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Calcaneal Fractures

Calcaneal Fractures. By Philip Parr. INTRODUCTION. Calcaneal fractures were first described by Malgaigne in 1843, but were not consistently diagnosed until the development of plain radiography in the late 1890’s. 10

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Calcaneal Fractures

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  1. Calcaneal Fractures By Philip Parr

  2. INTRODUCTION • Calcaneal fractures were first described by Malgaigne in 1843, but were not consistently diagnosed until the development of plain radiography in the late 1890’s.10 • The industrial revolution led to the development of taller buildings, and the automobile, so that falls from heights and MVA’s became increasingly more common, and remain the most common cause of calcaneal fractures.10

  3. INTRODUCTION • Calcaneal fractures account for 2% of all fractures. • Displaced intraarticular fractures represent 60-75% of all calcaneal fractures. • 10% of patients with calcaneal fractures have associated spine fractures, and 26% have other extremity injuries. • 90% of calcaneal fractures occur in young men in their working prime.

  4. Historical Treatment of Calcaneal Fractures • As early as 1908, Cotton and Wilson suggested that ORIF of a calcaneal fracture was contraindicated.1 • McLaughlin likened attempts of operative fixation as “nailing custard pie to a wall”.2 • Cotton and Wilson recommended closed treatment with use of a medially placed sandbag, a laterally placed felt pad, and a hammer to reduce the lateral wall and “reimpact” the fracture. • This treatment was abandoned in the 1920’s.

  5. Historical Treatment of Calcaneal Fractures • Bohler in 1931 recommended operative treatment. • However, operative treatment was rarely done due to technical problems associated with it. • Anesthesia not always effective • Radiology not well-developed • Abx did not exist • Sound understanding of internal fixation was lacking

  6. HISTORICAL TREATMENT OF CALCANEAL FRACTURES • Throughout the 1940’s and 1950’s treatment varied between ORIF attempts and subtalar joint arthrodesis. • In the 1960’s and 1970’s, as the result of an article by Lindsay and Dewar showing operative intervention was unnecessary, calcaneal fractures were mostly treated non-operatively.

  7. HISTORICAL TREATMENT OF CALCANEAL FRACTURES • In the last 30 years, better anesthesia, Abx, the AO principles, CT, and fluoroscopy, have allowed surgeons to obtain good outcomes with operative intervention in most fractures3. • Even with improvement, the treatment still remains challenging and with many complications.4 • To operate or not to operate???

  8. RADIOGRAPHIC ANATOMY • Bohler’s Angle- Formed by line from highest point of anterior process to highest point of posterior facet and the line running along the superior portion of the calcaneal tuberosity.

  9. RADIOGRAPHIC ANATOMY • Gissanes angle: Formed by a line that runs along the lateral border of the posterior facet, and a line extending along the beak of the calcaneus.

  10. http://radiographics.rsna.org/content/25/5/1215.long Radiographic Anatomy Compression Trabeculae - THICKENED THALAMIC PORTION - COMPRESSION TRABECULAE- TRACTION TRABECULAE Traction Trabeculae

  11. ANATOMY • Neurovascular Bundle • Sustentaculum Tali • Medial Talocalcaneal Ligament

  12. QUICK CLASSIFICATION REFRESHER: • Rowe 1a: Plantar Tuberosity • Rowe 1c: ant process • Rowe IIIa • Rowe IIIb • Rowe Va • Rowe 1b: ST secondary to inversion • Rowe IIa: Beak fx • Rowe IIb: Avulsion fx • Rowe IVa&b • Rowe Vb

  13. SANDERS CLASSIFICATION • Based on Posterior Facet • After coronal CT, Sanders typically used to classify. • A Non-displaced fracture, regardless of the amount of fracture lines is a Sanders Type I

  14. MECHANISM OF INJURY OF CALCANEAL FRACTURES

  15. MECHANISM OF INJURY OF CALCANEAL FRACTURES • High-energy • Force through subtalar joint driving talus lateral process into everted calcaneus to create fracture patterns described by Essex-Lopresti.5

  16. MECHANISM OF INJURY OF CALCANEAL FRACTURES • The “axe” of the lateral process of talus is driven into lateral wall of calcaneus. • The force extends posteriomedially into the ST and medial wall. • This produces a fracture that runs superior lateral to inferior medial.5

  17. MECHANISM OF INJURY OF CALCANEAL FRACTURES • The lateral process of the talus is impacted at the crucial angle of Gissane, which divides the lateral wall and the body of the calcaneus9. • Residual force is then dissipated medially into the sustentaculum tali which may be sheared off. • If the momentum stops here then part or all of the fissure described is what we see. • If the momentum continues however…

  18. MECHANISM OF INJURY OF CALCANEAL FRACTURES • A secondary fracture line is then resulted from increased force9: • Tongue-type fracture: • Secondary fracture line runs straight back to the posterior border of the tuberosity, from the crucial angle of Gissane.

  19. MECHANISM OF INJURY OF CALCANEAL FRACTURES • The final stage9: • The front end of the tongue is driven down, but the tuberosity is forced upwards by the ground. It separates from the body as the primary fracture line opens up.

  20. OPERATIVE VS NON-OPERATIVE CARE • Parmar et al, in a 1993 study of 56 patients who had been randomized by DOB to either operative or non-operative care, demonstrated that there was… • NO DIFFERENCE between the groups at one year of follow-up.

  21. OPERATIVE VS NON-OPERATIVE CARE • In another 1993 study by O’Farell et al, twelve patients were assigned, without randomization, to operative care and twelve were assigned to non-operative care.6 After fifteen months of follow-up, the patients who had been managed operatively had returned to work sooner and walked better than those who had been managed… • NON-OPERATIVELY

  22. OPERATIVE VS NON-OPERATIVE CARE • In a meta-analysis published in 2000, Randle et al stated that “there is a trend for surgically treated patients to have better outcomes; however, the strength of evidence for recommending operative treatment is weak.”7 • OPERATIVE TREATMENT WITH *

  23. OPERATIVE COMPARED WITH NON-OPERATIVE TREATMENT OF DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURES8 • Buckley et al published in 2002 JBJS a prospective randomized multicenter trial comparing operative treatment with non-operative treatment for displaced intra-articular calcaneal fractures. • 206 patients with 249 fractures treated operatively • 218 with 262 fractures treated nonoperatively • Certain subgroups showed better results treated operatively including: • Women • Younger patients • Patients with a lighter workload • Patients not involved in workers’ comp claims • Patients with a higher initial Bohler’s angle • Those with an anatomic reduction on post-op CT evaluation.

  24. OPERATIVE COMPARED WITH NON-OPERATIVE TREATMENT OF DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURES8 • Buckley et al study showed that overall, there was no significant difference in outcome between the operative and nonoperative groups. • However, patients undergoing nonoperative treatment of their fracture were 5.5 times more likely to require a STJ arthrodesis than those treated operatively.

  25. OPERATIVE TREATMENT SUMMARY • Operative treatment is generally indicated for displaced intra-articular fractures involving the posterior facet.10 • Incision is an extensile lateral approach. • Consistently allows reduction of the calcaneal body and restoration of calc height, length, and width, regardless of the extent of comminution, as well as reduction of the intra-articular surface when possible.* • Lag screw fixation, lag screw technique, and lateral neutralization plate of the calcaneal body. • Learning curve of 50 cases or 2 years of experience. • Sanders also concluded that articular surface in Type IV fractures was not salvageable and primary arthrodesis following calc reduction was indicated.

  26. OPERATIVE TREATMENT SUMMARY • Immediately elevate in the ED with Jones Compression and splint. • Profore! • Surgery should be within 3 weeks. • Positive wrinkle test

  27. References • 1. Cotton, F. J., and Wilson, L. T.: Fractures of the os calcis. Boston Med. J., 159: 559-565, 1908. • 2. McReynolds, I. S.: Trauma to the os calcis and heel cord. In Disorders of the Foot and Ankle, edited by M. H. Jahss. Vol. 2, pp. 1497-1538. Philadelphia, W. B. Saunders, 1982. • 3. Sanders, R: Intra-articular fractures of the calcaneus:present state of the art. J. Orthop. Trauma. 6: 252-265, 1992. • 4. Sanders, R: Displaced Intra-articular Fractures of the Calcaneus. JBJS. 2 Feb 2000 p. 225-250 • 5. Essex Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg 1952;39:395-419. • 6. Parmar HV, Triffitt PD, Gregg PJ. Intra-articular fractures of the calcaneum treated operatively or conservatively. A prospective study. J Bone Joint Surg Br. 1993;75:932-7. • 7. O’Farrell DA, O'Byrne JM, McCabe JP, Stephens MM. Fractures of the os • calcis: improved results with internal fixation. Injury. 1993;24:263-5. • 8. Buckley RE, Tough S, McCormack R, et al: Operative compared to nonoperative treatment of displaced intraarticular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am 84:1733-1744, 2002 • 9. Essex-Lopresti, P (March 1952). "The mechanism, reduction technique, and results in fractures of the os calcis.". Br J Surg.39 (157): 395–419. • 10. Coughlin and Mann. Surgery of the foot and ankle, 8th edition. “Fractures of the Calcaneus”. Pp 2017-2073.

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