MINIMALLY INVASIVE FIXATION OF CALCANEAL

FRACTURES

Dunja Delevska MS-4New York College of Podiatric Medicine

November 2012

OUTLINE

Imaging Classification Management Literature

PRESENTATION

35 y.o. male patient presents to ED with cc of foot pain b/l. S/p fell in a pothole while texting

No open fracture Patient is AAO x3 Denies LOC

IMAGINGDP X-Ray of the foot Calcaneocuboid joint

involvement Medial subluxation of

talus at TNJ – severe fractures

Lateral of the foot and ankle

Bohler’s tuberosity joint angle

Crucial angle of Gissane

IMAGING (cont.)

IMAGING (cont.)

Right foot X-Rays Evaluation: Bohler’s angle –

normal Gissane angle –

normal Increased sclerosis in

calcaneal body on MO No displacement

IMAGING (cont.)

Right foot CT Displaced?

IMAGING (cont.)

Left foot CT Displacement? Comminution?

IMAGING (cont.)

Spine X-Ray L2 compression fracture

CLASSIFICATIONROWE CLASSIFICATIONType Ia – fracture of the inferior calcaneal

tuberosity

CLASSIFICATION (cont.)

ROWE CLASSIFICATIONType Ib – sustentaculum tali fracture

CLASSIFICATION (cont.)

SANDERS CLASSIFICATION IIIACMedial edge of posterior facet (C) Through posterior facet (A)

CLASSIFICATION (cont.)

Medial primary fracture line Increased Sanders class Decrased Bohler’s angle CCJ involvement Anterior and middle facet

involvement increased severity

Silhanek et al. The Effect of Primary Fracture Line Location on the Pattern and Severity of Intraarticular Calcaneal Fractures: A Retrospective Radiographic Study. J Foot Ankle Surg. 2006 Jul/Aug; 45(4): 211-219

CLASSIFICATION (cont.)

Centrally depressed fragmentIncreased Gissane’s angle

MANAGEMENT

What should be addressed?

Immobilization of non-displaced fracture Reduction of joint depression and

correction of Gissane’s angle and cortical strut

Restoration of height and width of calcaneus

Anatomic alignment of articular surfaces Heel varus

MANAGEMENT (CONT.)

Right foot non-displaced fracture

Closed reduction (if necessary) Immobilized with below-the-knee cast Cast in mild inversion to take stress off

the fracture Early ROM of hallux to prevent

adhesion of FHL to the sustentaculum during healing

MANAGEMENT (CONT.)

Left foot comminuted fracture

General anesthesia with popliteal block Patient placed in lateral decubitus position

with left side up Minimal incision reduction with internal

fixation Fracture fragments anatomically reduced Restore posterior facet and angle of Gissane Four 4.0 cannulated screws

MANAGEMENT (CONT.)

POPLITEAL BLOCK

MANAGEMENT (CONT.)

MODIFIED OLLIER INCISION

MANAGEMENT (CONT.)

ORIF – Four 4.0 cannulated screws

MANAGEMENT (CONT.)

What was accomplished?

MANAGEMENT (CONT.)

Correction of Bohler’s angle

MANAGEMENT (CONT.)

Correction of angle of Gissane

LITERATURE REVIEW

The skin pliability and wrinkles are evaluated until the skin appears as it does here.

Bergin et al. Inpatient soft tissue protocol and wound complications in calcaneus fractures. Foot Ankle Int. 2012 Jun;33(6):492-7.

LITERATURE REVIEW (CONT.)

Mostafa et al. Surgical treatment of displaced intra-articular calcaneal fracture using a single small lateral approach. Strategies Trauma Limb Reconstr. 2010 Aug;5(2):87-95. Epub 2010 Mar 9.

LITERATURE REVIEW (CONT.)

Stulik et al. Minimally-invasive treatment of intra-articular fractures of the calcaneum. J Bone Joint Surg Br. 2006 Dec;88(12):1634-41.

LITERATURE REVIEW (CONT.)

Stulik et al. Minimally-invasive treatment of intra-articular fractures of the calcaneum. J Bone Joint Surg Br. 2006 Dec;88(12):1634-41.

LITERATURE REVIEW (CONT.)

Minimally invasive technique of Forgon and Zadravecz

Tomesen et al. Treatment of displaced intra-articular calcaneal fractures with closed reduction and percutaneous screw fixation. J Bone Joint Surg Am. 2011 May 18;93(10):920-8.

LITERATURE REVIEW (CONT.)

DeWall et al. Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures. J Orthop Trauma. 2010 Aug;24(8):466-72.

SUMMARY

Inspect for concomitant injuries and ensure patient is medically stable before definitive treatment / Inspect soft tissue

Obtain proper imaging that would aid in treatment decision making

Classify fractures to aid in surgical decision making and prognosis

Ensure proper anatomic alignment and employ stable/biologic internal fixation

REFERENCES Silhanek et al. The Effect of Primary Fracture Line Location on

the Pattern and Severity of Intraarticular Calcaneal Fractures: A Retrospective Radiographic Study. J Foot Ankle Surg. 2006 Jul/Aug; 45(4): 211-219

Bergin et al. Inpatient soft tissue protocol and wound complications in calcaneus fractures. Foot Ankle Int. 2012 Jun;33(6):492-7.

Mostafa et al. Surgical treatment of displaced intra-articular calcaneal fracture using a single small lateral approach. Strategies Trauma Limb Reconstr. 2010 Aug;5(2):87-95. Epub 2010 Mar 9.

Stulik et al. Minimally-invasive treatment of intra-articular fractures of the calcaneum. J Bone Joint Surg Br. 2006 Dec;88(12):1634-41.

Tomesen et al. Treatment of displaced intra-articular calcaneal fractures with closed reduction and percutaneous screw fixation. J Bone Joint Surg Am. 2011 May 18;93(10):920-8.

DeWall et al. Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures. J Orthop Trauma. 2010 Aug;24(8):466-72.

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