CALCANEAL FRACTURES By Philip Parr INTRODUCTION 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

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.

HISTORICAL TREATMENT OF CALCANEAL FRACTURES • • As early as 1908, Cotton and Wilson suggested that ORIF of a calcaneal fracture was contraindicated. 1 Mc. Laughlin 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 • • 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.

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 fractures 3. Even with improvement, the treatment still remains challenging and with many complications. 4 To operate or not to operate? ? ?

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.

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.

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

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

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

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

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 calcaneus 9. 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…

MECHANISM OF INJURY OF CALCANEAL FRACTURES A secondary fracture line is then resulted from increased force 9: Tongue-type fracture: 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 The final stage 9: 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 nonoperative 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

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 *

OPERATIVE COMPARED WITH NONOPERATIVE TREATMENT OF DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURES 8 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.

OPERATIVE COMPARED WITH NONOPERATIVE TREATMENT OF DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURES 8 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.

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.

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

REFERENCES 1. Cotton, F. J. , and Wilson, L. T. : Fractures of the os calcis. Boston Med. J. , 159: 559 -565, 1908. 2. Mc. Reynolds, 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, Mc. Cabe JP, Stephens MM. Fractures of the os calcis: improved results with internal fixation. Injury. 1993; 24: 263 -5. 8. Buckley RE, Tough S, Mc. Cormack 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, 8 th edition. “Fractures of the Calcaneus”. Pp 2017 -2073.