ortho

1. Fracture Calcaneum and
fracture Talus
DR ASHUTOSH KUMAR
AP ORTHOPAEDICS DEPARTMENT
RMCH BAREILLY

2. Introduction
• Approximately 2% of all fractures.
• Most frequent tarsal bone fracture
• Challenging fracture for orthopadeics
• 90% occur in males between 21-45 years of age.
• Although not all these fractures have bad results, the
results of treatment of calcaneus fractures over the
years have not been good.

3. Relevant Anatomy
• Largest tarsal bone.
• Dense cancellous bone
covered with a very thin
cortical bone.
• Articular surfaces-ant half
• Post half/ tuberosity
• Plantar fascia
Functions:
• Lever arm powered by
gastrocnemius
• Foundation for body wt.
• Supports/ maintains lat.
column of foot

4. • Articular surface for cuboid
• Ant./middle/post articular
facet for talus
• Post articular facet
– Is the calcaneal portion of
the subtalar joint
– Is the largest and is convex
in shape
– Is separated by the tarsal
sinus and the tarsal
ligament from the middle
and anterior facets
• Interosseous ligament
• Sinus tarsi
Post.
Middle
Ant.
Post.
Middle
CC
Ant.

5. Sustentaculum tali:
• Projects medially and supports
the neck of talus.
• FHL passes beneath it .
• Deltoid and talocalcaneal
ligament connect it to the talus
• Clinical significance :
contained in the
anteromedial
fragment, which remains
"constant" due to medial
talocalcaneal and
interosseous ligaments

6. Ant.
process
Tuberos
ity
nSi us tarsi
Lateral Aspect

7. Classification
• Intra-articular fractures 60-75%
• Extra-articular fractures 25-30% and include :
Anterior process fractures.
Beak or avulsion fractures of the tuberosity.
Medial process fractures.
Sustentaculum tali and body fractures.

8. Anterior process fracture
• Inversion “sprain”
• Frequently missed
• Most are small: treat like
sprain
• Large/displaced: ORIF

9. Tuberosity body fracture
• Fall/MVA
• Usually non-
operative
─ Swelling control
─ Early ROM
─ PWB

10. Tuberosity avulsion fractures
• Achilles avulsion
• Wound problems
• Surgical urgency
─ Lag screws or
tension band

11. Sustentacular fracture
• May alter ST jt.
mechanics
• Most small/
nondisplaced:
─ Non-operative
• Large/ displaced
─ ORIF (med.
approach)
─ Buttress plate

12. “Intra-articular” fractures

13. Mechanism of injury
• High energy: Axial load
─ MVA, fall
 Lateral process of talus acts as
wedge
• Oblique shear
1ry # line  2 fragments:
-- Superomedial (constant)
fragment.
-- Superolateral fragment>(intra-
articular aspect through post
facet)
 2ry # line dectates whether
there is joint depression or tongue-
type fracture

14. z
Mechanism of injury

15. • Secondary fracture
line runs in one of
two planes
• beneath the facet
exiting posteriorly
in tongue-type
fracture
• behind the posterior
facet in joint
depression fractures
Mechanism of injury

16. IMAGING: plain films
Standard Views
1. Lateral
2. Broden’s
3. Axial
• Scan other
regions
- Lumbar spine?
- Contra lateral side?
- Knees?

17. Lateral view
• Bohler’s angle
• 20-40
• Gissane’s angle
• 95-105

19. Broden’s view
• Positioning
– 20° IR view (mortise)
– 10°-40° plantar flex
Demonstrating the
articular surface of the
posterior facet.

20. Axial Harris view
• Very difficult to obtain in
the acute setting
• 45° axial of heel
• 2nd toe in line w/ tibia
• Assess varus/valgus
-- Normal »10° valgus --
• Joint displacement
• Tuberosity angulation
• Heel width.

21. Imaging: CT
Coronal Axial Sagittal

22. Classifications (intra-articular)
• Several used- None are
ideal
• Most commonly used
─ Essex-Lopresti
─ Sanders

23. 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

24. Sander’s

25. Sander’s

26. Associated injuries
– Extension into the calcaneocuboid joint occurs in
63%
– Vertebral injuries in 10%
– Contralateral calcaneus in 10%
– Compartment syndrome 2-10%

27. Principles of treatment
1) No reduction, with elevation of the foot, compression
dressing, and early ROM.
2) Closed reduction, with elevation of the foot,
compression dressing, and early ROM.
3) Percutaneous reduction (Essex-Lopresti) .
4) ORIF as popularized by Palmer and McReynolds .
5) Primary arthrodesis.
• Medial approaches, lateral approaches, or dual
approaches

28. TREATMENT: historical
• <1850: bandages/elevation
• 1850: Clark: traction
• 1931: Bohler: closed red./cast
• 1952: Essex-Lopresti: perQ fixation
• 1993+: Benirschke/Letournel/Sanders:
– Extensile lateral approach & plating

29. Management of intra-articular
calcaneal fractures
• Conservative
• Operative.
 Formal ORIF
 Minimally invasive techniques
 Ex. Fixation.
 Fusion

30. Operative treatment:
Rationale
• Restore anatomy
─ Shape and alignment of hindfoot
─ Articular congruency
• Return to function & prevent arthritis
• Typically, restoring articular anatomy gives
improved results if complications are avoided

31. Difficulties with ORIF
 Difficult exposure
 Complex 3D-shape of the bone
 Ever-changing fixation devices
 Open fractures
 Osteopenic bone disease.
 Increased incidence of wound complications in patients
with DM, HTN, or PVD, and tobacco chewers and
smokers

32. Indications for ORIF
• Displaced intra-articular fractures involving the
posterior facet.
• Anterior process of the calcaneus fractures with
more than 25% involvement of the calcaneocuboid
articulation.
• Displaced fractures of the calcaneal tuberosity.
• Fracture-dislocations of the calcaneus.
• Selected open fractures of the calcaneus

33. Rel. Contraindications
• Diabetes
• Vascular insufficiency
• Smoker
• Severe swelling
• Open fractures
• Elderly
• Neuropathic
• Non-compliant pt.
• In-experienced surgeon
• Lymphedema.
• Immune compromise

34. Folk et al., JOT, 1999
• Diabetes
• Vascular insufficiency
• Smoker
• Wound problems: these factors have additive effects. If
all 3, >90%.

35. Operative treatment: contraindications
• Open Fractures
–Mostly medial wounds, varied severity
–All treated with I&D/ IV abx
–Grade II-III: 48% infections
–Grade IIIB: 77% infections & 46% BKAs
Heier KA, Infante AF, WallingAK, et al.
J Bone Joint Surg Am 2003, 85-A: 2276-82

36. Preparing Soft Tissues
• Elevation
• Compression stocking
• Cast boot
• Care of blisters
• ORIF @ 10-17 days
• + Wrinkle test

37. ORIF via Extensile Lateral Approach

39. Non touch technique

40. • Schanz pin to
manipulate tuberosity
• Clean out fracture
• Disimpact sustentacular
fragment
• Reduce tuberosity
(body) fragment to
sustentaculum

41. Tuberosity Reduction

42. Restore Joint Surface +/- graft

43. Lag screw below post
facet
≥2 screws in each major fragment

44. Fixation Options

45. • Replace lateral wall
• Apply plate
• Recheck Xrays

46. Drain and deep closure

47. Post op care
• Elevate, splint
• Sutures out @ 3 wks.
• Fracture boot
• Early motion
• NWB for 8-12 weeks
• Improvement up to 2 yrs

48. Other Surgical Options
• Closed Reduction/ Int. Fixation
–Percutaneous
–Arthroscopic assisted
• Ilizarov
• Primary Fusion.

49. Surgery: percutaneous
• Fewer wound problems
• More difficult
reductions?
• Ex. Essex-Lopresti
maneuver (Tongue type)

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

51. Primary Fusion
• Sanders type IV or
severe cartilage injury
• ORIF calcaneus, debride
cartilage, and fuse ST
joint

52. Complications
 Malunion
 Varus hindfoot
 Shortened foot = short
lever arm
 Peroneal
impingement/
dislocation
 Shoewear problems
 Valgus>varus with
surgical

53. Complications
• Stiffness
─ Prevention (early ROM)
• Subtalar arthritis
• 5-20% of calcaneal fractures may require
subtalar arthrodesis
─ NSAIDs
─ Subtalar fusion

54. Complications
• Peroneal tendon problems
─Tendonitis- NSAIDs, therapy
─Entrapped-release tendons,
exostectomy
─Dislocated-open reduction

55. Complications
Wound problems
•Apical wound necrosis
– Stop ROM
– Leave sutures in
•Infection
– Antibiotics
– I&D
– Soft tissue coverage?

56. FRACTURETALUS

57. Introduction
Year 1919-Anderson – reported the first series of talar neck fractures in
World War I pilots and coined the term Aviators Astragalus .historically
refered to the rudder bar of a crashing airplane impacting the plantar
aspects of the foot resulting talar neck fracture.





The Talus (in latin ankle) is the 2ndlargest tarsal bone.
It lies between the Tibia above and Calcanium below, gripped on the
side by two malleoli.
60% is covered with articular cartilage
Talus fracture incidence 0.1 to 0.85% of all fractures and 5 to 7 % of
foot fractures.
14 to 26 % associated with # medial malleolus.

58. BriefAnatomy
 PARTS OF TALUS
1.HEAD
2.NECK
3.BODY
4.LATERAL
PROCESS
5.POSTERIOR
PROCESS

59. Anatomy

NECK OF TALUS
Constricted potion of bone between the
body and the oval head .
 Directed forward , medial and downward
 Angle of medial deviation is 15 to 20
degree in adults
 Plantar deviation is 24 degree approx
 Neck body angle is 150 degree in adults
 Relatively thin diameter makes it weaker
area and hence more vulnerable to
fractures

60. Anatomy HEAD OF TALUS
 Anterior articular surface is large , oval and convex articulating with
navicular bone
 Inferior surface have two facets medial and lateral for articulation with
calcaneum

61. Anatomy
 TARSAL CANAL
 Formed of sulcus of inferior
surface of talus and superior
sulcus of calcaneum
 Contents- artery of tarsal
canal and talocalcaneal
interosseous ligament
 Posterior process has a medial
and lateral tubercle separated
by a groove for the flexor
hallucis longus tendon

62. Anatomy
 Talus Articulates with 4
bones
 1.Tibia
 2. Fibula
 3. Calcaneus
 4. Navicular

63. Anatomy


ATTACHMENTS
NO MUSCLE
ATTACHMENTS
 Medial side


Anterior Tibio talar ligament
Posterior tibio talar ligament
•

Lateral side
Anterior talo fibular ligament


Posteriorly
Posterior talo fibular
ligament

64. Blood supply of talus -
EXTRAOSEOUS
ANTERIOR TIBIAL
ARTERY(36.2%)
POSTETIOR TIBIAL
ARTERY(47 %)
EXTRAOSSEOUS ARTERIES INCLUDE
ANTERIR TIBIAL OR DORSALIS PEDIS
ARTERY WHICH IS SMALLER TERMINAL
BRANCH OF POPLITEAL ARTERY.
POSTERIOR TIBIAL ARTERY WHICH IS
LARGER TERMINAL BRANCH OF POPLITEAL
ARTERY .
PEROFORATING PERONEAL ARTERY
BRANCH OF POSTERIOR TIBIALARTEY
THESE ARTEIES ANASTOMOSE TO FORM
SLING AROUND THE TALUS WHIS IS
SOURCE OF INTERAOSSEOUS BLOOD
SUPPLY OF TALLUS .
PERFORATING
PERONEAL
ARTERIES(16.9 %)
ARTERY TO
TARSAL SINUS

65. Blood supply to Tarsal Canal
This arises from the
Posterior tibial artery
1cm proximal to the
origin of medial and
lateral plantar artery
MEDIAL AND
LATERLA PLANTAR
ARTERIES
ARTERY TO TARSAL
CANAL

66. Blood supply of talus-
INTERAOSSEOUS
CORONAL SECTION

67. FRACTURE TALUS
ANATOMICAL CLASSIFICATION OF TALUS FRACTURE
:-
 1. Talar neck fracture
 2. Talar body fracture
 3. Talar head fracture
 4. Lateral process fracture
 5. Posterior process fracture

68. FRACTURE NECK OF TALUS
 Constitue 30 % of talar fractures.


MECHANISM OF INJURY
Forced hyperdorsiflexion of the ankle and
impingement of the taller neck on the distal
anterior tibia .


In children, mc cause - Fall from height
Talus fractures frequently occur in a young and
active population

69. CLINICAL EVALUATION
•


Clinical Features:
Intense pain , unable to move ankle,
Gross edema and echymosis usually present




When there is subluxation or dislocation the normal
contours of ankle and hind foot are distorted
Diffuse swelling of hind foot with tenderness at the talar and
subtalar joint.
Neuro vasular examination should be performed.
Associated # of the foot and ankle are commonly seen with
# of talar neck and body.

70. HAWKIN CLASSIFICATION OF
TALAR NECK FRACTURE
 Hawkins 1970 - talar neck fractures into four
types
 Canale and Kelly added type IV
 Based on displacement of body of talus.
 Useful to predict long term outcome and
development of avn of talar body

71. HAWKINS TYPE 1
 Undisplaced
fracture of talar
neck.
 Here medial blood
supply is still
assured

72. HAWKINS TYPE 2
 Displaced fracture
of the talar neck
with subtalar
dislocation or
subluxation.
 The medial blood
supply may be
preserved.

73. HAWKINS TYPE 3
 Associated Sub Talar
and Ankle
dislocation.
 All medial blood
supply to the body is
disrupted

74. HAWKINS TYPE 4
 (Canale and Kelly) Type 3
with associated Talonavicular
sublaxation and dislocation.
 Worst prognosis because of
avn of the body and often of
the head fragment

75. RADIOGRAPHIC
EVALUATION
 XRAYS
 AP VIEW – Alignment of Talar body
 ANKLE MORTISE VIEW -
 LATERAL VIEW – Talar neck and alignment of posterior
facet of subtalar joint
 CANALE VIEW – This provides optimum view of Talar
neck

76. RADIOGRAPHIC XRAYS


CANALE AND KELLY
VIEW
view of the talar neck
achieved by ankle in
maximum equinus, foot
placed on a cassette,
pronated 15 deg and the
radiographic source is
directed 15 deg from vertical.
 This view described for
evaluation of post traumatic
deformity and is difficult to
obtain in the acute setting.

77. DIAGNOSIS


CT SCAN
give excellent visualization of
the congruity of the subtalar
joint and provide superior
details of fracture.
 small but significant fractures
of the inferior aspect of the
talus, are better appreciated
on CT scans compared to
plain xray films alone.

78. DIAGNOSIS


MRI SCAN
demonstrates
osteonecrosis most
effectively.


Use of titanium screws
have been preffered if
AVN of bone is
suspected.
.

79. TREATMENT
 Goals of treatment:
1. Early anatomic reduction of the neck fracture
2. Reduction of dislocated joints
3. Stable fixation
4. Avoidance of complications

80. TREATMENT
 Non displaced # (Hawkins Type I )
 Non operative management
 Treated with below knee non weight bearing cast with ankle in slight
equinus for 1 month
 Cast should be removed and short leg walking cast is applied for 2 more
months until Clinical and x-ray signs of healing appears.
 Once secure union is achieved active range of motion and progressive
weight bearing as tolerated is started

81. SURGICAL TECHNIQUES
 Displaced # (Hawkins Type II to IV)
 SURGICAL APPROACH –
1. Antromedial:
This approach may be extended from limited capsulotomy to wide
exposure with malleolur Osteotomy (as the # progress towards the
body).
This approach allows visualization of talar neck and body. Care must be
taken to preserve the Sephenous vein ,nerve and deltoid artery.
2. Posteriolateral:
This approach provide posterior process and talar body. The interval is
between the Peroneus brevis and FHL. Sural N must be protected. It is
usually necessary to displace the FHL from its group in the posterior
process to facilitate exposure

82. SURGICAL TECHNIQUES
 Displaced # (Hawkins Type II to IV)
 SURGICAL APPROACH –
3. Antrolateral:
This approach allows visualization of Sinus Tarsi,
Lateral Talar neck and subtalar joint. Inadvertent
damage to the artery of tarsal sinus.
4. Combined Anteriomedial and Anteriolateral:
This is often used to allow maximum visualization
of talar neck.

83. TREATMENT




Hawkins Type III and Type IV fracture
Is Orthopaedic Emergency for two reasons:
1.Pressure from the dislocated body on the skin and neurovascular
structure can lead to skin slough, neurovascular insult.
2. Blood supply to the talus is compromised and leads to avascular
necrosis.
 Almost all require surgical stabilization



SCREW FIXATION
ANTERIOR TO POSTEROR
POSTERIOR TO ANTERIOR
• DIRECT PLATE FIXATION

84. TREATMENT OPTIONS
 Screw fixation
Advantages Disadvantages
Anterior-to-posterior
screw fixation1
1. Directvisualization
of fracture reduction
1.Difficulttoinsert
perpendicularto
fractureline
2. Avoidanceof
articularcartilage
damage
2.Lessstrong
comparedtoposterior-
to-anteriorscrewsand
platefixation
3. Useof compression
screwswhere
indicated
3.Inappropriateuseof
compressionmay
causemalalignment,
especiallyvarus

85. TREATMENT OPTIONS
 Screw fixation
Advantages Disadvantages
Posterior-to-Anterior
screw fixation1
Strongerfixation
comparedwithanterior
screwfixation
Indirect visualization of
reduction; may require
changein positioning
Easilyinserted
perpendicularto
fractureline
Somecartilage
damagetoposterior
talus.
Maycauselesssoft
tissuedisruption
Riskof iatrogenic
nerve damage

86. TREATMENT OPTIONS
 Plate fixation
Advantages Disadvantages
Direct Plate Fixation 1. Strong
fixation
1. Extensive
softtissue
dissection
2. Usefulto
buttress
comminute
d columns
2. Riskof
hardware
prominence

87. HAWKINS SIGN
Osteonecrosis is identified based on AP
radiograph between 6 and 8 week
 Subchondral lucency is indicative of
relative osteopenia secondary to bony
resorption and an intact blood supply
Progresses from medial to lateral due to vascular
re-establishing from medial side of dome through
deltoid ligament
Indicative of diffuse osteopenia with vascular
congestion suggests continuity of blood supply.
However the presence of sign doesn’t rule out the
Osteonecrosis, its absence also not diagnostic for
Osteonecrosis.

88. COMPLICATIONS
 Infection
Post Traumatic Arthritis
Delayed Union or Non Union
Malunion
Skin Slough
Inter position of long flexor tendon
Food Compartment syndrome
Osteonecrosis –
Hawkins I – 0 to 15%
Hawkins II – 20 to 50%
Hawkins III – 50 to 100%
Hawkins IV – Upto 100%

89. TALAR HEAD FRACTURE
 Plantar Flexion and Longitudinal
compression
Non displaced # - Short Leg Cast, Partial
weight bearing for 6 weeks to preserve
longitudinal arch
Displaced # - ORIF

90. LATERAL PROCESS
FRACTURE
 Foot is dorsiflexed and inverted
# are often missed on initial presentation. Misinterpreted
as ankle sprain
 CT Scan should be performed
Less than 2mm displacement - Short leg cast or boot for
6 weeks and non weight bearing atleast 4 weeks.
More than 2mm displacement – ORIF through lat.
Approach.
Comminuted # - Non viable fragment are excised.

91. POSTERIOR PROCESS
FRACTURE
 Foot is inverted
Diagnosis of # can be difficult in part relating to
the presence of an Os-Trigunm
Non displaced or minimal displaced - short leg
cast for 6 weeks and NBW for 4 weeks.
Displaced # - ORIF through Osterio lateral
approach.

92. Take home message
Thank you
• Complex injuries ,, patient education
• Don’t miss other injuries.
• Pay attention to soft tissue envelope.
• Functional impairment up to 5 years.
• Much controversies (classification, management, op
techniques…etc)
• ORIF is a good option for displaced intra-articular fractures
in selected group of pateints (on the long term)