Fractures of the Calcaneus

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Fractures of the Calcaneus
Cory Collinge, MD Keith Heier, MDCreated March
2004 Revised February 2007
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INTRODUCTION

• the man who breaks his heel bone is done.
• - Cotton and Henderson, 1916
• results of crush fractures of the os calcis are
  rotten.
• - Bankhart, 1942

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INTRODUCTION

• High potential for disability
• Pain
• Gait disturbance
• Unable to work
• Best treatment method controversial

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ANATOMY BONY
Medial
Sustentaculum

Tuberosity
Lateral
Sinus tarsi
Ant. process
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ANATOMY JOINTS

Calcaneo-cuboid
Subtalar
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ANATOMY FACETS of ST JOINT
Anterior
Middle
Inteross. ligament
Posterior

Tuberosity
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Peroneal Tendons
ANATOMY SOFT TISSUES
FHL
Achilles Tendon
Thin skin/ little SQ
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HINDFOOT FUNCTION

• Calcaneus
• Lever arm powered by gastrocnemius
• Foundation for body wt.
• Supports/ maintains lat. column of foot

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HINDFOOT FUNCTION

• Subtalar Joint
• Inversion/ eversion of hindfoot
• Hindfoot position locks/ unlocks midfoot joint

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EXTRA-ARTICULAR FRACTURES

• Anterior process fracture
• Tuberosity (body) fracture
• Tuberosity avulsion
• Sustentacular fracture

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ANTERIOR PROCESS FRACTURE

• Inversion sprain
• Frequently missed
• Most are small treat like sprain
• Large/displaced ORIF

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TUBEROSITY FRACTURE

• Fall/MVA
• Usually non-operative
• Swelling control
• Early ROM
• PWB

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TUBEROSITY AVULSION

• Achilles avulsion
• Wound problems
• Surgical urgency
• Lag screws or tension band

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SUSTENTACULAR FRACTURE

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

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INTRA-ARTICULAR FRACTURES

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MECHANISM OF INJURY

• High energy
• MVA, fall
• Lateral process of talus acts as wedge
• Impaction fracture

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PATHOANATOMY

• Primary fracture line
• Constant fragment

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PATHOANATOMY

• Secondary fracture line
• Extends posteriorly through tuberosity
• Creates 3 parts

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1
3
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PATHOANATOMY

• Articular incongruity
• Hindfoot varus
• Shape of foot
• Wide
• Loss of height/Short
• Peroneal impingement
• Heel pad crush

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PATHOANATOMY

• Compartment syndrome (up to 10)
• pressure, limited space
• tissue perfusion
• Tense foot or marked pain
• Fasciotomy??
• Claw toes, other??

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CLINICAL PROBLEMS

• Stiffness
• Loss of normal gait
• Walk on lateral border- varus hindfoot
• Shoewear problems- wide heel
• Arthritic pain- mainly subtalar joint
• Peroneals- subluxation or entrapment
• Heel pad pain

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IMAGING Plain Films
1.

• Standard Views
• 1. Lateral
• 2. Brodens
• 3. Axial (HLA)

2.
3.
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LATERAL VIEW
Bohlers Angle
Gissanes Angle

Normal 25-40
Normal 120-140
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BRODENS VIEW

• Posterior facet
• Positioning
• A. 20 IR view (mortise)
• B. 10-40 plantar flex.

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BRODENS VIEW

• Posterior facet

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AXIAL VIEW

• Assess varus/valgus
• 45 axial of heel
• 2nd toe in line w/ tibia
• Normal 10 valgus

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IMAGING CT
CORONAL

• Foot flat on table
• Coronal
• Transverse
• Sagittal Reconstruction

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IMAGING CT Scan
CORONAL

• ST joint
• Heel width/ shortening
• Lateral wall blowout
• Peroneal impingement or dislocation

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IMAGING CT Scan
TRANSVERSE
SAGITTAL
SAGITTAL

• Similar to lateral radiograph

• Calcaneocuboid jt.

• Similar to lateral Xray
  

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CLASSIFICATIONS

• Several used- None are ideal
• Most commonly used
• Essex-Lopresti
• Sanders

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ESSEX-LOPRESTI Classification

• Historical simple

• Joint depression
• Tongue type

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ESSEX-LOPRESTI

Joint Depression Tongue Type
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SANDERSCLASSIFICATION

• Based on CT findings
• joint fragments
• 2 type II
• 3 type III
• 4 or more type IV
• Subtype L ? M fx position
• Predictive of results

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SANDERS

• Example Type IIA

• 2 articular fragments
• Fracture line is lateral

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TREATMENT Historical

• lt1850 bandages/elevation
• 1850 Clark traction
• 1931 Bohler closed red./cast
• 1952 Essex-Lopresti perQ fixation
• 1993 Benirschke/Letournel/Sanders
• Extensile lateral approach plating

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NON-OP TREATMENT Natural History

• Nade and Monahan, Injury, 1973
• 57 long term symptoms (pain, swelling,
  stiffness)
• 95 symptoms on uneven ground
• 76 broad heel

As a standard treatment ..results are not
good enough and deserve further studies
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NON-OP TREATMENTComplications

• Malunion
• Varus hindfoot
• Locks midfoot
• Medializes foundation for stance
• Shortened foot short lever arm
• Peroneal impingement/ dislocation
• Shoewear problems

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NON-OP TREATMENT
Injury
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NON-OP TREATMENT
Malunion
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NON-OP TREATMENTComplications

• Malunion treatment
• Orthosis/ custom shoe
• Lateral wall exostectomy
• Peroneal tenolysis
• Subtalar fusion /- bone block
• Sliding wedge osteotomy

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NON-OP TREATMENTComplications

• Stiffness
• Prevention (early ROM)
• Therapy
• Subtalar arthritis
• NSAIDs
• Subtalar fusion

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NON-OP TREATMENTComplications

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

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NON-OP TREATMENTComplications

• Sural nerve pain
• Medications
• Orthosis
• Neurectomy
• Heel pad pain
• Orthosis

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OPERATIVE TREATMENT Natural History

• Early studies recommending non-op treatment
• Old ORIF techniques
• No CT classification
• No assessment of fracture reduction

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OPERATIVE TREATMENT Natural History

• Initial results were poor (wound problems)
• Newer ORIF techniques improved results
• Anatomic reduction for good result
• Fracture severity correlates with results
• Learning curve

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OPERATIVE TREATMENTRationale

• 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

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OPERATIVE vs. NON-OP TREATMENT

• Orthopedic literature is lacking
• No prospective, randomized studies with long term
  follow-up

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OPERATIVE vs. NON-OP TREATMENT

• Thodarson and Krueger, FA, 1996
• Matched set of op and non-op treatment
• Modern operative technique
• AOFAS scores Operative 86.7
• Non-op 55

Operative treatment successful and preferable
unless contraindications present
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OPERATIVE vs. NON-OP TREATMENT

• Canadian Calcaneus RegistryR. Buckley et al.,
  JBJS, 2002

• Prospective study- 471 calcaneus fractures
• Randomized
• ORIF vs. nonoperative treatment

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OPERATIVE vs. NON-OP TREATMENT

• Canadian Calcaneus RegistryR. Buckley et al.,
  JBJS, 2002

• Greater satisfaction rate with surgery
• Less expensive treatment is ORIF for calcaneus
  fractures (accounts for time off work and
  additional subtalar fusion)

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OPERATIVE vs. NON-OP TREATMENT

• Canadian Calcaneus RegistryR. Buckley et al.,
  JBJS, 2002
• The following did better with surgery
• Women
• Age lt29 years
• Non-Work-Comp

• Bohler angle lt10
• Comminuted fracture
• Large initial joint
• step off

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OPERATIVE TREATMENT Rel. Contraindications

• Elderly
• Neuropathic
• Non-compliant pt.
• In-experienced
• surgeon

• Diabetes
• Vascular insufficiency
• Smoker
• Severe swelling
• Open fractures

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OPERATIVE TREATMENT Contraindications

• Folk et al., JOT, 1999
• Diabetes
• Vascular insufficiency
• Smoker

Wound problems these factors have additive
effects. If all 3, gt90.
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OPERATIVE TREATMENT Contraindications

• Open Fractures
• Mostly medial wounds, varied severity
• All treated with ID/ IV abx
• Grade II-III 48 infections
• Grade IIIB 77 infections 46 BKAs

Heier KA, Infante AF, Walling AK, et al.J Bone
Joint Surg Am 2003, 85-A 2276-82
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OPERATIVE TREATMENT Contraindications

• Open Fracture Recommendations
• ORIF? Medial grade I open fx
• Closed treatment for all lateral wounds and grade
  III medial open fx
• Percutaneous methods?

Heier KA, Infante AF, Walling AK, et al.J Bone
Joint Surg Am 2003, 85-A 2276-82
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TREATMENT A Rational Approach?

• Many treatment methods attempted
• Best method remains controversial
• Assess each case individually
• Injury/ patient/ surgeon
• Risks vs. benefits

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ORIF via Extensile Lateral Approach

Benirschke/Sangeorzan, Clin Orthop, 292 128,
1993 Letournel, Clin Orthop, 290 60,
1993 Sanders et al., Clin Orthop, 290, 87, 1993
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Surgical TipsPreparing Soft Tissues

• Elevation
• Compression stocking
• Cast boot
• ORIF _at_ 10-17 days
• Wrinkle test

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Surgical TipsPositioning

• Lateral decubitus

• L incision

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Surgical TipsExposure

• No touch technique

• Lateral wall removed

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Surgical TipsRestore Joint Surface

• Schanz pin to manipulate tuberosity
• Clean out fracture
• Disimpact sustentacular fragment

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Surgical TipsTuberosity Reduction

• Reduce tuberosity (body) fragment to
  sustentaculum
• 1. Restore height
• 2. Restore valgus
• 3. Medial translation

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Reduce Body
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Surgical TipsTuberosity Reduction

• Pin reduced tuberosity

• Assess radiographically

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Lateral view
Axial view
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Surgical TipsRestore Joint Surface
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Surgical TipsRestore Joint Surface
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Surgical TipsRestore Joint Surface

• Reduce post. facet
• fragments if comminuted
• Multiple K-wires/ pins/
• mini-frag screws
• Reduce post. facet to sustentaculum-ant. process

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Fixation Options
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Surgical Tips Plate Application

• Replace lateral wall
• Apply plate
• Recheck Xrays

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Surgical TipsImplant Placement
Lag screw below post facet
2 screws in each major fragment
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Surgical TipsImplant Placement
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Surgical TipsBone Graft?

• Bone Void Filler
• Osteoconductive
• Best with Severe Joint Depression
• May prevent late collapse?

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Surgical TipsWound Closure
Full-thickness sutures tied towards apex
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Surgical TipsDrain and Deep Closure
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Surgical TipsSkin Closure Splint
Nylon
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POSTOPERATIVE CARE

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

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OPERATIVE TREATMENT Complications

• All those of non-operative care.
• Malunion
• Stiffness
• Subtalar arthritis
• Peroneal tendons
• Sural nerve pain
• Heel pad problems, plus

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OPERATIVE TREATMENT Complications

• Wound problems
• Apical wound necrosis
• Stop ROM
• Leave sutures in
• Infection
• Antibiotics
• ID
• Soft tissue coverage?

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OPERATIVE TREATMENT Other Surgical Options

• Closed Reduction/ Int. Fixation
• Percutaneous
• Arthroscopic assisted
• Ilizarov
• Primary Fusion
• Others?

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SURGERY Percutaneous

• Fewer wound problems
• More difficult reductions?
• Ex. Essex-Lopresti maneuver

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SURGERY Percutaneous I

• Essex-Lopresti maneuver
• Tongue type fractures

Essex-Lopresti, Clin Orthop, 290 3-16, 1993
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SURGERY Percutaneous I

Essex-Lopresti, Clin Orthop, 290 3-16, 1993
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SURGERY Percutaneous II

GIII open fracture
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SURGERY Percutaneous II

• Joint elevated through open wound
• Percutaneous fixation

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SURGERY Ilizarov

• Minimally invasive
• Indirect reduction
• Learning curve
• Immediate weightbearing

Paley and Fischgrund, Clin Orthop, 290 125-131,
1993
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SURGERY Ilizarov
GIII open fracture
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SURGERY Ilizarov
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SURGERY Primary Fusion

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

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SUMMARY

• High energy injuries
• Risk for long term morbidity
• ORIF can give good, reproducible results if
  complications are avoided
• Individualize treatment
• Longterm outcomes studies are needed comparing
  treatment alternatives

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