Calcaneal Fractures

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 1890s.10
• The industrial revolution led to the development
  of taller buildings, and the automobile, so that
  falls from heights and MVAs 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 1920s.

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 1940s and 1950s treatment varied
  between ORIF attempts and subtalar joint
  arthrodesis.
• In the 1960s and 1970s, 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

• Bohlers 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
- THICKENED THALAMIC PORTION - COMPRESSION
TRABECULAE- TRACTION TRABECULAE
Radiographic Anatomy
Compression Trabeculae
Traction Trabeculae

• http//radiographics.rsna.org/content/25/5/1215.lo
  ng

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 IVab
• 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 OFarell 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 Bohlers 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
  calcaneuspresent 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 195239395-419.
• 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. 199375932-7.
• 7. OFarrell DA, O'Byrne JM, McCabe JP, Stephens
  MM. Fractures of the os
• calcis improved results with internal fixation.
  Injury. 199324263-5.
• 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 841733-1744, 2002
• 9. Essex-Lopresti, P (March 1952). "The
  mechanism, reduction technique, and results in
  fractures of the os calcis.". Br J Surg. 39
  (157) 395419.
• 10. Coughlin and Mann. Surgery of the foot and
  ankle, 8th edition. Fractures of the Calcaneus.
  Pp 2017-2073.