CALCANEAL FRACTURES

Dr.Thanh

CLASSIFICATION Essex-LoprestiCLASSIFICATION Essex-Lopresti

Fx of the posterior facet: 2 Types

• Joint depression: fX line producing the posterior facet fragment exits behind the posterior facet and anterior to the attachment of the tendo calcaneus:.

• Tongue: distal to the tendo calcaneus insertion.

INTRA& EXTRA-ARTICULARINTRA& EXTRA-ARTICULAR

Sanders’s classificationSanders’s classification

• Type I: All nondisplaced articular fx (less than 2 mm), irrespective of the number of fx lines.

• Type II: two-part fx posterior facet. Three Types: IIA, IIB, and IIC existed, based on the location of the primary fracture line

• Type III: three-part fX that usually featured a centrally depressed fragment

Sanders’s classificationSanders’s classification

IIIAB, IIIAC, and IIIBC, again based on the location of the primary fracture line

• Type IV: four-part articular fX, were highly comminuted and often had more than four articular fragments

• Although the subclassification of articular fx lines by medial to lateral location is important prognostically, most surgeons simply identify the number of articular fragments

Rx EVALUATIONRx EVALUATION

• Rx evaluation should include five views .

• A lateral to assess height loss (loss of Böhler angle)& rotation posterior facet .

• The axial (or Harris) view assess varus position of tuberosity & width of the heel.

A single Brodén viewA single Brodén view

• AP & oblique views assess the anterior process & calcaneocuboid involvement.

• A single Brodén view, internally rotating the leg 40° with the ankle in neutral, then angling the beam 10 to 15 °cephalad, evaluate congruency posterior facet

CT scansCT scans

• CT scans evaluate the injury completely. ordered in two planes:

• Semicoronal plane, oriented perpendicular to the normal position of the posterior facet

• The axial plane, oriented parallel to the sole of the foot

Goals of operative?Goals of operative?

• Restoration congruency of the posterior facet of the subtalar joint

• Restoration the height of the calcaneus (Böhler angle),

• Reduction of the width of the calcaneus, • Decompression of the subfibular space

available for the peroneal tendons, • Realignment of the tuberosity into a valgus

position & reduction of the calcaneocuboid joint if fractured.

DISCUSSIONDISCUSSION

• Extra-articular: generally treated in a closed manner. Exceptions include sustentaculum tali with displacement > 2 mm, posterior avulsion fX & significant fX of the calcaneal body.

• Intra-articular: may be treated in a closed fashion, but commonly: open reduction, ostectomy, osteotomy, internal fixation, and/or arthrodesis of the subtalar and calcaneocuboid joints.

• Nondisplaced (Sanders type I) intra-articular fX are generally treated closed.

• Severely comminuted (Sanders type IV) intra-articular fX may be treated with a combination of open reduction and internal fixation (ORIF) and arthrodesis of the subtalar joint.

• Other factors influencing nonoperative versus operative intervention include the patient's age, comorbid health conditions, and any concurrent injuries.

DISCUSSIONDISCUSSION

• The timing of surgery is an important factor in determining surgical success, as measured by long-term functional outcomes. Ideally, surgery should occur within 3 weeks after injury.

• This period allows for any swelling and fracture blisters to resolve completely, but the procedure is still sufficiently early to prevent premature healing and coalescence of the fracture fragments.

• In the absence of fracture blisters, the return of normal skin wrinkling is an indication that significant swelling has resolved and operative intervention may proceed

DISCUSSIONDISCUSSION

• Despite improvements in imaging, as well as a better understanding of the patterns of injury in complex fx of the calcaneus, opinions on the management of such injuries differ.

• Prospective studies have attempted to show benefit with either early operative intervention or with nonoperative measures.

• Each modality has at times enjoyed more attention and enthusiasm in the literature.

• A frustrating factor that perpetuates this disagreement is the subset of calcaneus fractures with poor long-term outcomes, regardless of the management.

• Cotton commented in 1916 that "the man who breaks his heel bone is done so far as his industrial future is concerned."

DISCUSSIONDISCUSSION

• Compared with open procedures, closed reduction with percutaneous fixation has a lower risk of wound complications, a shorter operative time, and more rapid healing because the soft tissue is handled less.

• This approach is indicated in patients with significant comorbidities, soft-tissue compromise or impaired healing, or true tongue-type fracture patterns.

• The goals of this approach include improvement of heel alignment and reduction of the posterior facet. Unfortunately, the limited exposure that this technique affords sometimes prevents adequate reduction and fixation of the calcaneal injury.

• If anatomic joint reduction is sought, ORIF may be a preferred option.

DISCUSSIONDISCUSSION

• Calcaneal ORIF has improved as a result of enhanced preoperative evaluation with CT scanning.

• Enhancements in equipment and surgical technique, particularly in the area of soft-tissue handling, have also improved its surgical success rates.

• Another exciting development is the use of subtalar arthroscopy (as Rammelt et al described) for accurate evaluation of the posterior facet after the initial reduction is performed.

DISCUSSIONDISCUSSION

• The most popular incision for exposure during ORIF of calcaneus fractures is an extensile lateral approach.

• This approach allows the surgeon to visualize the entire fracture. It also allows for complete reduction from the tuberosity to the anterior process and the calcaneocuboid joint.

• In addition, this approach permits indirect reduction of the medial wall and the sustentaculum.

• The extensile lateral approach should include a full-thickness skin flap. Gentle tissue handling is a must, and adequate wound closure is equally important.

• Flap closure that avoids excessive tension on the skin is critical to prevent skin necrosis.

• The use of thin plates in calcaneal fixation has significantly addressed the issue of excessive skin tension, hardware prominence, and subsequent wound breakdown.