57 Extensile Open Reduction and Internal Fixation of Intra-articular Joint Calcaneus Fractures Abstract Calcaneus fractures continue to be the most common fractures in the foot and challenging in its treatment. A number of studies have described improved functional outcomes and decreased risk of posttraumatic subtalar joint arthritis with open reduction and internal fixation using various techniques. If you adhere to certain indications and a meticulous surgical technique, you can expect your patients to achieve a good functional result when compared to nonoperative treatment. This chapter will help guide you to evaluate calcaneus fractures, determine the appropriate treatment, and successfully perform an open reduction and internal fixation when indicated. Keywords: calcaneus fracture, open reduction and internal fixation, extensile lateral, percutaneous, sinus tarsi approach • Calcaneus fractures are the most common fractures of the foot: • Anatomy: – Also referred to as the “constant” fragment. • Mechanisms of injury: – Joint-depression-type (Fig. 57.1). – Tongue-type (Fig. 57.2). • Extra-articular (25–30%): – Forceful contraction of the gastroc-soleus muscle, which leads to an avulsion of the calcaneal tuberosity at the Achilles tendon insertion. – Forceful avulsion of the deltoid and talocalcaneal ligaments. – Inversion and plantarflexion of the foot, which leads to an avulsion at the bifurcate ligament and violation of the calcaneocuboid joint. – Also commonly seen with intra-articular fractures as well (~ 63%). • The initial step in evaluating any patient involved in a trauma is to employ the advanced trauma life support (ATLS) protocol. • A thorough history should be obtained to determine the mechanism of injury, the locations of pain, presence of loss of consciousness, and, in the setting of an MVA, whether the patient was a restrained driver/passenger and if air bags were deployed. Fig. 57.1 Joint-depression-type calcaneus fracture. • The physical examination of a patient with a presumed orthopaedic injury initially involves inspection of the skin integrity to determine if it is open or closed. The presence of any prior scars and skin quality should be carefully evaluated simultaneously. • Palpate the distal pulses and obtain a vascular consultation if there is any concern about the arterial vascular supply to the limb. • A thorough motor and sensory exam should then be obtained. It is not uncommon for weakness and numbness to be present after a foot and ankle injury and therefore one must have a high index of suspicion if a deficit is present. • Once the above have been established, further evaluation of the foot and ankle can be performed. Findings consistent with a calcaneus fracture include diffuse tenderness to palpation, ecchymosis, swelling, and shortening/widening/varus alignment of the hindfoot. The ankle should always be included in the examination to rule out additional injuries, such as a peroneal tendon dislocation. • The lumbar spine, pelvis, and bilateral lower extremities should always be evaluated in addition to the foot and ankle. • X-rays: – A “fleck” sign at the lateral aspect of the distal fibula on the AP and mortise views suggests dislocation of the peroneal tendons. – AP and mortise views allow for assessment of subfibular impingement due to lateral wall blowout if present. – Axial view of the calcaneus. – Allows for visualization of the tuberosity, hindfoot widening, varus alignment, and posterior facet involvement. – Foot is maximally dorsiflexed with the beam angled at 45 degrees. – Internal rotation views of the ankle in maximum dorsiflexion at 40, 30, 20, and 10 degrees – Useful intra-operatively to assess the reduction of the posterior facet. – Determined on the lateral X-ray of the foot/ankle. – Angle is created between the intersection of a line drawn from the most superior aspect of the tuberosity to the posterior/superior aspect of the posterior facet and another drawn from the posterior/superior aspect of the posterior facet to the most superior aspect of the anterior process. Fig. 57.3 Extra-articular calcaneal tuberosity fracture. Fig. 57.4 (a) Harris’ view of the calcaneus. (b) Harris’ view of a calcaneus fracture illustrating the typical varus hindfoot alignment. Fig. 57.5 (a) Normal Bohler’s angle. (b) Abnormal Bohler’s angle illustrating a depression-type calcaneus fracture. Fig. 57.6 The angle of Gissane. – Normal is 20 to 40 degrees: i. If an angle is less than 20 degrees, this illustrates collapse of the posterior facet, which in turn causes a concomitant decrease in talar inclination (Fig. 57.5b): a. Decreases in talar inclination can subsequently lead to anterior ankle impingement and further disability. – Determined on the lateral X-ray of the foot/ankle. – Angle is formed by the intersection of lines drawn at the downward and upward slopes of the calcaneal superior surface. – Follows the lateral process of the talus. – Normal is between 120 and 140 degrees. – If the angle is above 140 degrees, this illustrates collapse of the posterior facet. • Initially immobilize in a non-weight-bearing splint in order to allow for swelling to subside with subsequent transition to a short leg non-weight-bearing cast at 2 weeks after injury: – Short leg plantarflexion cast due to the pull of the Achilles tendon. • Once union is obtained as demonstrated by office X-rays (AP, oblique, lateral, and Harris’ views) and physical exam, transition to weight-bearing as tolerated in a CAM walker boot and start physical therapy, which should be performed in a sneaker for 6 weeks: • Computed tomography (CT) scan: – Type 1—nondisplaced fracture(s). – Type 2—one fracture line with two main fracture fragments. – Type 3—two fracture lines with three main fracture fragments. – Type 4—three or more fracture lines with four or more fracture fragments. • Magnetic resonance imaging (MRI) scan:
57.1 Indications
Closed fractures: 83%.
Open fractures: 17%.
Body/tuberosity:
Main attachment of the Achilles tendon.
Sustentaculum tali:
Acts as a fulcrum for the flexor hallucis longus tendon and supports the talar neck.
Attachment for the deltoid and talocalcaneal ligaments.
Contained in the anteromedial fragment in calcaneal fractures:
Anterior process:
Articulates with the calcaneocuboid joint and head of the talus.
Posterior articular facet:
The largest facet that makes up the subtalar joint and is the major weight-bearing surface of the calcaneus.
Anterior and middle articular facets:
Usually confluent with each other.
The middle facet sits on top of the sustentaculum tali.
Intra-articular (70–75%):
Axial load to the hindfoot, such as what occurs during a motor vehicle accident (MVA) or a fall from height.
Calcaneal tuberosity (Fig. 57.3).
Sustentaculum tali:
Anterior process:
Associated injuries:
Lumbar vertebrae.
Ipsilateral lower extremity.
Contralateral calcaneus.
57.1.1 Clinical Evaluation
57.1.2 Radiographic Evaluation
Mandatory views
Anteroposterior (AP), oblique, and lateral radiographs of the foot routinely provide sufficient information to make a definitive diagnosis of a calcaneus fracture.
AP, mortise, and lateral radiographs of the ankle should always be obtained as well.
Harris’ view (Fig. 57.4a,b):
Optional views
Broden’s view:
Measurements:
Bohler’s angle (Fig. 57.5a):
Crucial (critical) angle of Gissane (Fig. 57.6):
The Essex-Lopresti classification differentiates joint-depression patterns and tongue-type fractures, based on the primary and secondary fracture lines:
The primary fracture line is an oblique fracture line that divides the calcaneus into an anteromedial (constant fragment) and posterolateral fracture fragment, which routinely involves the posterior facet.
In joint-depression fractures, the secondary fracture line exits posterior to the posterior facet.
In tongue-type fractures, secondary fracture line exits at where the majority of the posterior facet remains in continuity with the tuberosity.
57.1.3 Nonoperative Options
Non-weight-bearing for 6 to 12 weeks:
Sanders’ type 1 fractures.
Nondisplaced to minimally displaced Sanders’ type 2 fractures (< 2 cm) with an intact Achilles mechanism.
Nondisplaced avulsion extra-articular fractures:
Nondisplaced anterior process fractures < 25% of the articular surface.
Wean out of the boot under the guidance of physical therapy.
Heel pain is common and can be controlled with either over-the-counter or custom-molded orthotics.
Additional physical therapy may be necessary to obtain optimal functional results.
Gold standard for evaluating calcaneus fracture configurations and determining whether nonoperative or operative intervention is indicated.
Obtain 30-degree semicoronal, axial, sagittal, and three-dimensional reconstructions.
Sanders’ classification (Fig. 57.7a, b):
Based on evaluation of the posterior facet at its widest point on the 30-degree semicoronal views:
Rarely indicated.
Only indication is to diagnose a calcaneal stress fracture in the setting of trauma and normal radiographs.
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