Calcaneal Fractures Flashcards
Main goal in management
- Restore the articular surface
- Restore the length, alignment and the heel width
–> to improve gait mechanics, shoe wear fitting, and to decrease post-traumatic arthritis
Non-operative management plan
- Rest
- Ice
- Elevation
- Early ROM (ankle and hind foot to prevent stiffness )
- Discontinue splinting after 5-10 days
- Non-weightbearing for 6 weeks
Gold standard approach for restoring the articular surface, heel length and width
Extended lateral approach
Why are full thickness flaps necessary?
- Avoid risk of skin necrosis
2. Avoid damage to the peroneal and lateral calcaneal arterial blood supply
Sanders classification
Types I-IV
Type I nondisplaced posterior facet (regardless of the number of fracture lines)
Type II One fracture line in the posterior facet (2 fragments)
Type III two fracture lines in the posterior facet (3 fragments)
Type IV comminuted with more than 3 fracture lines in the posterior facet
subclassified into A (lateral), B (central), and C (medial) depending on the position of the fracture line through the posterior facet
What is related to better long-term outcomes?
Good reduction
Indication Non-operative treatment
- Extra-articular fractures
- Undisplaced fractures
- Severly comminuted fractures (Sanders type IV) where the risk of surgical intervention is outweighed
Intra-articular fractures
Primary fracture line results from oblique shear and leads to the following 2 primary fragments
- Superomedial fragment (constant fragment), which includes the sustentaculum tali and is stabilised by strong ligamentous and capsular attachments
2. Superolateral fragment, which includes an Intra-articular aspect through the posterior facet
Secondary fracture lines dictate whether there is joint depression or tongue-type fracture
Extra-articular fractures
Strong association of gastrocnemius-soleus with concomitant avulsion at its insertion site on calcaneus
More common in osteopenic/osteoporotic bone
Anterior process fractures
Inversion and plantar flexion of the foot cause avulsion of the bifurcate ligament
Associated orthopaedic injuries
- Extension into the calcaneocuboid joint occurs in 63%
- Vertebral injuries in 10%
- Contralateral calcaneus in 10%
Prognosis
Poor with 40% complication rate
Increased due to mechanism (fall from height), smoking, and early surgery
Lateral soft tissue trauma increases the rate of complication
Major weight-bearing surface
Posterior facet
The flexor hallucis longus tenxon is medial to the posterior facet and inferior to the medial facet and can be injured with errant drills/screws that are too long
Sinus tarsi
Between the middle and posterior facets lies the interosseous sulcus (calcaneal groove) that together with the talar sulcus makes up the sinus tarsi
Sustentaculum tali
Projects medially and supports the neck of the talus
Flexor hallucis longus passes beneath it
Represented by the constant fragment
Deltoid and talocalcaneal ligament connect it to the talus
Contained in the anteromedial fragment, which remains ‘constant’ due to medial talocalcaneal and interosseous ligaments
Symptoms
- Pain
- Swelling
- Inability to bear weight
- Gross deformity
- Open fracture
Physical exam
- Inspection
Ecchymosis and swelling
Shortened and widened heel (may have apparent varus deformity)
Open skin lesions or fractures
Posterior heel skin compromise (tenting, Ecchymosis, or lack of skin blanching with tuberosity fractures) - necessitates urgent surgical reduction and fixation to avoid posterior heel skin necrosis)
Fracture blisters - must be debrided and epithelialized prior to surgical intervention - Palpation
Diffuse tenderness to palpation
Lack of heel cord continuity in avulsion fractures
Lack of posterior heel skin blanching with tenting fractures
Assess for compartment syndrome secondary to swelling (rare)
Presence of Langer’s lines and skin wrinkles suggests skin is appropriate for surgical intervention - Strength
Decreased ankle plantar flexion strength with avulsion fractures - Neurologic
Assess for neurologic compromise due to swelling - Vascular
Assess peripheral pulses - severe peripheral vascular disease may preclude surgical treatment due to poor wound healing
Radiographic findings
- Double density sign - represents subtalar incongruity
- Calcaneal shortening
- Varus tuberosity deformity
- Decreased Boehlers angle - represents collapse of the posterior facet
- Increased angle of Gissane - represents collapse of the posterior facet
Gold standard imaging
CT
should perform 2-3mm cuts
Primary subtalar arthrodesis
Sanders Type IV
combined with ORIF to restore height
Complications
- Wound complications (10-25%)
- Subtalar arthritis
- Lateral impingement with peroneal irritation
- Sural nerve neuroma
- Damaged Flexor hallucis longus (at risk with placement of lateral to medial screws, especially at level of sustentaculum tali (constant fragment)
- Compartment syndrome (10%)- results in claw toes
- Malunion
Distraction bone block Subtalar arthrodesis
Fusion technique for late complications of calcaneal fractures that were treated conservatively
Involves distraction of the subtalar joint, insertion of a bone block, and rigid screw fixation
If findings of anterior ankle impingement are present
