L15 calcaneus

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  • Fractures of the Calcaneus

    Cory Collinge, MD

    Keith Heier, MD

  • Introductionthe man who breaks his heel bone is done.- Cotton and Henderson, 1916

    results of crush fractures of the os calcis are rotten.- Bankhart, 1942

  • IntroductionHigh potential for disability Pain Gait disturbance Unable to workBest treatment method controversial

  • AnatomySubtalar joint Facets: anterior, middle, posteriorCalcaneocuboid jointSustentaculumTuberosityAnterior process

  • Anatomy: Bony

    SustentaculumMedialLateralAnt. processTuberositySinus tarsi

  • Anatomy: Joints SubtalarCalcaneo-cuboid

  • Anatomy: Facets of ST JointAnt.MiddlePost.Tub. IO lig.

  • Anatomy:

    Soft TissuesFHLPeroneal TendonsAchilles TendonThin skin/ little SQ

  • Hindfoot FunctionCalcaneusLever arm powered by gastrocnemiusFoundation for body wt.Supports/ maintains lat. column of foot

  • Hindfoot FunctionSubtalar JointInversion/ eversion of hindfootHindfoot position locks/ unlocks midfoot joint

  • Extra-articular FracturesAnterior process fractureTuberosity (body) fractureTuberosity avulsionSustentacular fracture

  • Anterior Process FractureInversion sprainFrequently missedMost are small: treat like sprainLarge/displaced: ORIF

  • Tuberosity FractureFall/MVAUsually non-operativeSwelling controlEarly ROMPWB

  • Tuberosity AvulsionAchilles avulsionWound problemsSurgical urgencyLag screws or tension band

  • Sustentacular FractureMay alter ST jt. mechanics Most small/ nondisplaced: Non-operativeLarge/ displacedORIF (med. approach)Buttress plate

  • Intra-articular Fractures

  • Mechanism of InjuryHigh energy: MVA, fallLateral process of talus acts as wedgeImpaction fracture

  • Pathoanatomy Primary fracture lineConstant fragment

  • Pathoanatomy

    Secondary fracture lineExtends posteriorly through tuberosityCreates 3 parts

    123

  • PathoanatomyArticular incongruityHindfoot varus Shape of foot Wide Loss of height ShortPeroneal impingementHeel pad crush

  • PathoanatomyCompartment syndrome (up to 10%)

    pressure, limited space tissue perfusionTense foot or marked pain, check pressureFasciotomy

  • Clinical ProblemsStiffnessLoss of normal gaitShoewear problemsArthritic painPeroneal painHeel pad pain

  • Imaging: Plain FilmsStandard Views1. Lateral2. Brodens3. Axial (HLA)

    1.3.2.

    17.psd

  • Lateral View Bohlers AngleGissanes Angle

  • Brodens View Posterior facet Positioning

    A. 20 IR view (mortise) B. 10-40 plantar flex.

  • Brodens View Posterior facet

  • Axial View Assesses varus/valgus 45 axial of heel 2nd toe in line w/ tibia Normal 10 valgus

  • Imaging: CT Foot flat on tableCoronalTransverseSagittal ReconstructionCORONAL

  • Imaging: CT ScanST jointHeel width/ shorteningLateral wallPeroneal impingement

    CORONAL

  • Imaging: CT Scan Calcaneocuboid jt.

    Similar to lateral radiograph

    TRANSVERSESAGITTALSAGITTAL Similar to lateral Xray

    1.psd

  • ClassificationsSeveral used- None are idealMost commonly used Essex-Lopresti Sanders

  • ESSEX-LOPRESTI ClassificationHistoricalBasic1. Joint depression type2. Tongue type1.

    2.

  • ESSEX-LOPRESTI

    Joint Depression TypeTongue Type

  • SandersClassificationBased on CT findings# joint fragments2 = type II3 = type III4 or more = type IVSubtype: L M fx positionPredictive of results

  • Sanders Example:Type IIA

  • Treatment: Historical
  • Non-op Treatment: Natural HistoryNade and Monahan, Injury, 197357% long term symptoms (pain, swelling, stiffness)95% symptoms on uneven ground76% broad heel

    As a standard treatment ..[results] are not good enough and deserve further studies

  • Non-op Treatment:ComplicationsMalunion Varus hindfoot Locks midfoot Medializes foundation for stanceShortened foot = short lever armPeroneal impingement/ dislocationShoewear problems

  • Non-op Treatment:Injury

  • Non-op Treatment:Malunion

  • Non-op Treatment:Complications Malunion treatmentOrthosis/ custom shoeLateral wall exostectomyPeroneal tenodesisSubtalar fusion +/- bone blockSliding wedge osteotomy

  • Non-op Treatment:Complications StiffnessPrevention (early ROM)Therapy Subtalar arthritisNSAIDsSubtalar fusion

  • Non-op Treatment:ComplicationsPeroneal tendon problemsTendonitis- NSAIDs, therapyEntrapped-release tendons, exostectomyDislocated-open reduction

  • Sural nerve painMedicationsOrthosisNeurectomyHeel pad painOrthosisNon-op Treatment:Complications

  • Operative Treatment: Natural HistoryEarly studies recommending non-op treatment:Old ORIF techniquesNo CT classificationNo assessment of fracture reduction

  • Operative Treatment: Natural HistoryInitial results were poor (wound problems)Newer ORIF techniques improved resultsAnatomic reduction for good resultFracture severity correlates with resultsLearning curve

  • Operative Treatment: RationaleRestore anatomyShape and alignment of hindfootArticular congruencyReturn to function & prevent arthritisTypically, restoring articular anatomy gives improved results if complications are avoided

  • Operative vs. Non-op TreatmentOrthopedic literature is lacking No prospective, randomized studies with longterm follow-up

  • Operative vs. Non-op TreatmentThodarson and Krueger, F&A, 1996Matched set of op and non-op treatmentModern operative techniqueAOFAS scores: Operative= 86.7 Non-op= 55

    Operative treatment successful and preferable unless contrainications present

  • Operative Treatment: ContraindicationsDiabetesVascular insufficiencySmokerSevere swellingOpen fractures

    Sanders type IV (very comminuted)ElderlyNeuropathicNon-compliant pt. In-experienced surgeon

  • Operative Treatment: ContraindicationsFolk et al., JOT, 1999DiabetesVascular insufficiencySmoker Wound problems: these factors have additive effects. If all 3, >90%.

  • Operative Treatment: ContraindicationsHeier, et al., OTA, 1999/AAOS, 2000Open FracturesMostly medial wounds, varied severityAll treated with I&D/ IV abxGrade II-III: 48% infectionsGrade IIIB: 77% infections & 46% BKAs

  • Operative Treatment: ContraindicationsOpen Fracture Recommendations

    ORIF?: Medial grade I open fx Closed treatment for all lateral wounds and grade III medial open fxPercutaneous methods?

  • Treatment: A Rational Approach?Many treatment methods attemptedBest method remains controversialAssess each case individuallyInjury/ patient/ surgeonRisks vs. benefits

  • ORIF via Extensile Lateral Approach Benirschke/Sangeorzan, Clin Orthop, 292: 128-134, 1993Letournel, Clin Orthop, 290: 60-67, 1993Sanders et al., Clin Orthop, 290, 87-95, 1993

    22.psd

  • ORIF: Pre-opElevationCompression stockingCast bootORIF @ 10-14 days+ Wrinkle test

  • ORIF: Lateral Approach Lateral decubitus

    L incision

  • ORIF: Lateral Approach No touch technique

    Lateral wall removed

  • ORIF: Lateral Approach Schanz pin to manipulate tuberosity Clean out fracture Disimpact sustentacular fragment

  • ORIF: Lateral ApproachReduce post. facet fragments if comm.K-wires/ absorbable pinsReduce post. facet to sustentaculum- ant. process

  • ORIF: Lateral ApproachReduce tuberosity fragment to sustentacular complex 1. Restore height2. Restore valgus3. Medial translation

  • ORIF: Lateral Approach Pin reduced tuberosity

    Assess radiographically

  • ORIF: Lateral Approach

    Bone graft?Replace lateral wall Apply plateRecheck radiographs

    7.psd

  • ORIF: Lateral ApproachCheck peroneal tendonsDrainLayered closure1. Periosteum/SQ 2. Skin Atraumatic techniqueAdvance flap toward apex Splint

    3.psd

  • Postoperative CareElevate, splintSutures out at 3 wks.Fracture bootEarly motionNWB for 9-12 weeksImprovement up to 2 yrs.

  • Operative Treatment: ComplicationsAll those of non-operative care.MalunionStiffnessSubtalar arthritisPeroneal tendonsSural nerve painHeel pad problems, plus

  • Operative Treatment: ComplicationsWound problemsApical wound necrosisStop ROMLeave sutures inInfectionAntibioticsI&DSoft tissue coverage?

  • Operative Treatment: Other Surgical OptionsClosed Reduction/ Int. FixationPercutaneous Arthroscopic assistedIlizarovPrimary FusionOthers?

  • Surgery: PercutaneousFewer wound problemsMore difficult reductions?Ex. Essex-Lopresti maneuver

  • Surgery: Percutaneous IEssex-Lopresti maneuverTongue type fracturesEssex-Lopresti, Clin Orthop, 290: 3-16, 1993

  • Surgery: Percutaneous I

    Essex-Lopresti, Clin Orthop, 290: 3-16, 1993

  • GIII open fractureSurgery: Percutaneous II

  • Surgery: Percutaneous II Joint elevated through open wound Percutaneous fixation

  • Surgery: IlizarovMinimally invasiveIndirect reductionLearning curveImmediate weightbearingPaley and Fischgrund, Clin Orthop, 290: 125-131, 1993

  • Surgery: Ilizarov

    GIII open fracture

  • Surgery: Ilizarov

  • Surgery: Primary FusionSanders type IVSevere cartilage injuryORIF calcaneus, debride cartilage, and fuse

  • SummaryHigh energy injuriesRisk for long term morbidityORIF can give good, reproducible results i