weeks
42. Last follow up
• Working on ROM
• No acute complications
• Developed DM in post op period
43. RA 37 YO male fell, type 1 open Sanders 4
• Swollen with blisters on
presentation
• Pin prick opening medially
• ABX, elevation
• Closed reduction Percutaneous
fixation and distraction with EX
FIX 13 days post injury
The mechanism of intra-articular calcaneal fractures is quiet complex and controversial. Axial force transmitted from the talus is responsible for developing various fracture lines and fracture patterns of the calcaneum (Fig. 27.2). EssexLopresti has elaborated the fracture mechanism, according to which, when an axial force is applied with foot placed flat on the ground, primary fracture line is first produced laterally by the lateral edge of the talus and the calcaneus is fractured obliquely in two parts, a medial sustentacular or constant fragment and a large inferolateral fragmentAnteriorly, the fracture line may exit at the angle of Gissane or may continue further to exit at the calcaneocuboid joint.1 Posteriorly, the fracture line runs medially.1 If the force causing the fracture is continued, a secondary fracture line is created, generating a three-part fracture. Three-part fractures are further divided into two groups depending on the position of the secondary line on lateral radiographs: a tongue-type fracture and a joint depression–type fracture.4 If the force is purely axial, the secondary fracture line appears just beneath the posterior facet and passes along the body of the calcaneus to exit laterally below the tendo-Achilles, creating a tonguetype fracture6 (Fig. 27.4). If the load is slightly more horizontal, the secondary fracture line passes down to the lateral side of the calcaneum just behind the posterior facet, creating a joint depression–type fracture6 (Fig. 27.5). A free lateral piece, of posterior facet may be created in such a situation, which is known as superolateral fragment, semilunar fragment, or comet fragment. The calcaneus becomes more deformed and comminuted if the force is continued further
Technique: - w/ the patient supine, the limb is internally rotated 30 to 45 deg w/ the ankle in neutral flexion; - center x-ray beam over lateral malleolus; - take 4 exposures with the x-ray tube angled 40 deg, 30 deg, 20 deg, and 10 deg cephalad to see all aspects of posterior facet40 deg showing anterior, and 10 deg showing posterior)
