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Calcaneus Fractures

Calcaneus Fractures. presented by Sepein Chiang, DO. Introduction. Displaced, intra-articular fractures of the calcaneus are a diagnostic and therapeutic challenge Limited by radiographic examination CT has revolutionized the understanding & treatment of calcaneus fractures.

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Calcaneus Fractures

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  1. Calcaneus Fractures presented by Sepein Chiang, DO

  2. Introduction • Displaced, intra-articular fractures of the calcaneus are a diagnostic and therapeutic challenge • Limited by radiographic examination • CT has revolutionized the understanding & treatment of calcaneus fractures

  3. Historical Treatments • Originally, focus was on restoration of overall shape & correction of Bohler’s angle via a medial approach. • This lead to poor reduction of the joint surface. • Stephenson: added a lateral approach for joint reduction • Sanders: medial approach is rarely needed

  4. Anatomy • Anterior half of the superior articular surface contains 3 facets which articulate with the talus

  5. Mechanism of Injury • Fall from heights • MVA

  6. Clinical Evaluation • Neurovascular status • Soft tissue swelling • Compartment syndrome • Opposite calcaneus (10%) • Bilateral lower extremity (25%) • Vertebral fractures (10%)

  7. Radiographic Evaluation • AP • Calcaneocuboid extension • Lateral wall bulge

  8. Radiographic Evaluation • LAT • Loss of height of the posterior facet • “Double density” • Bohler’s angle: 20-40° • Gissane’s angle: 120-140°

  9. Radiographic Evaluation • Harris axial heel view • Foot in maximum dorsiflexion • Beam angled 45° cephalad • Shows subtalar joint surface, loss of height, increase in width and varus/valgus angulation

  10. Radiographic Evaluation • Broden’s views • Supine, foot in neutral flexion, internally rotated 30-40° • X-ray centered over lateral malleolus, taken at 40,30,20,10° cephalad • Shows posterior facet (10°) • Useful intra-operatively to assess reduction

  11. Broden’s Views

  12. CT Scan • Scan both feet, 3 mm cuts • Coronal: perpendicular to posterior facet • Supine, hip & knees flexed, plantar surface resting on table • Shows articular surface of posterior facet, sustentaculum tali • Transverse: perpendicular to coronal view • Extend hip & knees • Shows calcaneocuboid joint, anteroinferior aspect of the posterior facet, sustentaculum tali, lateral wall • 3D spiral CT allows rotation, sections, removal of bones

  13. Sanders’ Classification • 1986, based on Soeur & Remy classification • Based on number & location of articular fragments on coronal view • Posterior facet divided into 3 equal, potential pieces (lateral, central, medial) & sustentaculum tali

  14. Sanders’ Type I • All nondisplaced fractures, regardless of number of pieces • Usually non-operative, unless severely displaced

  15. Sanders’ Type II • Two-part fracture of the posterior facet • Subtypes IIA, IIB, IIC • Similar to a split fracture of the tibial plateau

  16. Sanders’ Type III • Three-part fractures with a centrally depressed fragment • Subtypes IIIAB, IIIAC, IIIBC • Similar to a split, depressed fracture of the tibial plateau or die-punch distal radius fracture

  17. Sanders’ Type IV • Four-part, highly comminuted • Extremely difficult to reduce the articular surface • Irreversible damage to the “intact” articular cartilage

  18. Treatment Options • Tailor to the “personality of the fracture” • Non-operative • ORIF • Primary or delayed arthrodesis • Subtalar • Triple: talonavicular, talocalcaneal, calcaneocuboid

  19. Non-operative Treatment • Extra-articular, open fractures with life threatening injuries, soft tissue compromises, severe PVD or DM, severely comminuted in osteopenic bone • Tongue type fractures with little articular comminution can be reduced percutaneously with a Steinmann pin and placed in a cast

  20. Operative Treatment • Ideally within 3 weeks • Wait for swelling to decrease • Restore articular surface of posterior facet & calcaneocuboid joint • Take the heel out of varus • Restore the length of the heel • Reduce lateral wall blowout

  21. Surgical Technique • Kocher lateral incision • “No touch” technique • Careful of sural nerve & peroneal tendons

  22. Surgical Technique • Reduce posterior facet & hold with K-wires or lag screws • Reduce calcaneocuboid joint & lateral wall • Reduce heel out to length and out of varus • 3.5 recon plate, H plate, Sanders’ Y plate • Bone grafting: controversial

  23. Primary Arthrodesis • Subtalar fusion or triple arthrodesis • Type IV- extremely difficult to reduce the articular surface • Irreversible damage to the “intact” articular cartilage

  24. Post-op Management • Bulky Jones dressing • POD 2: remove drain • POD 3: removable SLC • Early supervised subtalar ROM exercises • NWB 8-12 weeks • FWB by 3 months

  25. Complications • Wound dehiscense • Osteomyelitis • Subtalar arthritis • Peroneal tendonitis • Sural nerve injury or entrapment from scarring

  26. Conclusion • Learning curve: 35 to 50 cases, or 2 years before results can become predictable for Type II and III fractures • Type IV are so severe that even the most experienced surgeons will have difficulty • An anatomic articular reduction is necessary for a good outcome, but cannot guarantee it, due to cartilage necrosis from the original injury

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