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Calcaneus Fractures

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Calcaneus Fractures presented by Sepein Chiang, DO Introduction Displaced, intra-articular fractures of the calcaneus are a diagnostic and therapeutic challenge ... – PowerPoint PPT presentation

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Title: Calcaneus Fractures


1
Calcaneus Fractures
  • presented by
  • Sepein Chiang, DO

2
Introduction
  • Displaced, intra-articular fractures of the
    calcaneus are a diagnostic and therapeutic
    challenge
  • Limited by radiographic examination
  • CT has revolutionized the understanding
    treatment of calcaneus fractures

3
Historical Treatments
  • Originally, focus was on restoration of overall
    shape correction of Bohlers angle via a medial
    approach.
  • This lead to poor reduction of the joint surface.
  • Stephenson added a lateral approach for joint
    reduction
  • Sanders medial approach is rarely needed

4
Anatomy
  • Anterior half of the superior articular surface
    contains 3 facets which articulate with the talus

5
Mechanism of Injury
  • Fall from heights
  • MVA

6
Clinical Evaluation
  • Neurovascular status
  • Soft tissue swelling
  • Compartment syndrome
  • Opposite calcaneus (10)
  • Bilateral lower extremity (25)
  • Vertebral fractures (10)

7
Radiographic Evaluation
  • AP
  • Calcaneocuboid extension
  • Lateral wall bulge

8
Radiographic Evaluation
  • LAT
  • Loss of height of the posterior facet
  • Double density
  • Bohlers angle 20-40
  • Gissanes angle 120-140

9
Radiographic Evaluation
  • Harris axial heel view
  • Foot in maximum dorsiflexion
  • Beam angled 45 cephalad
  • Shows subtalar joint surface, loss of height,
    increase in width and varus/valgus angulation

10
Radiographic Evaluation
  • Brodens views
  • Supine, foot in neutral flexion, internally
    rotated 30-40
  • X-ray centered over lateral malleolus, taken at
    40,30,20,10 cephalad
  • Shows posterior facet (10)
  • Useful intra-operatively to assess reduction

11
Brodens Views
12
CT Scan
  • Scan both feet, 3 mm cuts
  • Coronal perpendicular to posterior facet
  • Supine, hip knees flexed, plantar surface
    resting on table
  • Shows articular surface of posterior facet,
    sustentaculum tali
  • Transverse perpendicular to coronal view
  • Extend hip knees
  • Shows calcaneocuboid joint, anteroinferior aspect
    of the posterior facet, sustentaculum tali,
    lateral wall
  • 3D spiral CT allows rotation, sections, removal
    of bones

13
Sanders Classification
  • 1986, based on Soeur Remy classification
  • Based on number location of articular fragments
    on coronal view
  • Posterior facet divided into 3 equal, potential
    pieces (lateral, central, medial) sustentaculum
    tali

14
Sanders Type I
  • All nondisplaced fractures, regardless of number
    of pieces
  • Usually non-operative, unless severely displaced

15
Sanders Type II
  • Two-part fracture of the posterior facet
  • Subtypes IIA, IIB, IIC
  • Similar to a split fracture of the tibial plateau

16
Sanders Type III
  • Three-part fractures with a centrally depressed
    fragment
  • Subtypes IIIAB, IIIAC, IIIBC
  • Similar to a split, depressed fracture of the
    tibial plateau or die-punch distal radius
    fracture

17
Sanders Type IV
  • Four-part, highly comminuted
  • Extremely difficult to reduce the articular
    surface
  • Irreversible damage to the intact articular
    cartilage

18
Treatment Options
  • Tailor to the personality of the fracture
  • Non-operative
  • ORIF
  • Primary or delayed arthrodesis
  • Subtalar
  • Triple talonavicular, talocalcaneal,
    calcaneocuboid

19
Non-operative Treatment
  • Extra-articular, open fractures with life
    threatening injuries, soft tissue compromises,
    severe PVD or DM, severely comminuted in
    osteopenic bone
  • Tongue type fractures with little articular
    comminution can be reduced percutaneously with a
    Steinmann pin and placed in a cast

20
Operative Treatment
  • Ideally within 3 weeks
  • Wait for swelling to decrease
  • Restore articular surface of posterior facet
    calcaneocuboid joint
  • Take the heel out of varus
  • Restore the length of the heel
  • Reduce lateral wall blowout

21
Surgical Technique
  • Kocher lateral incision
  • No touch technique
  • Careful of sural nerve peroneal tendons

22
Surgical Technique
  • Reduce posterior facet hold with K-wires or lag
    screws
  • Reduce calcaneocuboid joint lateral wall
  • Reduce heel out to length and out of varus
  • 3.5 recon plate, H plate, Sanders Y plate
  • Bone grafting controversial

23
Primary Arthrodesis
  • Subtalar fusion or triple arthrodesis
  • Type IV- extremely difficult to reduce the
    articular surface
  • Irreversible damage to the intact articular
    cartilage

24
Post-op Management
  • Bulky Jones dressing
  • POD 2 remove drain
  • POD 3 removable SLC
  • Early supervised subtalar ROM exercises
  • NWB 8-12 weeks
  • FWB by 3 months

25
Complications
  • Wound dehiscense
  • Osteomyelitis
  • Subtalar arthritis
  • Peroneal tendonitis
  • Sural nerve injury or entrapment from scarring

26
Conclusion
  • Learning curve 35 to 50 cases, or 2 years before
    results can become predictable for Type II and
    III fractures
  • Type IV are so severe that even the most
    experienced surgeons will have difficulty
  • An anatomic articular reduction is necessary for
    a good outcome, but cannot guarantee it, due to
    cartilage necrosis from the original injury
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