Fractures of Calcaneus - Orthopaedic Trauma - Lecture Slides, Slides of Orthopedics

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Fractures of

the Calcaneus

INTRODUCTION

“…the man who breaks his heel bone is

done.”

- Cotton and Henderson, 1916

“…results of crush fractures of the os

calcis are rotten.”

- Bankhart, 1942

INTRODUCTION

• High potential for disability

─ Pain ─ Gait disturbance ─ Unable to work

• “Best” treatment method controversial

HINDFOOT FUNCTION

Calcaneus

• Lever arm powered by gastrocnemius
• Foundation for body wt.
• Supports/ maintains lat. column of foot

HINDFOOT FUNCTION

Subtalar Joint

• Inversion/ eversion of hindfoot
• Hindfoot position locks/ unlocks midfoot joint

“EXTRA-ARTICULAR” FRACTURES

• Anterior process fracture
• Tuberosity (body) fracture
• Tuberosity avulsion
• Sustentacular fracture

ANTERIOR PROCESS FRACTURE

• Inversion “sprain”
• Frequently missed
• Most are small: treat like

sprain

• Large/displaced: ORIF

TUBEROSITY FRACTURE

• Fall/MVA
• Usually non-operative

─ Swelling control ─ Early ROM ─ PWB

TUBEROSITY AVULSION

• Achilles avulsion
• Wound problems
• Surgical urgency

─ Lag screws or tension band

SUSTENTACULAR FRACTURE

• May alter ST jt. mechanics
• Most small/ nondisplaced:

─ Non-operative

• Large/ displaced

─ ORIF (med. approach) ─ Buttress plate

MECHANISM OF INJURY

• High energy:

─ MVA, fall

• Lateral process of

talus acts as wedge

• Impaction fracture

PATHOANATOMY

• Articular incongruity
• Hindfoot varus
• Shape of foot ─ Wide ─ Loss of height/Short
• Peroneal impingement
• Heel pad crush

PATHOANATOMY

• Compartment syndrome (up to 10%)
• pressure, limited space
• ¯ tissue perfusion
• Tense foot or marked pain
• Fasciotomy??
• Claw toes, other??

CLINICAL PROBLEMS

• Stiffness
• Loss of normal gait
• Walk on lateral border- varus hindfoot
• Shoewear problems- wide heel
• Arthritic pain- mainly subtalar joint
• Peroneals- subluxation or entrapment
• Heel pad pain

IMAGING: Plain Films

Standard Views

• 1. Lateral
• 2. Broden’s
• 3. Axial (HLA)

BRODEN’S VIEW

• Posterior facet
• Positioning

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

IMAGING: CT

Foot flat on table

• Coronal
• Transverse
• Sagittal Reconstruction

CORONAL

IMAGING: CT Scan

• ST joint
• Heel width/ shortening
• Lateral wall “blowout”
• Peroneal impingement

or dislocation

CORONAL

CLASSIFICATIONS

• Several used- None are ideal
• Most commonly used

─ Essex-Lopresti ─ Sanders

ESSEX-LOPRESTI Classification

• **Historical & simple

1. Joint depression
2. Tongue type**

SANDERS

CLASSIFICATION

• Based on CT findings
• # joint fragments
  • 2 = type II
  • 3 = type III
  • 4 or more = type IV
• Subtype: L → M fx position
• Predictive of results

SANDERS

• Example: Type IIA
• 2 articular fragments
• Fracture line is lateral

TREATMENT: Historical

• <1850: bandages/elevation
• 1850: Clark: traction
• 1931: Bohler: closed red./cast
• 1952: Essex-Lopresti: perQ fixation
• 1993+: Benirschke/Letournel/Sanders:
  • Extensile lateral approach & plating

NON-OP TREATMENT:

Natural History

Nade and Monahan, Injury, 1973

• 57% long term symptoms (pain, swelling, stiffness)
• 95% symptoms on uneven ground
• 76% broad heel

As a standard treatment …..”[results] are not

good enough and deserve further studies”

NON-OP TREATMENT:

Complications

Malunion

• Varus hindfoot ─ Locks midfoot ─ Medializes “foundation” for stance
• Shortened foot = short lever arm
• Peroneal impingement/ dislocation
• Shoewear problems