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Calcaneum fracture- pathoanatomy & various fracture pattern.
DR. GIRISH MOTWANI Consultant Foot & Ankle surgeon (Paediatric & Adult)
1)Sushrut Hospital, Research Centre & PostGraduate Institute of Orthopaedics, Nagpur west
2)Aman hospital,Nagpur east
3)South point clinic, Nagpur south
Qualifications o MS orthopaedics (Gold medalist)
o Fellowship in Foot & Ankle ortho(university of Alabama at Birmingham ,USA)
o Fellowship in paediatric ortho(B.J.wadia hospital for childrens ,Mumbai)
o Certification in Ankle sports medicine(Northwestern university ,Chicago,USA)
Calcaneum fracture
“The man who breaks his heel bone is done “
• 2 % of all fractures• Most commonly fracture tarsal bone.
• 60 % of tarsal fracture• 75 % are displaced intraarticular fracture.
Calcaneum fracture
ANATOMY• TUBEROSITY serves as attachment for achillis tendon & plantar
fascia.
• ANTERIOR PROCESS1.Articulates with cuboid (CC joint).2.Origin for extensor digitorum brevis muscle belly.
• SUSTENTACULUM TALI1.Support middle facet of talus.2.Fulcrum for FHL tendon.3.Close relationship with posterior tibial nerves &
terminal branches of tibial nerve.
ANATOMY
• POSTERIOR FACETSupport the talar body
• ANTERIOR & MIDDLE FACETS“Form the sustentaculum tali constant fragment”Bear more weight per unit area than the posterior facet.
NORMAL FUNCTION OF SUBTALAR JOINT RELIES ON RESTORATION OF THE RELATIONSHIP OF THESE
JOINTS
Anatomy
• POSTERIOR FACET slopes downward posteriomedially.
• Difficult to visualize intraoperatively.
• Must be awake to avoid intraarticular screw placement.
POSTERIOR FACET
MEDIAL (SUSTENTACULUM)
LATERAL
Vascularity
1. lateral calcaneal artery(LCA) – Br. Of peroneal A 2. lateral malleolar artery(LMA) – Br. Of anterior tibial A 3. lateral tarsal artery(LTA) – Br. Of dorsalis pedis A The lateral calcaneal artery appeared to be responsible for
“majority of the blood supply to the corner of the flap” and, because of its proximity to the vertical portion of the
typical incision, it appeared most likely to be injured from inaccurate placement of the incision.
LCA
ANATOMY
• More than just a bone.• Thin soft tissue envelop.• Multiple structure at risk.• Sural nerve & posterior tibial tendons at particular risk with lateral dissection.
•How does a displaced intraarticular calcaneum fracture disrupt normal anatomy?
HIGH ENERGY AXIAL LOADING( MVA, FALL FROM HEIGHT)
LATERAL PROCESS OF TALUS DRIVEN INTO ANGLE OF GISSANE, ACTS AS WEDGE
Primary fracture line from anteriolateral to posteriomedial
PRIMARY FRACTURE LINE
AMF
PLF
Secondary fracture line runs in one of two planes,depending on direction of force
1)beneath the facet exiting posteriorly in Tongue-type fracture
2) behind the posterior facet in Joint depression fractures
SECONDARY FRACTURE LINE dectates whether there is joint depression or tongue-type fracture
SECONDARY FRACTURE LINE dectates whether there is joint depression or tongue-type fracture
NO ESSEX LOPRESTI
TECHNIQUE FOR JOINT
DEPRESSION TYPE
CONSTANT FRAGMENT -Sustentaculum
Location of this fragment and the density in this area are critical For reduction and fixation of calcaneal fracture
SUSTENTACULUM
Typically maintains Its relationship withTalus via interosseousLigament & medial joint capsule
Coronal Axial Sagittal
Pathoanatomy of calcaneum fracture
Broden’s view
• Positioning
20° IR view (mortise)
10°-40° plantar flex
Demonstrating the articular surface of the posterior facet.
Harris axial view• Very difficult to obtain in the acute setting• 45° axial of heel• 2nd toe in line w/ tibia
Assess varus/valgus -- Normal »10° valgus –
Joint displacement
Tuberosity angulation
Heel width.
• Bohler’s angle• 20-40
• Gissane’s angle• 95-105
Lateral view
Lateral view
Sander’s classification
Sanders R, Fortin P, DiPasquale T et-al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin. Orthop. Relat. Res. 1993; (290): 87-95. Pubmed citation
It is based on the coronal CT scan which shows the widest under-surface of the posterior facet for the talus.
1)number of intraarticular fracture lines and 2)their location on semicoronal CT images.
Sander’s classification
Sanders R, Fortin P, DiPasquale T et-al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin. Orthop. Relat. Res. 1993; (290): 87-95. Pubmed citation
”This classification is useful not only in understanding typical fracture patterns of the calcaneus, but also in predicting outcome.
As you move from type 1 to type 4 injuries, expected outcomes are progressively worse”
Sander’s classification
“We conclude that, despite the popularity of the classification system of Sanders for intra-articular fractures of the calcaneum, there is a high degree of variability and inconsistency in its interpretation with only a fair to moderate agreement among its users. Our aim is neither to advocate this system nor to undermine it, but to highlight its shortcomings so that caution is exercised in its usage and interpretation.”
Published 14 January 2005
Consistent features
• There is significant variability in the fracture pattern of displaced intraarticular calcaneal fractures however there are 3 consistent features…
1) sustentaculum typically remain attached to the talus.2) The anterior process translates dorsally.3) The tuberosity translates laterally,displaces superiorly
(pull of achillis),rotates into varus and shortens into the fracture.
Extraarticular calcaneal fracture
Medial process fracture
Anterior processfracture
Verticle tuberosityfracture
Avulsion fracture at EDB attachment
ANTERIOR PROCESS OF CALCANEUM FRACTURE
SUSTENTACULUM TALI FRACTURE Tuberosity avulsion fracturesDue to axial loading and inversion
Usually treated conservatively with non weightBearing or fixed by screw
Associated FHL tendon injury
• Achilles avulsion• Wound problems• Surgical urgency
─ Lag screws or tension band
Take home message…..
• When calcaneum fracture occurs, the heel can widen, shorten, and become deformed. Consider all pathoanatomical features of fracture to evaluate its complex geometry.
• Although there is significant variability in the fracture pattern of displaced intraarticular calcaneal fractures, always look for 3 consistent features – sustentaculum,anterior process & tuberosity varus.
• Defining calcaneal fracture in different xray views & CT scan is crucial part in its management.
THANKS