Calcaneal Fractures


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Calcaneal Fractures


Richard E. Buckley MD FRCSC


University of Calgary, Calgary, AB, Canada


Clinical scenario



  • A 35‐year‐old male construction worker is brought to the Emergency Department following a 3 m fall at work. He complains of left heel pain and is unable to weight bear on the left.
  • Initial trauma workup reveals an isolated injury to the left calcaneus, with no spinal or ipsilateral lower limb fractures. His left foot is very swollen and tender posteriorly with a few blisters.
  • This man has no medical problems except he has smoked one pack/day for 20 years.

Top three questions



  1. In adults with displaced intra‐articular calcaneal fractures, does nonoperative treatment provide long‐term functional outcomes as good as operative care (open reduction and internal fixation [ORIF])?
  2. In adults with displaced intra‐articular calcaneal fractures, does minimally invasive reduction and percutaneous fixation provide long‐term functional outcomes as good as ORIF?
  3. In adults with displaced intra‐articular calcaneal fractures, does primary fusion provide long‐term functional outcomes as good as ORIF?

Question 1: In adults with displaced intra‐articular calcaneal fractures, does nonoperative treatment provide long‐term functional outcomes as good as operative care (open reduction and internal fixation [ORIF])?


Rationale


Operative treatment of calcaneal fractures is associated with a significant risk of serious complications. As such, it is important that both the treating surgeon and the patient are aware of the expected outcome of the three options of operative treatment (ORIF, minimally invasive reduction, and primary fusion) and nonoperative treatment so that this can be accurately balanced against the risks involved with the chosen treatment.


Clinical comment


Most trauma surgeons would currently suggest operative treatment of a displaced intra‐articular calcaneal fracture in an otherwise healthy young male manual worker. Clinical features that would push a surgeon to do an ORIF in a patient with a displaced intra‐articular calcaneal fracture are young age, active lifestyle, simple fracture, good soft tissue envelope, nonsmoker, and good clinical expertise.


Available literature and quality of the evidence


A literature search provided us with eight randomized controlled trials (RCTs)18 and four meta‐analyses.912 All of these RCTs are of level II strength (as they each have some methodologic flaws) and none of them is of the size to accurately answer this tough problem alone. However, together they create a good body of work and can provide some clinical direction to answer this tough question.


The four meta‐analyses were done between 2009 and 2017 and thus reflect the difference in timing of the appearance of the above RCTs.912 When combined, these four papers have very similar summaries.


Findings


These papers state that we are still in need of a large RCT to answer this question definitively.112 They also state that surgical complications are the big downside of ORIF but that clinical outcomes are somewhat better with ORIF.


Pooled results of the eight RCTs showed that patients managed nonoperatively failed to resume pre‐injury work (risk ratio [RR] = 0.60; 95% confidence interval [CI]: 0.37–0.98; p = 0.04). However operative intervention was associated with more complications (RR = 1.74; 95% CI: 1.28–2.37; p = 0.0005). There was no statistically significant difference in residual pain (RR = 0.73; 95% CI: 0.40–1.36; p = 0.33) and re‐operation (RR = 0.75; 95% CI: 0.48–1.16; p = 0.20) between the two groups.


Surgically managed patients are more likely to resume their pre‐injury work. Buckley et al. noted that patients with light‐to‐moderate work may lead to better recovery with surgery.4 However, patients with heavy workloads are unlikely to recover well regardless of the treatment type. Buckley et al. and others reported better functional results and less pain when Bohler’s angle was restored and anatomic reductions were achieved. On the other hand, Ibrahim et al. found no association between radiographically measured restoration of the angle and clinical outcome.5


Operatively managed patients had fewer problems while wearing shoes. This may be due to the fact that surgery results in the restoration of preinjury calcaneal width. Patients who underwent surgery were likely to have less pain as compared to those who underwent nonoperative management, although the difference did not reach statistical significance.


Although operative intervention showed good outcomes, they also had a significantly higher incidence of complications. Complication rates were much higher with surgery with the most frequent complication being infection with rates between 5 and 15%.


Resolution of clinical scenario



  • Complications must be avoided for the best results when managing these patients (RR = 1.74; 95% CI: 1.28–2.37, p = 0.0005).
  • Operative care is slightly better in younger patients as they have fewer complications than the older patient with more medical problems (overall quality: moderate).
  • Functional outcome is slightly better in the operatively managed patient provided complications are not encountered (overall quality: moderate).
  • Return to heavy labor is unlikely after a displaced intra‐articular calcaneal fracture regardless of treatment type; return to work may be improved with operative treatment (overall quality: moderate).
  • Better restoration of anatomy can lead to a better clinical result as footwear is easier to manage in the operatively treated patient (overall quality: moderate).
  • No statistically significant difference in pain or functional outcome between operative treatment modalities and nonoperative treatment (overall quality: moderate).
  • Subtalar arthrodesis rates are significantly decreased after operative treatment (overall quality: moderate).
  • This young laborer should undergo ORIF of his calcaneal fracture.

Question 2: In adults with displaced intra‐articular calcaneal fractures, does minimally invasive reduction and percutaneous fixation provide long‐term functional outcomes as good as ORIF?


Rationale


With minimally invasive reduction and fixation techniques becoming widely accepted in orthopedic trauma practice, the role of this technique in calcaneal fracture fixation is becoming clearer. Complications certainly are less with smaller incisions, and with less surgery, range of motion may be better, providing better long‐term outcomes for patients.


Current opinion


Currently, over the last five years, there has been a real swing in popularity for surgeons to routinely use minimally invasive techniques for the treatment of displaced intra‐articular calcaneal fractures rather than the classic extensile lateral calcaneal exposure. Fewer complications and better range of motion with less postoperative pain are pushing surgeons to move toward less invasive surgery to accomplish the same goals for patients.


Available literature and quality of the evidence


A literature search provided us with:



  • Level II: 5 randomized trials1317 and 2 systematic reviews.18,19
  • Level III: 3 prospective cohort or retrospective reviews.2022

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Calcaneal Fractures
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