22 Calcaneal Fracture STG.pdf

Sean T. Grambart DPM FACFAS Assistant Professor and Assistant Dean of Clinical Affairs College of Podiatric Medicine and Surgery Calcaneal Fractures: Intra-articular Objectives ❖Identify the anatomy and osseous and soft tissue relationships of the calcaneus. ❖Demonstrate knowledge of the mechanism...

Sean T. Grambart DPM FACFAS Assistant Professor and Assistant Dean of Clinical Affairs College of Podiatric Medicine and Surgery Calcaneal Fractures: Intra-articular Objectives ❖Identify the anatomy and osseous and soft tissue relationships of the calcaneus. ❖Demonstrate knowledge of the mechanism of injury of calcaneal fractures. ❖Demonstrate knowledge of the various calcaneal fracture patterns. ❖Demonstrate knowledge of conservative and surgical management of calcaneal fractures. Incidence ❖2% of all fractures ❖Most commonly fractured tarsal bone ❖60% of tarsal fractures ❖75% are displaced intra-articular fractures How bad are calcaneal fractures???? ❖“The man who breaks his heel bone is done” Cotton, 1916 ❖“Calcaneus fractures are serious and debilitating injuries in which the end result continues to be incredibly bad” Conn, 1935 ❖“Opearitve treatment of calcaneus fractures is like nailing a custard pie to the wall” McLaughlin, 1942 How bad are calcaneal fractures???? ❖Age 21-45 ❖Majority are male laborers ❖Substantial implications on the workforce and economy How bad are calcaneal fractures???? ❖Life Altering Event ❖ High risk for disability ❖ Chronic pain ❖ Gait issues ❖ Inability to return to work Anatomy - Calcaneus ❖ Counteracts the compressive forces exerted by the plantar fascia, tendons and ligaments during weightbearing ❖ Serves as the lever arm of the triceps surae ❖ Sustentaculum tali ❖ Site of insertion for the tibiocalcaneal component of the deltoid ligament and the superomedial spring ligament ❖ protrudes medially from the calcaneal body to provide a shelf of dense cortical bone to support the talar neck ❖ Fulcrum for the FHL tendon Anatomy - Calcaneus ❖ The calcaneus has four articulations with its adjacent tarsal bones: ❖ The anterosuperior calcaneus and talus share three articulating surfaces: ❖ Anterior facet ❖ Middle facet ❖ Posterior facet ❖ Posterior facet is the primary load-bearing articulation ❖ Anterior and middle facets bear more weight per until area Anatomy - Calcaneus ❖Key Concept ❖ Posterior facet slopes downward from lateral to medial ❖ Difficult to visualize during surgery ❖ Screw placement!! Anatomy - Vasculature Anatomy – Soft Tissue History ❖Patient should be asked about location and extent of pain ❖Most patients present with severe pain, soft tissue swelling, ecchymosis, and distortion of the heel contour ❖Plantar ecchymosis is commonly observed with this injury ❖Determine the degree of neurovascular compromise ❖High index of suspicion for associated injuries (up to 50%) ❖Compartment syndrome ❖Spinal injuries (10%) ❖Lower extremity (25%) Detailed History Taking ❖Pre-Injury Activities ❖Occupation ❖Social ❖PMH Physical Exam ❖Condition of the Skin ❖Fracture Blisters ❖Open Wounds ❖Skin Necrosis ❖Neurovascular ❖Toe Movement Mechanism of Injury ❖High-velocity MVA ❖Fall from height Intra-articular Fractures https://www.youtube.com/watch?v=7LKOcB-wNrM Mechanism of Injury Essex-Lopresti ❖Lateral process of the talus is driven into the critical angle like a wedge ❖Primary fracture line ❖ Travels anterolateral to posteromedial ❖ Lateral wall blowout ❖Secondary fracture line ❖ Depends on the direction of the force ❖ Posterior leads to Tongue-type ❖ Axial leads to Joint depression Imaging ❖X-rays ❖AP, Lateral, Mortise of the Ankle ❖AP, Lateral, Oblique of the Foot ❖Contralateral?? Imaging – Lateral ❖Double Density sign ❖Loss in the height of the posterior facet ❖Shortening of the calcaneus ❖Böhler’s Angle ❖ Angle is measured by a line connecting the highest point of the anterior process to the highest point of the posterior facet and a line drawn tangential to the superior edge of the tuberosity ❖ The angle is normally between 20 and 40 degrees ❖ Decrease in this angle indicating displacement of the weightbearing posterior facet Imaging - Lateral ❖Neutral Triangle ❖Critical angle of Gissane ❖ Angle is formed by two strong cortical columns, seen beneath the lateral process of the talus ❖ Form an angle between 95 to 105 degrees ❖ Increase in the angle with fracture Imaging - Lateral ❖Essex-Lopresti Classification Imaging – AP/Oblique ❖The anteroposterior view allows visualization of the calcaneocuboid joint and the distal location of the primary fracture line Special Imaging Harris Beath Axial ❖Disruption of the articular surface ❖Displacement of the lateral wall ❖Increase in heel width/translation ❖Amount of varus or valgus angulation of the tuberosity ❖Intra-Op ❖Medial wall reduction ❖Screw placement Special Imaging Broden’s Views ❖CT has replaced this pre-op ❖Allow for visualization of the entire posterior facet from posterior to anterior ❖ Patient lying supine ❖ Foot in neutral flexion and the leg internally rotated 30 degrees ❖ X-ray beam is centered on the lateral malleolus ❖ Sequential X-rays are obtained with the tube angled 40, 30, 20, and 10 degrees cephalad ❖Intraoperatively with fluoroscopy to verify reduction of the posterior facet CT Scans Sanders Classification ❖ Utilizes a coronal CT image through the widest portion of the posterior facet to describe joint depression fractures ❖ Roman numerals I through IV to indicate the number of fragments involving the posterior facet ❖ Type I is no displacement ❖ Type IV fracture identifies highly comminuted fractures with four or more fragments ❖ Letters A, B and C denote the location of the fracture lines within the posterior facet ❖ Type A represents a lateral fracture line ❖ Type B a fracture line through the middle of the facet ❖ Type C a medial fracture line adjacent to the sustenaculum tali Sanders 1 Sanders Type 2A, 2B, 2C Sanders Type 3AB, 3AC, 3BC Sanders Type 4 What do we definitely know… ❖There is significant variability in the fracture pattern of displaced intra-articular fractures. ❖3 Consistent Features: ❖ The sustentaculum tali remains attached to the talus (constant fragment) ❖ The anterior process of the calcaneus translate dorsally ❖ The tubersosity of the calcaneus displaces superiorly, rotates into varus, and shortens into the fracture How do we treat these? Results of Non-Operative Treatment ❖Long-term outcomes on 19 patients treated without surgery ❖At 10-year followup, 63% had good or excellent results on the Iowa Calcaneal Scale (ICS) and 37% had fair or poor results ❖At 20-year followup, only 47% of the patients had good or excellent results on the ICS and 53% had fair or poor results ALLMACHER, DH; GALLES, KS; MARSH, JL: INTRA-ARTICULAR CALCANEAL FRACTURES TREATED NONOPERATIVELY AND FOLLOWED SEQUENTIALLY FOR 2 DECADES. J ORTHOP TRAUMA. 20(7):464 –9, 2006. Non-Operative Treatment ❖Elevation ❖Splinting ❖Initial management may consist of a bulky Jones type compressive dressing under a posterior splint ❖Immobilization may be converted to a cast or a fracture boot within 7 to 14 days after injury ❖Begin gentle range of motion ❖Nonweightbearing for up to 12 weeks Operative Treatment ❖Indications ❖ Displaced intra-articular fractures involving the posterior facet ❖ Fracture dislocations ❖ Fractures with more than 25% involvement of the calcaneocuboid joint ❖Preparing for the future?? Operative Treatment ❖ORIF with Lateral Extensile incision ❖ORIF with Sinus Tarsi incision ❖Percutaneous ❖External-Fixation Timing of Surgery ❖Lateral extensile versus sinus tarsi versus percutaneous ❖Surgery should be delayed up to 2 to 3 weeks after injury ❖Adequate reduction of swelling and rest of the traumatized soft tissues ❖Positive wrinkle test Joint Depression-Traditional Lateral Extensile Correct All Deformities!!! Correct All Deformities!!! ❖Morphology ❖Lateral Wall Blowout ❖ Width, Varus ❖Tubersosity ❖Shortening ❖Anterior Process ❖ Height, Length ❖Calcaneocuboid Joint ❖Articular Incongruity ❖Subtalar Joint ❖ Subtalar Joint, Calcaneocuboid ❖Indirect reduction of the Joint sustentaculum tali Joint Depression-Traditional Lateral Extensile Positioning Joint Depression-Traditional Lateral Extensile ❖Skin to bone along the calcaneus ❖Flap Contains ❖ Sural Nerve ❖ Peroneal Tendons ❖ Calcaneofibular ligament Joint Depression-Traditional Lateral Extensile ❖Minimal Skin Retraction ❖K-wire Retraction ❖ Fibula ❖ Talar neck ❖ Cuboid Joint Depression-Traditional Lateral Extensile Joint Depression-Traditional Lateral Extensile Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Reduction https://surgeryreference.aofoundation.org/orthopedic- trauma/adult-trauma/calcaneous/displaced-body- fractures/orif-plate-and-screw-fixation#general- considerations Joint Depression-Traditional Lateral Extensile Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Traditional Lateral Extensile Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Traditional Lateral Extensile Reduction of the tuberosity Joint Depression-Traditional Lateral Extensile Tuberosity Fragment!!! 1. Short: Get back the Height and Length 2. Varus: Get back the valgus 3. Wide: Move it medial Joint Depression-Traditional Lateral Extensile Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Traditional Lateral Extensile Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Traditional Lateral Extensile Joint Depression-Traditional Lateral Extensile Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Traditional Lateral Extensile Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Traditional Lateral Extensile Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Traditional Lateral Extensile Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Traditional Lateral Extensile Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Traditional Lateral Extensile ❖Closure in the key! Joint Depression-Traditional Lateral Extensile Post-op Protocol ❖NWB 2-3 Weeks in a Splint ❖NWB boot for about 8 weeks/ROM ❖Weightbearing boot for 4 weeks ❖Therapy ❖Compression Socks ❖RTW?????? Why do we need to change that approach? ❖The #1 predictor of poor outcome from calcaneus fracture is stiffness ❖The most significant complications of calcaneal fracture involve soft tissue healing ❖Improved outcomes??? Why do we need to change that approach? ❖Patient’s like the idea of minimally invasive ❖Reduction in stiffness ❖Decrease hospital stay ❖Decrease healing time ❖Decrease soft tissue damage ❖Quicker to OR? Joint Depression-Sinus tarsi Approach ❖Indication ❖Sanders 2 fractures ❖Minimal anterior process/calcaneocuboid involvement ❖Poor soft tissue ❖Good surgeon ❖Sinus tarsi incisions started out at 1cm ❖We have increased the length of that incision!! Joint Depression-Sinus tarsi Approach ❖Still need to follow the reduction Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Sinus tarsi Approach Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Sinus tarsi Approach Tuberosity Fragment!!! 1. Short: Get back the Height and Length 2. Varus: Get back the valgus 3. Wide: Move it medial Joint Depression-Sinus tarsi Approach Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Sinus tarsi Approach Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Sinus tarsi Approach Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Sinus tarsi Approach Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Sinus tarsi Approach Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Sinus tarsi Approach Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Joint Depression-Sinus tarsi Approach ❖NWB 2-3 Weeks in a Splint ❖NWB boot for about 8 weeks/ROM ❖Weightbearing boot for 4 weeks ❖Therapy ❖Compression Socks ❖RTW?????? Joint Depression-Sinus tarsi Approach Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint, Calcaneocuboid Joint Percutaneous Fixation ❖Tongue Type (Sanders 2C) Percutaneous Fixation Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint Percutaneous Fixation ❖Timing of Surgery Percutaneous Fixation Correct All Deformities!!! ❖Morphology ❖ Width, Varus ❖Shortening ❖ Height, Length ❖Articular Incongruity ❖ Subtalar Joint External Fixation Percutaneous Reduction with Ring Fixation Percutaneous Reduction with Ring Fixation ❖ Soft tissue not a concern ❖Bone fragmentation not a concern ❖Distraction of the Calcaneus, STJ and Ankle joint ❖Size and Weight bearing not a factor Distraction of the Joints Allows the articular surfaces of the subtalar joint to be protected from weight bearing stresses, prevents disruption of the reduced posterior facet Goals of the Surgery ❖Soft tissue respect ❖Anatomic reduction of the Calcaneus ❖Full Weight Bearing/Immediate ❖Restoration of Function Surgical Technique Skeletal traction Fracture Reduction Surgical Technique Skeletal traction Fracture Reduction Frame Application Skeletal Traction Fracture Reduction Intra Operative Evaluation Frame Application Advantages ❖Weight Bearing Status ❖OR time ( less than 45 min) ❖Soft tissue sparring ❖Reproducible results ❖Classification System IRREVELANT Calcaneal Fractures: “Extra-Articular” ROWE CLASSIFICATION ❖I a - Fracture of the calcaneal tubercle ❖I b - Fracture of the sustentaculum tali ❖I c - Fracture of the anterior process ❖II a - Beak fracture of the tuberosity ❖II b - Avulsion fracture of the tuberosity ❖III - Oblique body fracture not involving the STJ ❖IV - Body fracture involving the STJ ❖V - Joint depression with comminution ROWE I a ❖Fall with the heel everted or inverted ❖Fracture of the medial or lateral tubercle ❖Lateral ❖Treatment depends on displacement and size of the fragment ROWE I b ❖Fall with twisting on a supinated foot ❖Fracture of the sustentaculum tali ❖First stage in a joint depression fracture ❖ROM of FHL ❖Calcaneal axial ❖Treatment depends on displacement ROWE I c ❖Supination and plantarflexion ❖Most common type I ❖Fracture of anterior process ❖MO and lateral ❖Treatment depends on displacement ROWE II a ❖Direct trauma ❖Fracture of the superior portion of the tuberosity ❖Lateral ❖Spares achilles tendon insertion ❖Treatment depends on displacement ROWE II b ❖Strong pull of achilles tendon ❖Avulsion fracture of tuberosity ❖Involves achilles tendon insertion ❖Lateral ❖Treatment depends on displacement, but favors surgical ROWE III ❖Fall from height with heel in varus or valgus ❖Fracture of body without STJ involvement ❖Most common extra-articular ❖Treatment depends on displacement ROWE IV ❖Fall from height with foot plantarflexed ❖Fracture of the body that is intra-articular ❖CT scan ❖Treatment? ❖Same as Essex-lopresti tongue type fracture ROWE V ❖Fall from height with foot dorsiflexed ❖Intra-articular fracture with joint depression and comminution ❖Same as Essex-Lopresti joint depression fracture ❖Treatment? Sustentaculum Fractures ❖Mechansim of Injury ❖Isolated sustentaculum fractures are the result of axial load and forced inversion of the hindfoot ❖Classically regarded as extraarticular fractures ❖CT analysis has shown that they are frequently associated with incongruity of the medial facet of the subtalar joint, subtalar dislocations Sustentaculum Fractures ❖Non-operative Treatment ❖ Nondisplaced or minimally displaced fractures ❖ Immobilization in a fracture boot ❖ Early range-of-motion exercises ❖ Nonweight-bearing restrictions for 10 to 12 weeks Sustentaculum Fractures ❖Operative Treatment ❖ More than 2 mm of displacement ❖ Depression of the whole medial facet ❖ Extension into the posterior facet Sustentaculum Fractures ❖Operative Treatment ❖ More than 2 mm of displacement ❖ Depression of the whole medial facet ❖ Extension into the posterior facet Anterior Process Fracture ❖Forced inversion and plantar flexion of the foot, which increases tension on the bifurcate ligament and produces an avulsion fracture ❖Fracture line exits in the calcaneocuboid joint and typically involves only a minimal portion of the articular surface ❖Degan Classificaiton ❖ Type I: Non-displaced, extra-articular ❖ Type II: Displaced, extra-articular ❖ Type III: Displaced, intra-articular Anterior Process Fracture ❖Non-operative Treatment ❖Smaller fragments with minimal intraarticular involvement ❖Nondisplaced or minimally displaced ❖Fracture boot, WB as tolerated ❖Range-of-motion exercises are begun once the acute swelling is decreased Anterior Process Fracture ❖Operative Treatment ❖Excision of Fragment ❖Painful nonunion ❖ORIF ❖Larger, displaced fragments ❖significant intraarticular involvement ❖fractures that occur as part of an unstable midfoot injury Tuberosity Avulsion Fracture ❖Violent pull of the gastrocnemius–soleus complex, such as with forced ankle dorsiflexion after a low-energy stumble and fall ❖Avulsed fragment is of variable size and typically includes the entire Achilles tendon insertion ❖Marked displacement of the fracture fragment can endanger the surrounding skin because of the limited soft tissue envelope overlying the tuberosity Tuberosity Avulsion Fracture ❖Treatment Tuberosity Avulsion Fracture ❖Treatment Calcaneal Body Fracture ❖20% of all calcaneal fractures and by definition are true extraarticular fractures with no involvement of the subtalar joint ❖Injury mechanisms identical to those of intraarticular fractures ❖ Lower energy involved = the fracture lines do not extend into the posterior facet Calcaneal Fractures Complications ❖Subtalar Arthrosis ❖ Decrease ROM ❖Wound Dehiscence ❖ Osteomyelitis ❖Loss of Fixation ❖Malaligment ❖ Subfibular Impingement Calcaneal Fractures Salvage Procedures ❖Subtalar Arthrosis ❖ Common Sequelae ❖Options ❖ In Situ ❖ Distraction Arthrodesis Calcaneal Fractures Salvage Procedures ❖Wound Dehiscence ❖ Aggressive Wound Care ❖Osteomyelitis ❖ Aggressive Debridement Thank You!