Calcaneal Fractures Flashcards
What proportion of these fractures are open?
17%
What is the aetiology of calcaneal fractures?
A fall from a height or RTA
What do you find on clinical presentation?
Diffuse pain and tenderness
Ecchymosis
swelling
widened heel- varus defomity
What are the types of calcaneal fractures?
EXTRA- ARTICULAR
INTRA-ARTICULAR
Can you describe the types of extra-artocular fractures?
ANTERIOR PROCESS fractures
TUBEROSITY BODY fractures
TUBEROSITY AVULSION fractures
SUSTENACULUM fractures
What is mechanism for anterior process fractures and their tx?
FORCED PLANTIFLEXION AND INVERSION
MOST CAST/BRACE
ORIF IF DISPLACED >25% AT CC JOINT
What is mechanism for tuberosity body fractures and their tx?
AXIAL LOADING
CT USED TO RULE OF INTRA-ART FRACTURE
DISPLACED = ORIF
What is mechanism for tuberosity avulsion fracture fractures and their tx?
FORCEFUL ACHILLES TENDON
IF SKIN COMPRISE- EMERGENCY ORIF- PERCUTANEOUS SCREW FIXATION- SUP-POST TO INFERIOR DISTAL
What is mechanism for sustenacular fractures and their tx?
HEEL LOADING AND FOOT INVERSION
SURGERY RARELY REQUIRED
ORIF IF DISPLACED
What is classification system for intra-articular fractures?
ESSEX LOPRESTI- diff between joint depression fracture and tongue type
SAUNDERS CLASSIFICATION- key one!!
Describe the SAUNDERS classification?
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
What xrays would be helpful ? what angles would you look for?
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
What is the tx of a stress calcaneal fracture?
Cast nwb 6 wks
What is the tx of a saunders 1,extra articular fracture <1cm or pt comorbdiites?
Cast nwb 10-12 wks
What tx would be for a tongue type or extra-articular fracture?
CLOSED REDUCTION AND PERCUTANEOUS PINNING
EMERGENCY IF SKIN COMPROMISE
What tx would be for a SAUNDERS type 2-3, or large displaced extra-articular fracture >1cm?
What approach would be used?
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
What are the risks of an extensile lateral approach to calcaneum?
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%
What are the outcomes of surgery dictated by?
NO OF INTRA-ARTICULAR FRAGMENTS
QUALITY IF REDUCTION of fragments
What are poor outcomes associated with?
AGE >50 OBESITY SMOKERS DM PVD BILATERAL CALCANEAL FRACTURES MULTIPLE TRAUMA MEN > WOMEN MANUAL LABOURERS WORKERS COMP
What is the tx for Saunders type IV?
PRIMARY SUBTALAR ARTHRODESIS
What are the complications of calcaneal fractures ?
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
How des the saunders classification predict outcome ?
PROGNOSIS WORSENS AS THE COMMINUTION OF POST FACET WORSENS
