22-24 - Calcaneal Fractures Flashcards
(39 cards)
1
Q
Lecture objectives
A
- Anatomy of the calcaneus (review).
- Mechanisms of injury, classification schemes and management principles for calcaneal fractures
2
Q
Radiographic evaluation
A
- AP, MO, lateral and calcaneal axial b/l
- Bohler’s angle
- Gissane’s crucial angle
- CT scan
- Lumbar spine films
- Additional radiographs based on presentation
3
Q
Bohler’s angle – Tuberosity joint angle
A
- Measures intra-articular depression of the calcaneus
- Line from highest point of the posterior articular
surface to the highest point of tuberosity - Line from highest point of the posterior articular
surface to the highest point of anterior process - Normal 25 - 40 degrees
4
Q
Gissane’s crucial angle
A
- Evaluate the relationship of the articular facets
- Created by the subchondral bone of the posterior facet and
the subchondral bone of the anterior and middle facets - Normal 120 - 145 degrees
5
Q
CT scan
A
- Evaluate the extent of injury (Articular involvement, Comminution, Displacement, Joint depression)
- Enhance preoperative planning
- Sanders and Hannover classifications
6
Q
Lumbar spinal films
A
- Spinal fractures 10 - 20%
- T12 to L2
- L1 most common
- Compression fractures
7
Q
Classifications – KNOW FOR EXAM***
A
- Extra-articular and Intra-articular
- Rowe: Extra-articular (does describe some intra-articular fractures)
- Essex-Lopresti: Intra-articular
- Sanders: Intra-articular CT classification
- Hannover: Extra-articular and intra-articular CT classification
8
Q
Rowe classification
A
- I a - Fracture of the calcaneal tubercle
- I b - Fracture of the sustentaculum tali
- I c - Fracture of the anterior process
- II a - Beak fracture of the tuberosity (spares Achilles?)
- II b - Avulsion fracture of the tuberosity (ruptures Achilles?)
- III - Oblique body fracture not involving the STJ
- IV - Body fracture involving the STJ
- V - Joint depression with comminution
- NOTE: whenever you have a patient with an inversion sprain, there are certain places in the foot that you need to palpate
9
Q
Rowe Ia
A
- Fall with the heel everted or inverted
- Fracture of the medial or lateral tubercle
- Lateral
- Treatment depends on displacement and size of the fragment
10
Q
Rowe Ib
A
- Fall with twisting on a supinated foot
- Fracture of the sustentaculum tali
- First stage in a joint depression fracture
- ROM of FHL
- Calcaneal axial
- Treatment depends on displacement
11
Q
Rowe Ic
A
- NOTE: FOR THE EXAM – be prepared to know these images
- Supination and plantarflexion
- Most common type I
- Fracture of anterior process
- MO and lateral
- Treatment depends on displacement
12
Q
Rowe IIa
A
- Direct trauma
- Fracture of the superior portion of the tuberosity
- Lateral
- Spares Achilles tendon insertion
- Treatment depends on displacement
13
Q
Rowe IIb
A
- Strong pull of Achilles tendon
- Avulsion fracture of tuberosity
- Involves Achilles tendon insertion
- Lateral
- Treatment depends on displacement, but favors surgical
14
Q
Rowe III
A
- Fall from height with heel in varus or valgus
- Fracture of body without STJ involvement
- Most common extra-articular
- Treatment depends on displacement
15
Q
Rowe IV
A
- Fall from height with foot plantar flexed
- Fracture of the body that is intra-articular
- CT scan
- Treatment? Depends on how comminuted it is
- Same as Essex-Lopresti tongue type fracture
16
Q
Rowe V
A
- Fall from height with foot dorsiflexed
- Intra-articular fracture with joint depression and comminution
- Same as Essex-Lopresti joint depression fracture
- Treatment?
17
Q
Essex-Lopresti tongue type fracture
A
- Primary fracture line (shear fracture) which is intra-articular separates the sustentaculum tali from the lateral body
- Secondary fracture line through the tuberosity
- Resembles avulsion fracture
18
Q
Essex-Lopresti joint depression type fracture
A
- Shear fracture divides the calcaneus into two parts - sustentaculum fragment and tuberosity fragment
- Lateral portion of posterior facet is isolated and impacted into the body
- Lateral wall blow-out
- Position of the foot may determine the type of blow-out fracture
- Decrease in the height and increase in width of calcaneus
19
Q
Sanders classification
A
- CT classification - coronal and axial
- Section with widest part of posterior facet used
- The calcaneus can be divided into four parts by
- three fracture lines*
- Lines named A, B and C from lateral to medial
- Four types with sub-classifications
20
Q
Sanders type I
A
- All nondisplaced intra-articular fractures are Type I, irrespective of the number of fracture lines
21
Q
Sanders type II
A
- Two part fractures of the posterior facet (TYPE 2 = TWO PIECES = ONE FX)
- Type IIA, IIB and IIC based on primary fracture line
22
Q
Sanders type IIA
A
- Two-part fracture
- Primary fracture line is lateral separating the lateral column from the central
23
Q
Sanders type IIB
A
- Two-part fracture
- Primary fracture line is central separating the central column from the medial
24
Q
Sanders type IIC
A
- Two-part fracture
- Primary fracture line is medial separating the
medial column from the sustentaculum column
25
Sanders type III
- Three-part fracture of posterior facet
- Features a centrally depressed fragment
- Type IIIAB, IIIAC and IIIBC based on two fracture lines
26
Sanders type IIAB
- Three-part fracture
- Two fracture lines separate the posterior facet into lateral,
central and medial columns
27
Sanders type IIIAC
- Three-part fracture
- Two fracture lines separate the posterior facet into lateral
column, central/medial column and sustentaculum column
28
Sanders type IIIBC
- Three-part fracture
- Two fracture lines separate the posterior facet into lateral/central
column, medial column and sustentaculum column
29
Sanders type IV
- Four-part fracture
- Highly comminuted
- Usually more than four fragments
- Joint depression present
- Three fracture lines which separate all of the columns of
the posterior facet and sustentaculum
30
Sanders classification study
- Main finding: The more fragments you have, the worse they do
- This is with traditional open reduction internal fixation (ORIF)
- For a calcaneal, this involves a lateral incision from lateral malleolus down to cuboid metatarsal joint and flap back skin
- Due to angiosomes, this is not an ideal place to make an incision, so we go straight down to bone to decrease disruption of vasculature
- Remove lateral wall blow out, elevate posterior facet to where it is supposed to be
- Use Lamina spreader into calcaneus to open it up, to raise up the posterior facet so that you can pin it and put a screw across it
- This fixes the primary fracture (sheer fracture) then we plate it with a bone graft in the calcaneus to hold up the posterior facet
- This is what this study is talking about – very poor results with a more comminuted fracture
- Some people might just try to pin it and cast it due to such poor failure rates with ORIF of calc fx
- Then you can do an STJ fusion at follow up after the initial fracture has healed (some use ex-fix)
31
Case study 1
o A 37-year-old male was admitted to the emergency room with a deep cut in the posterior aspect of his right foot, caused by a penetrating trauma originating from a meat cleaver. During a physical fight the patient fell to his knees, with his ankle in dorsi- flexion and toes in extension, and was exposed to a manual, direct cutting injury. The patient's history was uneventful.
o Physical examination revealed a 12-cm long, deep transverse laceration on the posterior aspect of the right ankle, which had intersected the bone (Fig. 1). The avulsed section of the calcaneus was visible through the open wound line. The patient was unable to stand on his toes or to walk, and the Thompson's test was positive (Achilles tendon involvement)
32
Thompson's test
o Thompson test is diagnostic for a complete tear of the Achilles tendon
o Thompson Test: when the tendon is intact, and the calf is squeezed, the ankle will plantar flex. When the tendon is town, ankle does not plantar flex upon squeezing
33
Classification of wound
o This is a Rowe IIB – open calcaneal fracture
| o Based on the size of the wound, it would be a Gustillo and Anderson type IIIA
34
Treatment
o I & D of wound
o Fixate the calcaneal fracture
o Leave the wound open (do not close this)
o Change dressing in 12 hours,
o Take back to OR in 2-3 days, another I & D then closure
35
Case study 2
o A 13-year-old male presented to the emergency room for heel pain after jumping off a 12-foot roof. Initial radiographs were read as negative and patient was discharged. Patient returned to the emergency room a few days later still complaining of left foot pain. Patient had subsequent radiographs taken of the left foot that revealed a fracture of the lateral wall of the calcaneus. Patient was then referred to Des Moines University for further evaluation.
o Patient presented in a posterior splint, non-weight bearing on the left foot with crutches. On physical examination neurovascular status was intact. Skin was noted to have normal texture and turgor. Mild edema and ecchymosis was present on the lateral aspect of the left heel, no blisters present. No evidence of erythema, cyanosis, or open ulcerations. Pain was elicited upon palpation of the calcaneal tuberosity of the left heel.
36
Radiographs
o There is a tiny fracture visible on lateral x-ray
| o Medial oblique shows a full calcaneal blow out, which was missed
37
CT
o This patient needs a CT to evaluate the lateral wall blow out
38
Classification
o Sanders II B due to where the fracture location is
o When you are classifying things for an attending, you might be right or wrong, but what they are looking for is a good thought process
39
Treatment
o ORIF because of the joint compression and because of the patient’s age
o Trying to get the fragment that is intraarticular into the correct position
o “Homerun screw” is right under posterior facet into the primary fracture line or sheer fracture, which means the screw is place right above the plate
o The plate is then applied to the lateral wall of the calcaneus
o Cancellous screws are used because the calcaneus is mainly cancellous bone
o Usually a low profile plate is used because there is not a lot of tissue covering the lateral aspect of the calcaneus
