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Calcaneal Fractures

Calcaneal Fractures. Sulaiman A. Almousa PGY3. Introduction. The most frequently injured tarsal bone 1–2% of all fractures 75% of foot fractures 25% Extra-articular 75% Intra-articular. Introduction. The management continue to be topics for debate.

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Calcaneal Fractures

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  1. Calcaneal Fractures Sulaiman A. Almousa PGY3

  2. Introduction • The most frequently injured tarsal bone • 1–2% of all fractures • 75% of foot fractures • 25% Extra-articular • 75% Intra-articular

  3. Introduction • The management continue to be topics for debate. • The irregular anatomy of the calcaneus • The delicate soft tissue envelope have made operative treatment a challenging task to orthopedic surgeon. • Considerable socio-economic impact since it usually occur in young and middle-aged male industrial workers.

  4. Anatomy

  5. Anatomy

  6. Anatomy • a cortical shell of varying thickness (thin at the lateral wall) • trabecular cancellous bone reflects : • the axial compression forces (body weight ) • The tensile forces generated by tendinous and fascial insertions. • the trabeculae are condensed beneath the posterior facet (thalamic portion). • (neutral triangle) is prone to impaction • sustentaculum tali:connected to the talus via strong medial and lateral talocalcaneal ligaments. • Within the sinus tarsi lies the talocalcaneal interosseous ligament

  7. Anatomy Normal values: Bohler=25-40 deg Gissane=100 deg

  8. Calcaneal Function • Body weight baring • lever arm to increase the power of the gastrosoleus mechanism. • Structural support for the maintenance of normal lateral column length

  9. Mechanism of Injury • High-energy axial load • Fall from a height • MVC • Fracture pattern depends on: • The direction and amount of force applied • The position of the foot at the time of impact • Bone quality

  10. Pathomechanics • The vertical load axis of the talus lies medially to that of the calcaneus • Eccentrically directed vertical axial force results in the primary frature line. • results in two main fragments: • superomedial (sustentacular) • posterolateral (tuberosity and body) • With the hindfoot in : • Eversion the fracture line runs laterally creating a large superomedial fragment • Inversion the fracture line lies more medially producing isolated fractures of the sustentaculum.

  11. Pathomechanics • If the energy is not completely expended • A secondary fracture lines develop at the posterior aspect of the subtalar joint. • If marginally involving the tuberosity will results in a joint depression type fractures • If extends longitudinally into the tuberosity results in In tongue type fractures

  12. Pathomechanics • Variable tertiary fracture lines may extend anteriorly into the calcaneocuboid joint forming an anterolateral fragment

  13. Radiography • lateral x-ray of the hindfoot: • Height of the posterior facet • Decrease in the angle of Böhler • Increase in the angle of Gissane • Double density : • If only the lateral half of the posterior facet is fractured

  14. Radiography • AP x-ray of the foot • Extension of the fracture line into the calcaneocuboid joint

  15. Radiography • Harris axial x-ray of the heel • subtalar joint surface • loss of height • increase in width • angulation of the tuberosity fragment

  16. Radiography • Brodén’s view : • articular surface of the posterior facet • patient supine • The x-ray cassette under the ankle. • The foot is in neutral flexion, and the leg is internally rotated 30 to 40 degrees • The x-ray beam then is centered over the lateral malleolus • four x-rays are made with the tube angled 40, 30, 20, and 10 degrees toward the head of the patient • the 10-degree view shows the posterior portion of the facet, • the 40-degree view shows the anterior portion.

  17. Radiography • Associated injuries: • Bilateral fractures in 5-9% • Spine fracture 10% • Other lower limb injuries 26% • Compartment syndrome up to 10%. • Spine • Other side foot xray • Ankle • Tibial plafond

  18. CT scan • Transverse Plane

  19. CT scan • Semicoronal Plane

  20. Classification

  21. Classification • Essex-Lopresti 1952 described 2 types • Tongue • Joint depression (more common)

  22. Classification Sanders Classification: • CT based • Based on the number and location of articular fracture fragments on coronal CT scans. • Type I Non-displaced fracture). • Type II Two parts fracture of the posterior facet. • Type III Three parts fracture • Type IV Four (or more) parts fracture

  23. Classification • Sub-type: • A: lateral • B: central • C: medial

  24. Classification

  25. Classification

  26. History • Mechanism of injury • Other injuries • Associated injuries • Bilateral fractures in 5-9% • Spine fracture 10% • Other lower limb injuries 26% • Compartment syndrome up to 10%. • Pain is usually severe ( bleeding into a tightly enveloped fascia of the heel)

  27. Clinical Examination • Inspection: • soft-tissue disruption • proportional to the force generated to produce the injury. • low-energy minimum swelling and ecchymosis • high-energy Severe softtissue disruption /open fractures. • Skin creases have disappeared • Blisters • Cleavage at the dermal-epidermal junction

  28. Clinical Examination • The heel is tender to palpation. The patients • Palpation of the lateral malleolus peroneal tendons have dislocated. • Unable to fully to pronate and supinate the foot. • lateral bulging and valgus deformity of the hindfoot • Compartment syndrome of the foot has to be ruled out.

  29. Calcaneal fractures • Extraarticular 25% • Intraarticular 75%

  30. Extra-articular fractures • 25% of all calcaneus fractures • Lower energy/simple injuries • usually affect • the anterior process • The tuberosity • the body of the calcaneum • the sustentaculumtali • Treated conservatively

  31. Anterior process fractures • two types : • avulsion of the bifurcate ligament. • affecting the upper and lateral part of the Anterior process • Conservative treatment • intra-articular fracture affecting the calcaneocuboid joint • eversion in dorsiflexion • Associated with intra-articular fractures of the subtalar joint

  32. Anterior process fractures • Best seen on oblique view • Below knee walking cast • WBAT 4-6 weeks • Consider ORIF if >25% articular surface

  33. Fractures of the body • Body Fracture • posterior and inferior parts of the body lying behind the posterior facet • conservatively treated • NWB or TTWB for 4-6 weeks • ORIF for loss of height or heel widening

  34. Fractures of the tuberosity • Avulsion of the tendo Achilles or direct blow • Positive Thompson test • equinus BKC • CRPP or screw if fx displace • Plantar flexion and bone tenaculum • 7.3mm cannulated screw • 6-8 weeks casting in equinus

  35. Intra-articular fractures • 75% • Operative vs. non-operative

  36. Non-operative treatment • Indications: • non-displaced fractures (Sanders type I) Sanders R (1992)J Orthop Trauma Sanders R, (1993) Clin Orthop • patients with severe PVD/ IDDM • Medical co-morbidities prohibiting surgery • elderly patients who are minimal ambulators • Chronological age itself is not a contraindication to surgical treatment • fractures with large open wounds

  37. Non-operative treatment • Initial splint immobilization to allow dissipation of the acute fracture hematoma • Elastic compression stocking to lessen dependent edema • Fracture boot locked in neutral flexion to prevent an equinus contracture. • Early range of motion exercises • Weight bearing is not allowed for 10–12 weeks until radiographic union

  38. Operative Treatment • Indications: • Displaced intra-articular fractures involving the posterior facet. • The primary goal of surgery: • anatomic restoration of alignment • return of function without pain.

  39. Timing of surgery • Should be performed within the first three weeks before fracture consolidation • However, Surgery must be delayed until the associated soft tissue swelling markedly decreased. • to reduce edema: • Splinting • Elevation • Jones dressing • Elastic compression stocking • Fracture boot locked in neutral flexion • foot pump

  40. Timing of surgery • Positive wrinkle test • The patient dorsiflexes and everts the foot. • If skin-wrinkling is seen and no pitting edema is evident operative intervention may be undertaken.

  41. Closed reduction/percutaneous pining • Essex-Lopresti technique • Tongue type (Sanders type IIC) • Prone position • Two teminally-threaded 3.2 mm guide pins • The reduction is then performed according to the method of Tornetta

  42. ORIF • Goals • Reduction/fixation of posterior facet • Correct loss of height/increased width • Fix calcaneocuboid, ant/mid facet fx’s

  43. Patient positioning • lateral decubitus /prone position • Translucent table • Tourniquet • Flex the operative limb at the knee • Extended the non-operative limb • an operating “platform” is created with blankets and foam padding to elevate the operative limb

  44. Approach • 2 cm proximal to the tip of the lateral malleolus lateral to the Achilles tendon • Junction of the skin of the lateral foot and heel pad • A full-thickness, subperiosteal flap • The calcaneofibular ligament is sharply released from the lateral calcaneal wall • The peroneal tendons are released from the peroneal tubercle • K-wires are placed for retraction of the flap into the fibula and the talar neck and the cuboid

  45. Reduction • Identify the fracture line • Mobilize the lateral wall fragment • Elevate the articular fragment • A periosteal elevator is into the primary fracture line to disimpact the tuberosity fragment from the sustentacular fragment, and restore calcaneal height • A 4.5 mm Schantz pin in the calcaneal tuberosity • manipulat using a longitudinal traction/medial translation/valgus angulation

  46. Medial approach • No control over the posterior facet • simple two-part • extra-articular fractures • Medial wall blow out. • Horizontal incision half way between the tip of the M.M. and the sole. • The neurovascular bundle is carefully retracted. • The abductor hallucis longus muscle is retracted downward • 25% incidence of damage to the calcaneal branch of the posterior tibial nerve Paley and Hall JBJS Am 1993

  47. Sustentacular approach • isolated sustentacular fractures • To supplement the extended lateral approach in complex fractures pattern • 3—5 cm horizontal incision directly over the sustentaculum

  48. 20 fresh frozen amputated human legs • impacted by a 20 kg weight dropped from a 155 cm height • Group 1: a lateral buttress plate and parallel screws in latero-medial direction • Group 2: a longitudinal screw was added • Applying load until the internal fixation failed.

  49. Post-operative protocol • Below knee NWB cast • sutures removed in 3 weeks • elastic compression stocking and fracture boot at 3 weeks • early range-of-motion exercises • progressive weightbearing at 10–12 weeks

  50. ORIF/primary arthrodesis • Highly comminuted intra-articular (Sanderstype IV) fractures • in the event of: • poor intra-articular reduction • severe cartilage delamination • absence of a substantial portion of the joint surface, • Extensile lateral approach re-establish calcaneal length, alignment • Remove the articular cartilage drill the subchondral surfaces of both talus and calcaneus • Supplemental cancellous autograft or allograft • Two large cannulated screws placed from posterior to anterior in diverging fashion perpendicular to the plane of the posterior facet

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