29: Calcaneus Fractures w/ Dr. Dowd

Listen to our episode on Calcaneus injuries as Dr. Dowd gives us an excellent overview!

Dr. Dowd did a great job in the podcast episode! He graduated from medical school at the Uniformed Services University of the Health Sciences. He completed residency at San Antonio Uniformed Services Health Education Consortium and he finished his fellowship at Harvard in foot and ankle.

Goal of episode: To develop a baseline knowledge on calcaneus fractures.

We cover:

History and physical
Pertinent imaging
Classification
Treatment options (non-on v op)

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Disclosures:

NailedIt Ortho reports no relevant financial disclosures. Dr. Cole and Dr. Fitts report no relevant disclosures. This podcast is NOT medical advice, the podcast is for educational purposes only. Please consult your doctor prior to making any medical decisions.

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Dr. Fitts and Dr. Cole are orthopaedic surgery residents and the hosts of the NailedIt Ortho podcast.

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Dr. Dowd- Calc Podcast Notes

History/Physical

Assess the soft tissue envelope for swelling

skin blisters
compartment syndrome
skin necrosis
open fractures

Associated injuries

L spine fractures

Tibial plateau fxs,

Tibial pilon

Talar neck

Imaging

AP/ Lateral Radiograph

Base camp analogy

Can assess Angle of Bohler on lateral view
- a line drawn from the highest point of the anterior process of the calcaneus to the highest point of the posterior facet and a line drawn tangential to the superior edge of the tuberosity
- Normal is 20-40 degrees
- Decrease indicates weight bearing posterior facet of the calc has collapsed
Critical angle of Gissane
- Formed by two strong cortical struts extending laterally
  - One along lateral margin of posterior facet and other from anterior to beak of calc
  - Can see it directly below the lateral process of the talus
  - A decease bohlers and increase in gissane is only seen if the entire facet is separated from the sustentaculum and depressed

Harris heel view

Allows visualization of the joint
Loss of height
Increase in width
Angulation of the tuberosity fragment

Broden’s view

– Foot in neutral flexion, and leg internally rotated 30-40 degrees. Beam centered over lateral mal

– Xrays at 10-40 degrees towards head of patient. 10 degree view shows posterior portion of facet, 40 degrees shows anterior portion of facet

– A mortise ankle view will reproduce

Ankle series

Consider CT imaging if intra-articular component to fracture

Anatomy/Mechanism

Typically high energy trauma, such as a fall from a height or a MVA
Essex-Lopresti

Primarily fracture line produced by lateral talus impacting the crucial angle of Gissane, dividing the lateral wall and body of the calc. Fracture line exit at anterior process or calcaneocuboid joint
Secondary fracture line –

If force directed posterior = fracture continues posterior into posterior facet = joint depression type
If force was directed axially, a tongue type fracture is produced

Classification

Via xray (Essex Lopresti)
- Tongue Type
- Joint depression type –
Via CT (Sanders)-
- Based on coronal images
- Posterior facet divided into 3 fragments- Lateral,Central, Medial (A,B,C)
  - Type 1-4 (Non displaced > 4 part articular fragments)
- Tongue type typically IIC, IIB if extends intra-articular

Fragment Terminology

Anterolateral fragment- encompasses lateral wall of anterior process
Anterior main fragment- large fragment anterior to primary fx line
Superomedial fragment (sustentacular or constant fragment)-almost always remains attached to talus through deltoid ligament complex- and is stable
Superolateral fragment (semilunar fragment)- lateral portion of posterior facet – sheared from remaining posterior facet in joint-depression fx
Tongue fragment- the super-lateral fragment that remains attached to portion of posterior tuberosity including the achilles tendon insertion
Posterior main fragment- posterior tuberosity
Fracture dislocations

Treatment

Indications

Nondisplaced extra-articular/ intra-articular fractures
Anterior process w/ less than 25% involvement of the Calcaneocuboid joint
Severe PVD or diabetes
Minimally ambulatory elderly patients

Splinting, bulky jones

Conversion to fracture boot after swelling improves

Early ROM and NWB 10-12 weeks

Indications

Displaced intra-articular fractures involving the posterior facet
Anterior process calc fx w/ >25% involvement
Displaced calcaneus fxs of the calcaneal tuberosity
Fracture/Dislocations
Open fractures

Medial Ex Fix

Can be useful w/ soft tissue injury

Percutaneous + minimally invasive

Pre-op planning
Sanders 2C tongue type where entire posterior facet is attached to tongue fragment; Displaced calc tuberosity or beak fx
Patterns w/ relative contraindications to open surgery (heavy smokers, pmts on chronic anticoagulants).

Definitive fixation w/ large 6.5-8.0mm cannulated lag screws.
Medial/Lateral pins through superior calc

Lateral Extensile

Pre-op planning
No touch technique (wire in fibula, talar neck, cuboid, talar body)
Technique:
- Fragment mobilization (posterior tuberosity disimpacted from sustentaculum- restores height and calc length)
- articular reduction (type 3- assemble medial>lateral)
  - Anterior process- assess anterolateral fragment- reduce to A1 portion of articular fragment- restores crucial angle of gissane
- definitive fixation (lag screws, plate, +/- grafting)
Locking plates
Repair SPR? Peroneals assessment?

Complications: