Calcaneal fractures --sito--29th aug 2015
-
Upload
uday-bangalore -
Category
Health & Medicine
-
view
1.093 -
download
3
Transcript of Calcaneal fractures --sito--29th aug 2015
29TH Aug 2015SITOCON
“The man who breaks his heel bone is done” ---Cotton (1912)
“The results of crush fractures of the os calcis are rotten” ---Bankart (1942)
Calcaneal fractures - 2% of all fractures
- 60-75% of them are displaced intraarticular fractures
- 10% have associated spine fractures - 26% have other extremity injuries
-90% occur in young men(21 to 45 yrs)
Posterior Facet
Anterior andMiddle Facets
Mechanism of Injury
•High energy─ MVA─ fall from a height
•Lateral process of talus acts as wedge•Impaction fracture
CLINICAL FEATURES C/O pain swelling not able to bear weight On Examination–
>marked swelling >ecchymosis blisters
>tenderness & movements restricted
>other foot and spine also should examined
Initial Evaluation• Thorough primary,
secondary, tertiary survey• Bilateral injuries spine injuries other extremity fractures can occur in 10 – 15%• Routine Lumbar spine films
Exam• Note condition of skin
• Open fractures• Fracture Blisters• Threatened skin (pressurefrom displaced fracture fragments)
• Neurovascular exam
RADIOGRAPHIC EXAMINATION
Xrays ---foot
a)AP b)AXIAL c)LATERAL d)BRODEN’S VIEW OTHER X-RAYS--- >ANKLE JOINT >OPPOSITE FOOT >DORSOLUMBAR SPINEC.T SCAN ----for pathoanatomy of intra-articular fracture
Displaced Posterior Facet
Flattened Bohler’s Angle
Bohler’s Angle
Xray measurements
Bohler’s angle• Normal 25-40 degrees• Severity (lower Bohler’s
angle) correlates with outcome
Xray Measurements• Critical Angle of Gissane
• Normal 120-145 degrees
• Change in angle indicates change in relationship between posterior, medial, and anterior facets
F
Critical Angle of Gissane
If only the lateral half of the posterior facet is fractured and displaced a split in the articular surface will be seen as a double density
Broden’s View
Helpful intra-op• Posterior facet • Check intraarticular
displacement• Positioning
A. 20° IR view (mortise)
B. 10°- 40° plantar
Broden’s View
• Posterior facet
CT Scan and 3D
Axial Coronal Sagital
Pathoanatomy
• • Primary
fracture line
• Constant fragment
Pathoanatomy
1 2 3
• Secondary fracture lines
• Extend posteriorly through tuberosity or into anterior process
• Create 3 + parts
Essex-Lopresti• Described two distinct fracture patterns
Joint-Depression Tongue-Type
Posterior Tuberosity NOT attached to Posterior Facet
Posterior Tuberosity attached to Posterior Facet
Not amenable to Essex-Loprestipercutaneous reduction technique
ESSEX-LOPRESTI CLASSIFICTIONJOINT DEPRESSION TYPE
Essex-Lopresti Classification:Tongue Type
B
May be amenable to Essex-Lopresti percutaneousreduction technique
Classifications• Essex-Lopresti
• Sanders:• Based on CT findings• Coronal plane • # joint fragments
• 2 = type II• 3 = type III• 4 or more = type IV
• Predictive of results
Sander’s
Sanders Classification
A B C
A B C
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• Intra-articular fractures 60-75%
• Extra-articular fractures 25-30% Anterior process fractures. Avulsion fractures of the tuberosity.Medial process fractures.Sustentaculum tali and body fractures.
Anterior process fracture• Inversion “sprain”• Frequently missed• Most are small: treat like
sprain• Large/displaced: ORIF
Tuberosity Fracture:
•Fall/MVA•Usually non-operative (displacement)
─ Swelling control─ Early ROM
Tuberosity avulsion fractures• Achilles avulsion• Wound problems• Surgical urgency
─ Lag screws or tension band
Sustentaculum Fracture:
•Most small/ nondisplaced: ─ Non-operative
•Large/ displaced─ ORIF (med. approach)─ Buttress plate
Goals of Treatment
• Restore Anatomy
• Restore Function
OPERATIVE vs. NON-OP TREATMENT
Canadian Calcaneus RegistryR. Buckley et al., JBJS, 2002
The following did better with surgery:• Women• Age <29 years• Non-Work-Comp
• Bohler angle <10˚ • Comminuted fracture• Large initial joint step off
Treatment : Non-Operative
• Non- / minimally displaced fractures (<2mm intra-articular displacement)
• Patients with significant risk factors for complications with operative treatment
• NWB X 12 weeks
• Early ROM of ankle, hindfoot and midfoot
• Prevent equinus contracture (splint or Fx Brace)
Non-op Treatment: Complications
Malunion
Timing of Surgery• Wrinkle Test
• when the patient dorsiflexes and everts the foot
• If skin wrinkling is seen no edema is present, the test is positive
patient is ready for surgery
Indications for ORIF• Displaced intra-articular fractures
• Displaced fractures of calcaneal tuberosity
• Fracture-dislocations of calcaneus
• Selected open fractures of calcaneus
Operative Treatment via Extended Lateral Approach: Contraindications
•Diabetes (relative)•Vascular insufficiency•Smoker (relative)•Severe swelling•Open fractures (relative)
•Neuropathic•Non-compliant pt. •In-experienced surgeon
Positioning
Approaches Extensile Lateral (ELA)
Most commonSinus TarsiFor selected fractures and situations
s
ORIF: Extended Lateral Approach
• • “No touch” technique
• Lateral wall removed
Full thickness skin incision with periosteal flapWatch sural nerve at proximal and distal extent of incision
Lateral wall must be removed before reduction is able to be performed anteriorly
ORIF: Extended Lateral Approach
• Schanz pin to manipulate tuberosity• Clean out fracture • Disimpact sustentacular fragment
ORIF: Extended Lateral Approach
•Use K-wires•Reduce post. facet to sustentaculum- ant. process
ORIF: Lateral Approach•Provisionally reduce tuberosity fragment to sustentacular complex
•Pin with K-wires through stab incisions in posterio-inferior heel
ORIF: Extended Lateral Approach
•Fine tune tuberosity reduction to sustentacular complex
-- Restore height and length
-- Restore valgus-- Medial translation
•Pin reduced tuberosity
Bone Graft•No benefit with bone grafting
•Bone graft substitute (i.e. Norian SRS) may allow for earlier weight-bearing
Fixation Options
ORIF: Extended Lateral Approach
•Replace lateral wall •Apply plate and screws
•Recheck radiographs• Alignment• Subtalar-/ CC joint• Hardware position• Screw length
•Check peroneal tendons•Drain•Layered closure
1. Periosteum/SQ one layer2. Skin • Atraumatic technique• Advance flap toward apex• Allgower-Donati sutures
•Splint in neutral
Operative TreatmentComplications• Wound problems
• Apical wound necrosis
• Infection
Sinus Tarsi Approach
•Incision from tip of fibula across sinus tarsi to anterior process
•Retract sural nerve and peroneal tendons plantar
Branch of Sural Nerve
For fractures with wound problems prohibiting extended lateral approach
ST Approach (“Ollier’s”)
•Reduce anterior process
•Mobilize and reduce tuberosity
•Reduce Subtalar joint
ST Approach
•Arthroscope (placed through the incision) can be helpful to assure anatomic joint reduction
Click icon to add clip art
ST Approach: Fixation•Small screw/ small plate to span angle of Gissane
•Medial Wall Screw
•“Articular Support Screw”
•Lateral Column Screw
Click icon to add clip art
Surgery: Percutaneous
•Essex-Lopresti maneuver•Tongue type fractures
Essex-Lopresti, Clin Orthop, 290: 3-16, 1993
•
Surgery: Percutaneous
Essex-Lopresti, Clin Orthop, 290: 3-16, 1993
Open Fractures• Up to 10% in some series
• Most commonly medial wound
• Staged management –ext fixation/K wires & skin cover medially
• High rate (29%) of soft tissue complications
Open Fractures
C D
Indirect reduction and percutaneous stabilization
Complications Malunion
Varus
Shortened foot
Peroneal impingement
Shoewear problems
Complications• Stiffness
─ Prevention (early ROM)
• Subtalar arthritis
─ NSAIDs─ Subtalar fusion
Ilizarov• Minimally invasive• Indirect reduction• Learning curve• Immediate weightbearing
CALCANAIL
CALCANAIL
Surgery: Primary Fusion
•Articular comminution
•Severe cartilage injury
•ORIF calcaneus, debride cartilage, and fuse
Postoperative Care• Elevate, splint• Sutures out at 2-3 wks.• Fracture boot to prevent
equinus contracture• Early motion ankle and foot• NWB for 12 weeks
SUMMARY• High energy injuries
• Risk for long term morbidity
• ORIF can give good, reproducible results if complications are avoided
• Individualize treatment
Thank you