Calcaneal Fractures

Question 1

What proportion of these fractures are open?

Answer 1

17%

Question 2

What is the aetiology of calcaneal fractures?

Answer 2

A fall from a height or RTA

Question 3

What do you find on clinical presentation?

Answer 3

Diffuse pain and tenderness
Ecchymosis
swelling
widened heel- varus defomity

Question 4

What are the types of calcaneal fractures?

Answer 4

EXTRA- ARTICULAR

INTRA-ARTICULAR

Question 5

Can you describe the types of extra-artocular fractures?

Answer 5

ANTERIOR PROCESS fractures
TUBEROSITY BODY fractures
TUBEROSITY AVULSION fractures
SUSTENACULUM fractures

Question 6

What is mechanism for anterior process fractures and their tx?

Answer 6

FORCED PLANTIFLEXION AND INVERSION
MOST CAST/BRACE
ORIF IF DISPLACED >25% AT CC JOINT

Question 7

What is mechanism for tuberosity body fractures and their tx?

Answer 7

AXIAL LOADING
CT USED TO RULE OF INTRA-ART FRACTURE
DISPLACED = ORIF

Question 8

What is mechanism for tuberosity avulsion fracture fractures and their tx?

Answer 8

FORCEFUL ACHILLES TENDON

IF SKIN COMPRISE- EMERGENCY ORIF- PERCUTANEOUS SCREW FIXATION- SUP-POST TO INFERIOR DISTAL

Question 9

What is mechanism for sustenacular fractures and their tx?

Answer 9

HEEL LOADING AND FOOT INVERSION
SURGERY RARELY REQUIRED
ORIF IF DISPLACED

Question 10

What is classification system for intra-articular fractures?

Answer 10

ESSEX LOPRESTI- diff between joint depression fracture and tongue type
SAUNDERS CLASSIFICATION- key one!!

Question 11

Describe the SAUNDERS classification?

Answer 11

Based on INTRA-ARTICULAR FRAGMENTS on CORONAL CT
TYPE 1= NONDISPLACED post facet (regardless of no of fractures)
TYPE 2 = 1 FRACTURE in POST FACET- 2 FRAGMENTS
TYPE 3= 2 FRACTURES in post facet,3 FRAGMENTS
TYPE 4= COMMINUTED, >3 Frac lines but 4+ FRAGMENTS

SUBTYPES a,b,c- where fracture lines are
a= most LATERAL + EASIEST TO FIX
C= most MEDIAL + HARDEST to fix

Question 12

What xrays would be helpful ? what angles would you look for?

Answer 12

AP, Lateral, oblique
Harris-to see tuberosity widen
Broden view- visualise post facet-neutral ankle with int rotation of X-ray 10-40 degrees

ANGLE OF GISSANE- NORMAL 135-140 intersection of anterior process and post facet- increase = flattening post facet
BOHLER ANGLE- NORMAL 20-40- intersection of line superior tuberosity to post facet and ant process to post facet. flattening of post facet decreases angle

Question 13

What is the tx of a stress calcaneal fracture?

Answer 13

Cast nwb 6 wks

Question 14

What is the tx of a saunders 1,extra articular fracture <1cm or pt comorbdiites?

Answer 14

Cast nwb 10-12 wks

Question 15

What tx would be for a tongue type or extra-articular fracture?

Answer 15

CLOSED REDUCTION AND PERCUTANEOUS PINNING

EMERGENCY IF SKIN COMPROMISE

Question 16

What tx would be for a SAUNDERS type 2-3, or large displaced extra-articular fracture >1cm?
What approach would be used?

Answer 16

ORIF
EXTENSILE LATERAL APPROACH - gives access to subtalar and CC joint
ALLOWS for lateral plate placement
HIGH RATE OF WOUND COMPLICATIONS

PIN IN TUBEROSITY- AID REDUCTION
PROVISIONAL FIXATION K WIRES
THEN PLATE
NO BENEFIT To USE OF BONE GRAFT

Question 17

What are the risks of an extensile lateral approach to calcaneum?

Answer 17

HIGH RATE OF WOUND COMPLICATIONS- DELAYED WOUND HEALING 25%
FHL RISK- during screw placement LATERAL TO MEDIAL IN sustenaculum tarsi
DEEP INFECTIONS LOWER 1-4%

Question 18

What are the outcomes of surgery dictated by?

Answer 18

NO OF INTRA-ARTICULAR FRAGMENTS

QUALITY IF REDUCTION of fragments

Question 19

What are poor outcomes associated with?

Answer 19

AGE >50
OBESITY
SMOKERS
DM
PVD
BILATERAL CALCANEAL FRACTURES
MULTIPLE TRAUMA
MEN > WOMEN
MANUAL LABOURERS
WORKERS COMP

Question 20

What is the tx for Saunders type IV?

Answer 20

PRIMARY SUBTALAR ARTHRODESIS

Question 21

What are the complications of calcaneal fractures ?

Answer 21

WOUND 10-25% esp DM, smokers, Open fractures
SUBTALAR ARTHRITIS
LAT IMPINGEMENT- PERONEUS irritation
DAMAGE TO FHL- screws lat- medial
COMPARTMENT SYNDROME
MALUNION-> LIMITED dorsiflexion-> BLOCK SUBTALAR ARTHRODESIS

Question 22

How des the saunders classification predict outcome ?

Answer 22

PROGNOSIS WORSENS AS THE COMMINUTION OF POST FACET WORSENS