Calcaneus Fractures

Question 1

Epidemiology and prognosis

Answer 1

incidence

most frequent tarsal fracture

17% open fractures

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

Question 2

Classification

Answer 2

• Extra-articular (25%)
  
  • avulsion injury of
    
    • anterior process by bifurcate ligament
    • sustentaculum tali
    • calcaneal tuberosity (Achilles tendon avulsion)
• Intra-articular (75%)
  
  • Essex-Lopresti classification
    
    • the primary fracture line runs obliquely through the posterior facet forming two fragments
      
      • superomedial fragment (constant fragment)
        
        • includes the sustentaculum tali and is stabilized by strong ligamentous and capsular attachments
      • superolateral fragment
        
        • includes an intra-articular aspect through the posterior facet
    • the secondary fracture line runs in one of two planes
      
      • the axial plane beneath the facet exiting posteriorly in tongue-type fractures
        
        • when the superolateral fragment and posterior facet remain attached to the tuberosity posteriorly
      • behind the posterior facet in joint depression fractures
  • Sanders classification
    
    • based on the number of articular fragments seen on the coronal CT image at the widest point of the posterior facet

Question 3

Sanders classification

Answer 3

Question 4

Xray views

Answer 4

1. AP foot
2. lateral
3. oblique
4. Broden View
5. Harris
6. AP ankle

Question 5

what are the xray findings

Answer 5

• double-density sign
  
  • represents subtalar incongruity
  • indicates partial separation of facet from sustentaculum
• calcaneal shortening
• varus tuberosity deformity
• decreased Bohler angle
  
  • angle between line from highest point of anterior process to highest point of posterior facet + line tangential to superior edge of tuberosity
  • measured on lateral view
  • normal 20-40°
  • represents collapse of the posterior facet
• increased angle of Gissane
  
  • angle between line along lateral margin of posterior facet + line anterior to beak of calcaneus
  • measured on lateral view
  • normal 120-145°
  • represents collapse of the posterior facet

Question 6

CT

Answer 6

• indications
  
  • gold standard
• views
  
  • 30-degree semicoronal
    
    • demonstrates posterior and middle facet displacement
  • axial
    
    • demonstrates calcaneocuboid joint involvement
  • sagittal
    
    • demonstrates tuberosity displacement

Question 7

MRI

Answer 7

indications

• used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis

Question 8

Nonoperative

Answer 8

1. cast immobilization with nonweightbearing for 6 weeks
2. cast immobilization with nonweightbearing for 10 to 12 weeks

Question 9

Operative

Answer 9

1. closed reduction with percutaneous pinning
2. ORIF
   
   1. ORIF with extensile lateral or medial approach
   2. ORIF with sinus tarsi approach and Essex-Lopresti maneuver
3. primary subtalar arthrodesis

Question 10

Complications

Answer 10

1. Wound complications (10-25%)
2. Subtalar arthritis
3. Lateral impingement with peroneal irritation
4. Damaged FHL
5. Compartment syndrome 10%
6. Malunion

Question 11

finding in malunion?

Answer 11

1. Varus deformity
2. loss of height, widening, and lateral impingement

Question 12

physical exam finding in malunion

Answer 12

• limited ankle dorsiflexion
• due to dorsiflexed talus with talar declination angle <20

Question 13

classification of malunion

Answer 13

Malunion CT Classification & Treatment

Type I • Lateral exostosis with no subtalar arthritis
• Treat with lateral wall resection

Type II • Lateral exostosis with subtalar arthritis
• Treat with lateral wall resection and subtalar fusion

Type III • Lateral exostosis, subtalar arthritis, and varus malunion
• Treat with lateral wall resection, subtalar fusion, and +/- valgus osteotomy (controversial)

Question 14

treatment of loss of hight

Answer 14

distraction bone block subtalar arthrodesis

• indications
  
  • chronic pain from subtalar joint
  • incongruous subtalar joint/post-traumatic DJD
  • loss of calcaneal height
  • mechanical block to ankle dorsiflexion
    
    • results from posterior talar collapse into the posterior calcaneus

Question 15

goal is to correct what in malunion

Answer 15

1. hindfoot height
2. ankle impingement
3. subfibular impingement
4. subtalar arthritis

Question 16

why calcaneal 3 is a bad fracture

Answer 16

1. loss of hight
2. articular incongruity

Question 17

what is the extensile lateral approach?

Answer 17

• wide exposure
• reduce everything
  
  • post facet
  • anterior process
  • tuberosity
  • lateral wall
• meticulous closure

Question 18

does surgery lead to improved outcomes for pateint with calcaneal #?

Answer 18

Biggest study done by

Buckley et al, JBJS (2002)

• 309 PT , 2-8 YRS followup
• SF-36, VAS
• Overall, no benefit to surgery for DIACF’S
• Some subgroupshad benefit
  
  1. women
  2. non work compensator
  3. young pt
  4. good reduction

Question 19

what are the problems with buckley study

Answer 19

1. 73% of pt were done by single surgeon (not multicentre)
2. 85% fixed with 1/3 tubular plate
3. no report of postop Bohler angle
4. 1/3 had Bohler <0 (not reduced)
5. 40% had >2mm step off onpostop CT

Question 20

What can we understand from the recent letrature

Answer 20

Prospective, randomized controlled trials have shown surgical treatment has no significant advantages compared with conservative care.

• Agren : surgical treatment was associated with a higher risk of complications
  
  • At 1-year follow-up, the results were not superior to those of nonoperative management.
  • At 12-year follow-up, however, surgical treatment was associated with a reduced radiographic prevalence of posttraumatic arthritis
• Ibrahim: equivalent results at 15-year follow-up.

Question 21

problems with non-op treatment

Answer 21

• loss of hight
  
  • achilles weak
  • skin contracts
• ankle impingement
  
  • ankle and subtalar arthritis

Question 22

how to retore height?

Answer 22

1. distraction bone - block
2. push screw technique