Transcript Parr- 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
 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
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INTRODUCTION
Calcaneal fractures account for 2% of all
fractures.
 Displaced intraarticular fractures represent 6075% 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.
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HISTORICAL TREATMENT OF CALCANEAL
FRACTURES
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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.
HISTORICAL TREATMENT OF CALCANEAL
FRACTURES
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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
–
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.
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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???
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RADIOGRAPHIC ANATOMY
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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.
RADIOGRAPHIC ANATOMY
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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.
Radiographic Anatomy
Compression Trabeculae
Traction Trabeculae
- THICKENED THALAMIC PORTION
- COMPRESSION TRABECULAE
- TRACTION TRABECULAE
http://radiographics.rsna.org/content/25/5/1215.long
ANATOMY
Neurovascular Bundle
 Sustentaculum Tali
 Medial Talocalcaneal
Ligament
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QUICK CLASSIFICATION
REFRESHER:
Rowe 1a: Plantar
Tuberosity
 Rowe 1c: ant
process
 Rowe IIIa
 Rowe IIIb
 Rowe Va
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Rowe 1b: ST secondary
to inversion
 Rowe IIa: Beak fx
 Rowe IIb: Avulsion fx
 Rowe IVa&b
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Rowe Vb
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
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MECHANISM OF INJURY OF
CALCANEAL FRACTURES
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
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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
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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…
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MECHANISM OF INJURY OF
CALCANEAL FRACTURES
A secondary fracture line is then resulted from
increased force9:
 Tongue-type fracture:
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Secondary fracture line runs
straight back to the posterior
border of the tuberosity, from
the crucial angle of Gissane.
MECHANISM OF INJURY OF
CALCANEAL FRACTURES
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The final stage9:
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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.
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.

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
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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 *
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OPERATIVE COMPARED WITH NONOPERATIVE TREATMENT OF DISPLACED
INTRA-ARTICULAR CALCANEAL
FRACTURES8
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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:
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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.
OPERATIVE COMPARED WITH NONOPERATIVE 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.
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OPERATIVE TREATMENT SUMMARY
Operative treatment is generally indicated for
displaced intra-articular fractures involving the
posterior facet.10
 Incision is an extensile lateral approach.
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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.
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OPERATIVE TREATMENT SUMMARY
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Immediately elevate in the ED with Jones
Compression and splint.
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Profore!
Surgery should be within 3 weeks.
 Positive wrinkle test
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REFERENCES
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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.
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7. O’Farrell DA, O'Byrne JM, McCabe JP, Stephens MM. Fractures of the os
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calcis: improved results with internal fixation. Injury. 1993;24:263-5.
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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.