Calcaneum fractures

why when and how to operate...

1. Calcaneum fractures By – Dr. Siddharth Gupta

2. INTRODUCTION ANATOMY FRACTURE CHARACTERISTICS MANAGEMENT

3. HISTORY “ The Man Who Breaks His Heel Bone Is Done” - Cotton 1916

4. HISTORY “ Calcaneus Fractures Are Serious And Debiliting Injuries In Which The End Result Continues To Be Incredibly Bad ” - Conn 1935

5. HISTORY “ Operative Treatment Of Calcaneus Fractures Is Like Nailing A Custard Pie To The Wall ” - McLaughin 1942

6. ANATOMY 5 CLINICAL SIGNIFICANT ASPECTS OF BONY ANATOMY 3 SUPERIOR ARTICULAR FACETS SUSTENTICULLUM TALI MEDIAL WALL LATERAL WALL DISTAL ANTERIOR CUBOID ARTICULATION

7. M easurements BOHLER’S ANGLE CRITICAL ANGLE OF GISSANE CALCANEUM DIMENSIONS HEIGHT WIDTH HORIZONTAL LENGTH

8. MECHANISM OF INJURY OF CALCANEAL FRACTURES

9. Force through subtalar joint driving talus lateral process into everted calcaneus to create fracture patterns described by Essex- Lopresti . The “axe” of the lateral process of talus is driven into lateral wall of calcaneus . This produces a fracture that runs superior lateral to inferior medial. MECHANISM OF INJURY OF CALCANEAL FRACTURES Ref - 5. Essex Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis . Br J Surg 1952;39:395-419.

10. MECHANISM

11. A secondary fracture line is then resulted from increased force Joint Depressed type Tongue-type fracture CALCANEAL FRACTURE PATTERNS Ref- Essex- Lopresti , P (March 1952). "The mechanism, reduction technique, and results in fractures of the os calcis .". Br J Surg. 39 (157): 395–419.

12. CALCANEAL FRACTURE PATTERNS

13. Sequelae of fracture Posterior facet comminution Sub fibular impingement Heel widening Horizontal Attitude of talus

14. Sub fibular impingement

15. Heel widening

16. Horizontal Attitude of talus Gissane angle >145 degree

17. Horizontal Attitude of talus Bohler’s angle <25 degree

18. Horizontal Attitude of talus

19. Classification Bohler 8 types Extra – Articular - 4 Intra – Articular - 4 No correlation between fracture type and outcome. Ref - Bohler L. Diagnosis, pathology, and treatment of fractures of the os calcis . J Bone Joint Surg 1931;13:75 – 89

20. Palmer - Essex- Lopresti TONGUE TYPE JOINT DEPRESSION–TYPE Based on mechanism and secondary fracture line Classification Ref - Palmer I. The mechanism and treatment of fractures of the calcaneus . J Bone Joint Surg Am 1948;30:2 – 8 Essex- Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis . Br J Surg 1952;39:395 – 419.

21. Soeur and Remy Based on the number of articular fracture fragments - Plain radiographs No mention - comminution - calcaneal body or of the articular facet Did not correlate results with outcomes Classification Ref - Soeur R, Remy R. Fractures of the calcaneus with displacement of the thalamic portion. J Bone Joint Surg Br 1975;57:413 – 21

22. Sanders et al – widely accepted Ref - Sanders R, Fortin P, DiPasquale A, et al. Operative treatment in 120 displaced intra- articular calcaneal fractures. Results using a prognostic computed tomographic scan classification. Clin Orthop 1993;290:87 – 95. Classification

23. Virtually every aspect of management of complex calcaneum fractures is controversial.

24. Management Closed Without reduction With reduction Extensile lateral Minimal invasive Salvage procedure – primary fusions

25. 84 fractures Ankle arthritis – 100% Sub- talar arthritis -90% Cheaper and low rate of sof tissue complications

26. MANAGEMENT OPERATIVE VS NON-OPERATIVE

27. 471 fractures, followed up to 2-8 years VAS and SF-36 No appreciable difference

28. Certain subgroups showed better results treated operatively including: Women Younger patients Patients with a lighter workload Patients not involved in workers’ comp claims Patients with a higher initial Bohler’s angle Those with an anatomic reduction on post-op CT evaluation.

29. 82 fractures, 12 year follow up VAS and SF-36(non-responsive), AOFAS(non-validated) One year – no appreciable diffrences

30. 8-12 years – surgical group lower rate of post-traumatic subtala r arthritis (risk reduction – 41%) Trend in VAS (pain and function) and physical component of SF-36 – improved Higher complications rate – in terms of soft tissue healing

31. COMPLICATIONS FROM NONOPERATIVE TREATMENT malposition of the talus which leads to tibiotalar impingement and ankle pain, shortening or widening of the hindfoot , fibulocalcaneal impingement, varus or valgus malalignment , impingement or subluxation of the peroneal tendons, or sural or posterior tibial neuritis Malunions can be responsible for painful subtalar arthritis

32. painful subtalar joint arthritis - treated with an isolated subtalar fusion the deformity of the calcaneus must be corrected to restore adequate function to the hindfoot Ref - Gallie WE. Subastragalar arthrodesis in fractures of the os calcis . J Bone Joint Surg 1943;25: 731 – 6

33. 47 cases 10 years follow up Reduction co-related with outcomes 38.3% excellent results

34. Retroscpective review, 112 fractures SF-36, foot function index, VAS More wound complications and secondary surgeries with extensile lateral No difference in Bohler’s angle or angle of Gissane Similar clinical results

35. OPERATED CASE – 1 35yrs male h/o fall from bike Right calcaneal Fracture No co morbidity

36. GISSANE ANGLE > 145 DEGREE

37. BOHLER ANGLE < 25 DEGREE

38. Case - 2 42yrs male h/o fall from 10 feet height With spinal injuries T9 and L1 compression fracture With B/l calcaneum fracture

39. THANK YOU!!!