L15 calcaneus

Fractures of the Calcaneus

Cory Collinge, MD

Keith Heier, MD

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

Introduction

• High potential for disability─ Pain─ Gait disturbance─ Unable to work

• “Best” treatment method controversial

Anatomy

• Subtalar joint─ Facets: anterior, middle, posterior

• Calcaneocuboid joint• Sustentaculum• Tuberosity• Anterior process

Anatomy:

Bony

SustentaculumSustentaculumMedial

Lateral

Ant. Ant. processprocess

TuberosityTuberosity

Sinus tarsiSinus tarsi

Anatomy: Joints

SubtalarSubtalar CalcaneoCalcaneo-cuboid-cuboid

Anatomy:

Facets of ST Joint

Ant.Ant.

MiddleMiddle

Post.Post.

Tub.Tub.

IO IO lig.lig.

Anatomy:

Soft Tissues

FHL

Peroneal Tendons

Achilles Tendon

Thin Thin skin/ skin/ little SQlittle SQ

Hindfoot Function

Calcaneus• Lever arm powered by

gastrocnemius• Foundation for body wt.• Supports/ maintains lat.

column of foot

Hindfoot Function

Subtalar Joint• Inversion/ eversion of

hindfoot• Hindfoot position

locks/ unlocks midfoot joint

“Extra-articular” Fractures

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

Anterior Process Fracture

• Inversion “sprain”• Frequently missed• Most are small: treat like

sprain• Large/displaced: ORIF

• Fall/MVA• Usually non-operative

─ Swelling control─ Early ROM─ PWB

Tuberosity Fracture

Tuberosity Avulsion

• Achilles avulsion• Wound problems• Surgical urgency

─ Lag screws or tension band

Sustentacular Fracture

• May alter ST jt. mechanics • Most small/ nondisplaced:

─ Non-operative• Large/ displaced

─ ORIF (med. approach)─ Buttress plate

“Intra-articular” Fractures

Mechanism of Injury

• High energy: ─ MVA, fall

• Lateral process of talus acts as wedge

• Impaction fracture

Pathoanatomy

• Primary

fracture line

• Constant fragment

Pathoanatomy

• Secondary fracture line

• Extends posteriorly through tuberosity

• Creates 3 parts123

Pathoanatomy

• Articular incongruity• Hindfoot varus • Shape of foot

─ Wide─ Loss of height─ Short

• Peroneal impingement• Heel pad crush

Pathoanatomy

Compartment syndrome (up to 10%) pressure, limited space tissue perfusion– Tense foot or marked

pain, check pressure– Fasciotomy

Clinical Problems

• Stiffness• Loss of normal gait• Shoewear problems• Arthritic pain• Peroneal pain• Heel pad pain

Imaging: Plain Films

Standard Views• 1. Lateral• 2. Broden’s• 3. Axial (HLA)

1.1.

3.3.2.2.

Lateral View

Bohler’s Bohler’s AngleAngle Gissane’s Gissane’s

AngleAngle

Broden’s View

• Posterior facet

• Positioning

A. 20° IR view (mortise)

B. 10°-40° plantar flex.

Broden’s View

• Posterior facet

Axial View

• Assesses varus/valgus

• 45° axial of heel

• 2nd toe in line w/ tibia

• Normal 10° valgus

Imaging: CT

Foot flat on table• Coronal• Transverse• Sagittal Reconstruction

CORONALCORONAL

Imaging: CT Scan

• ST joint• Heel width/ shortening• Lateral wall• Peroneal impingement

CORONALCORONAL

Imaging: CT Scan

• Calcaneocuboid Calcaneocuboid jt.jt.

• Similar to Similar to lateral lateral radiographradiograph

TRANSVERSETRANSVERSE SAGITTALSAGITTALSAGITTALSAGITTAL

• Similar to Similar to lateral Xraylateral Xray

Classifications

• Several used- None are ideal• Most commonly used

─ Essex-Lopresti─ Sanders

ESSEX-LOPRESTI Classification

• Historical• Basic

1. Joint depression type2. Tongue type

1.

2.

ESSEX-LOPRESTI

Joint Depression Type Tongue Type

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

Sanders

Example:Type IIA

Treatment: Historical

• <1850: bandages/elevation• 1850: Clark: traction• 1931: Bohler: cl. red./cast • 1952: Essex-Lopresti: perc. fixation• 1993: Benirschke/Letournel/Sanders: “modern”

plating

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”

Non-op Treatment:Complications

Malunion • Varus hindfoot

─ Locks midfoot─ Medializes “foundation” for stance

• Shortened foot = short lever arm• Peroneal impingement/ dislocation• Shoewear problems

Non-op Treatment:Injury

Non-op Treatment:Malunion

Non-op Treatment:Complications

• Malunion treatmentOrthosis/ custom shoeLateral wall exostectomyPeroneal tenodesisSubtalar fusion +/- bone blockSliding wedge osteotomy

Non-op Treatment:Complications

• Stiffness─ Prevention (early ROM)─ Therapy

• Subtalar arthritis─ NSAIDs─ Subtalar fusion

Non-op Treatment:Complications

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

• Sural nerve pain─ Medications─ Orthosis─ Neurectomy

• Heel pad pain─ Orthosis

Non-op Treatment:Complications

Operative Treatment: Natural History

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

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

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

Operative vs. Non-op Treatment

• Orthopedic literature is lacking • No prospective, randomized studies with

longterm follow-up

Operative vs. Non-op Treatment

Thodarson and Krueger, F&A, 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 contrainications present”

Operative Treatment: Contraindications

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

• Sanders type IV (very comminuted)

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

surgeon

Operative Treatment: Contraindications

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

Wound problems: these factors have additive effects. If all 3, >90%.

Operative Treatment: Contraindications

Heier, et al., OTA, 1999/AAOS, 2000• 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

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?

Treatment: A Rational Approach?

• Many treatment methods attempted• “Best” method remains controversial• Assess each case individually

– Injury/ patient/ surgeon– Risks vs. benefits

ORIF via Extensile Lateral Approach

Benirschke/Sangeorzan, Clin Orthop, 292: 128-134, 1993

Letournel, Clin Orthop, 290: 60-67, 1993

Sanders et al., Clin Orthop, 290, 87-95, 1993

ORIF: Pre-op

• Elevation• Compression stocking• Cast boot• ORIF @ 10-14 days• + Wrinkle test

ORIF: Lateral Approach

• Lateral decubitusLateral decubitus • ““L” incisionL” incision

ORIF: Lateral Approach

• ““No touch” No touch” techniquetechnique

• Lateral wall Lateral wall removedremoved

ORIF: Lateral Approach

• Schanz pin to manipulate tuberosity

• Clean out fracture

• Disimpact sustentacular fragment

ORIF: Lateral Approach

• Reduce post. facet fragments if comm.

• K-wires/ absorbable pins

• Reduce post. facet to sustentaculum- ant. process

ORIF: Lateral Approach

• Reduce tuberosity fragment to sustentacular complex 1. Restore height2. Restore valgus3. Medial translation

ORIF: Lateral Approach

•Pin reduced Pin reduced tuberositytuberosity

•Assess Assess radiographicallyradiographically

ORIF: Lateral Approach

• Bone graft?• Replace lateral wall • Apply plate• Recheck radiographs

ORIF: Lateral Approach

• Check peroneal tendons• Drain• Layered closure

1. Periosteum/SQ 2. Skin • Atraumatic technique• Advance flap toward apex

• Splint

Postoperative Care

• Elevate, splint• Sutures out at 3 wks.• Fracture boot• Early motion• NWB for 9-12 weeks• Improvement up to 2 yrs.

Operative Treatment: Complications

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

Operative Treatment: Complications

Wound problems• Apical wound necrosis

– Stop ROM– Leave sutures in

• Infection– Antibiotics– I&D– Soft tissue coverage?

Operative Treatment: Other Surgical Options

• Closed Reduction/ Int. Fixation─ Percutaneous ─ Arthroscopic assisted

• Ilizarov• Primary Fusion• Others?

Surgery: Percutaneous

• Fewer wound problems

• More difficult reductions?

• Ex. Essex-Lopresti maneuver

Surgery: Percutaneous I

• Essex-Lopresti maneuver

• Tongue type fractures

Essex-Lopresti, Clin Orthop, 290: 3-16, 1993

Surgery: Percutaneous I

Essex-Lopresti, Clin Orthop, 290: 3-16, 1993

GIII open fractureGIII open fracture

Surgery: Percutaneous II

Surgery: Percutaneous II

• Joint elevated through open Joint elevated through open woundwound• Percutaneous fixationPercutaneous fixation

Surgery: Ilizarov

• Minimally invasive• Indirect reduction• Learning curve• Immediate

weightbearing

Paley and Fischgrund, Clin Orthop, 290: 125-131, 1993

Surgery: Ilizarov

GIII open fractureGIII open fracture

Surgery: Ilizarov

Surgery: Primary Fusion

• Sanders type IV• Severe cartilage

injury• ORIF calcaneus,

debride cartilage, and fuse

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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