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CLASSICAL MANAGEMENT OF CALCANEAL
FRACTURES
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POSTERIORANTERIOR
DORSAL
ANATOMY
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MECHANISM OF INJURY
MVA
FALL
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CLINICAL FINDINGS
SWELLING
PLANTAR HEAMETOMA
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RADIOLOGICAL FINDINGS
LATERAL
AXIAL
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BRODEN VIEW
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AXIAL
CT SCAN
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CORONAL
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FRACTURE CLASSIFICATION
Extra articular
Anterior process
Tuberosity
Medial process
Sustentaculum tali
body
Intra articular
Tongue type
Joint depression
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TUBEROSITY
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SUSTENTACULUM TALI
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ANTERIOR PROCESS
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TONGUE TYPE
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JOINT DEPRESSION
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BOHLERS ANGLE
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SANDERS CLASSIFICATION
SANDERS IISANDERS III
SANDERS IV
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DEFINITION OF THE
PROBLEM Damage to subtalar joint and loss of function
Alteration in the normal architecture of the
calcaneus changing its function as:
Lever arm (triceps surface area)
Vertical support (avoid tilt stresses in ankle)
Horizontal support of lateral column
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METHODS OF TREATMENT
NO REDUCTION & EARLY MOTION
CLOSED REDUCTION & FIXATION
OPEN REDUCTION & INTERNAL FIXATION
ARTHRODESIS
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TREATMENT WITHOUT REDUCTION
ELEVATION,COMPRESSION AND EARLY ACTIVE
MOTION (McLaughlin)
non displaced intra articular fractures ,patients
who refuse surgery or not a candidate for
surgical treatment
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CLOSE REDUCTION AND FIXATION
Goal: restoring congruity of subtalar joint,
Bohlers angle and normal width of the
calcaneus
Disimpaction of fracture fragment,reduction by
manual manipulation/percutaneous pin and
maintainance of reduction with plaster,pin
traction or external fixation
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ORIF IN CALCANEUS FRACTURES
Resurgent interest in 1980s due to: Patient expectations
CT scan
Expertise with anatomic reduction & rigid internal fixation
allowing early functional treatment
Demand
The hardware must be sturdy & secure enough to allow post
operative mobilization
BUT broad plates are a barrier to revascularize(interposition
between bone and soft tissue)
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ORIF FOR CALCANEUS
FRACTUREMust restore :
Subtalar joint (posterior facet)
Calcaneal height (Bohlers angle)
Calcaneal width and length
Decompression of the subfibular space
Realignment oftuberosity into valgus
Reduction of the calcaneocuboid joint fracture
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FACTORS TO BE CONSIDERED
Age
Health status
Fracture pattern
Soft tissue injury
Surgeons experience
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APPROACHES
Medial approach(McReynolds, Burdeaux)
Combined medial and lateral
approach(Stephenson)
Lateral Extensile approach(Benirshke and
Sangeorzan)
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LATERAL EXTENSILE APPROACH
Thick fascial cutaneous flap Avoid injury to sural nerve Direct
visualization of post. Facet Facilitate lateral decompression The
standard approach in recent days
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ADVANTAGES DISADVANTES
WIDE EXPOSURE TO
SUBTALR JOINT
DECOMPRESSION OF THE
LATERAL WALL
EXPOSURE OF THE
CALCANEOCUBOID JOINT
SUFFICIENT AREA LATERALLY
FOR PLATE
INABILITY TO DIRECTLY
ASSESS THE MEDIAL WALL
MORE SOFT TISSUE
DISSECTION AND HIGHER
INCIDENCE OF WOUND
PROBLEMS AND SKIN
NECROSIS
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REDUCTION TECHNIQUE
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CHECK RADIOGRAPH
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PRE -OP POST- OP
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COMPLICATIONS (EARLY)
Wound infection , dehiscence
Malreduction
Loss of reduction
Sural nerve and peoneal tendon injuries
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PRIMARY ARTHRODESIS
Has been recommended for severe
comminution of subtalar joint (Sanders IV)
Restore the architecture and decompression of
the peroneal tendon and sural nerve
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INTRAARTICULAR CALCANEUS
FRACTURE
CT scan classification not only aid
fracture treatment, it is also
prognostic.
Type I fracture is best treated with
non-weight bearing and early ROM
exercise .
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INTRAARTICULAR CALCANEUS
FRACTURE
Type II fractures are best treated with
ORIF and good results can be expected
Type III fractures also benefit from ORIF,
but the result is inferior to that of type
II fracture.
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INTRAARTICULAR CALCANEUS
FRACTURE Open reduction in type IV fractures is to
maintain hindfoot architecture so that future reconstructive
surgery can focus on the joint, rather than a 3-D mal-aligned
bone.
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Although ORIF can not achieve
excellent/good results in type IV
fracture, it does provide a more
normal architecture of hindfoot
which facilitates later fusion.
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PROGNOSIS
Degree of displacement
Decrease Tuber angle
Age
Degree of comminution
Premature weight bearing
