Management Of Fractures Of The Calcaneum

Gurdeep Singh Ratra*, Bhartendra Jain

Abstract:

Introduction: Fractures of the Calcaneum are still considered difficult to treat with opinions varying between conservative and operative.

Method: We had 51 cases in 45 patients of fracture Calcaneum treated by operative as well as conservative methods. Duration of follow up ranged from 1 year to 10.5 years, average being a 3 years follow up.

Result: Fractures were classified as extra—articular or intra—articular and clinical results were evaluated according to the “Maryland Foot Score” based on pain, gait, cosmesis and subtalar joint motion.

Conclusion: It was found that the clinical outcome of extra—articular fractures was good, whatever be the method of treatment. But, the results of intra—articular displaced fractures were better with operative intervention than with conservative management.

J.Orthopaedics 2009;6(1)e3

Keywords:

fracture calcaneum; intraarticular; extraarticular; surgery; outcome

Introduction:
There remains a great deal of controversy regarding the management of calcaneal fractures ^1,2: operative versus non-operative. In operative, this controversy is further fueled by the disagreement on which operative approach is preferable: medial or lateral. 

Treatment of calcaneum fractures has varied from Bohler’s compression clamp ^3,4 and plaster immobilization to Essex Lopresti’s ⁵ percutaneous leverage techniques and open reduction internal fixation (ORIF ^6,7) by medial ⁸ or lateral ⁹ approach or even primary subtalar arthodesis ¹⁰.

While initially, the results of surgery in calcaneal fractures were considered dismal, recent papers have shown good functional outcomes after operative intervention ^11,12.

The purpose of this study was to assess the results of operative and conservative management and to attempt to decide the best treatment protocol.

Material Methods:

This study included 51 cases in 45 patients with fracture (#) calcaneum treated by conservative as well as operative methods.  Basic investigations were conventional radiographs ¹³ including Lateral view of hindfoot, Axial view of heel, A—P view of foot, Broden’s view and Anthonsen’s oblique view ¹⁴.

             Fractures were divided into 2 groups based on radiographs:

(a)      Extra—articular (Anterior process #/ Tuberosity #/ Sustentaculum #/ Body #)

(b)      Intra—articular (Essex – Lopresti Classification) (Tongue type #/ Joint Depression type #)

             We treated all displaced fractures operatively unless patients refused for or were unfit for surgery.

               Patients were followed up from a period ranging from 1 year to 10.5 years, average being a 3-years follow up. Evaluation at follow up was both clinical and radiological (Fig 1-4).

Fig 1. Case 1 Pre op X-Ray

Fig 2. Case 1 Post op X-Ray

Fig 3. Case 2 Pre op X-Ray

Fig 4. Case 2 Post op X-Ray

Movements at subtalar joint were measured using Mc Master’s method¹⁵. Clinical outcome was assessed based on the “Maryland Foot Score ¹⁶” (based on pain, gait, cosmesis and subtalar joint motion). On a scale of 0—100, clinical outcome was graded as Excellent (90—100), Good (75—89), Fair (50—74) and Poor (less than 50).

The collected data was analyzed and compared with the reported series of Robert Soeur and Robert Remy 9; Eugene Lance and Edward Carey ¹⁷.

Results:

Of the 45 patients (37males and 8 females) included, 39 had unilateral fracture (21 right side and 18 left side), while 6 had bilateral fractures. Most of the patients belonged to 3rd, 4th and 5th decades, youngest being 17years and oldest 70years.

Fall from height was the most common mode of injury (39 patients) while 6 patients had history of road traffic accidents.

8 of the patients had associated injuries (2 spine injuries, 1 pelvic injury, 1 blunt abdominal trauma, 1 nasal bone fracture and 3 had other limb injuries).    

The 51 fractures included 8 extra—articular (2 anterior process #, 2 tuberosity # and 4 body #) and 43 intra—articular fractures (20 tongue type and 23 joint depression type #).

Out of these 51 fractures, 23 were treated conservatively and 28 were operated (Table I). 26 intra—articular and 2 displaced extra—articular fractures were operated.

Table I . Treatment Given

Based on the “Maryland Foot Score”, 75% of the operated patients had good or excellent results while 60.8% of conservatively treated patients fell in the same category (Table II).

Table II. Results (Based on MARYLAND FOOT SCORE)

We found that none of the extra—articular fractures had fair or poor results, while a significant majority of patients with intra—articular fractures treated with Steinmann (ST) pin + Below Knee (BK) Cast/ Essex-Lopresti percutaneous leverage technique and only K—wire fixation showed fair or poor results.

Finally Table III compares the results of BK Cast with ORIF by Staple/Plating in Intra—articular fractures. All the cases treated by ORIF were displaced fractures. Out of these 26 cases, 21 (80.7%) had excellent or good results. While the 4 undisplaced intra—articular fractures treated with  BK Cast had excellent or good results, all the 3 displaced cases had a fair outcome, none of them falling in the excellent or good category indicating the need for anatomical reduction and stable internal fixation in such cases.  

Table III. Comparing Below Knee Cast and ORIF by Staple or Plate in Intra-articular fractures

Discussion:

As in the series of Robert Soeur and Remy 9, the commonest mode of injury was a fall from height and males sustain this fracture much more commonly than females, most probably due to their more active outdoor lifestyle.

We preferred operative intervention in intra articular calcaneal fractures, except in undisplaced fractures or in patients who refused for or were unfit for surgery, in which case, conservative regime was undertaken.

While in the series of Lance and Carey 17, operated patients were given post operative plaster immobilization for an average 14 weeks, we allowed earlier ankle and subtalar joint mobilization in patients with secure internal fixation (average 4.7 weeks and in some cases even immediate post—operative) although operated patients were generally kept non—weight

bearing longer than those treated conservatively because internal fixation was done in cases of displaced intra—articular fractures. From our short experience, we sincerely believe that early non—weight bearing joint mobilization had better results than longer periods of immobilization.          

We found the lateral approach quite satisfactory, provided a full thickness lateral flap was raised. The problem of flap necrosis was encountered in just 1 out of the 28 operated patients.

The major complication in intra—articular fractures was subtalar arthritis, which seems almost inevitable; only the severity can be reduced by good reduction and alignment. With time, however, the complaints of most patients reduced, the most plausible explanation being modification of daily activities by the patient.

Conclusion:

After analyzing the results of both conservative and operative methods of treatment, the following conclusions can be drawn:

 1. Accurate understanding of fracture pathoanatomy 18 and joint biomechanics 19 is an essential prerequisite for deciding the line of management.

2. Good  conventional roentgenography, which includes lateral, axial, and if required, oblique x—rays of the calcaneum is a must in understanding the displacement of major fracture fragments.

3. Results of extra—articular fractures are good, whatever be the mode of treatment.

4. Outcome of intra—articular displaced fractures is better with operative intervention than with conservative management. Secure fixation and early subtalar joint mobilization must be stressed upon.

As a parting comment, it may be said that “Fractures of the Os Calcis remain atleast partially unsolved” and the question still lingers on—“Can we put the Humpty—Dumpty together again?” 

Reference :

1. Dror Paley and Hamilton Hall. Calcaneal fracture controversies.OCNA Vol. 20, No. 4, Oct. 1989. 665—677.

2. John Randle, Hans Kreder. Should Calcaneal fractures be treated Surgically. CORR No. 377, Aug 2000.

3. Alexander P. Aitken. Fractures of the OS Calcis—Treatment by closed reduction. CORR No. 30, 1963.

4. Lorenz Bohler. Treatment of fractures, 4th Edn, 1935.

5. Essex—Lopresti. Mechanism, Reduction technique and results in fractures of Os Calcis. CORR No. 290, May 1993.

6. Roy Sanders, Paul Gregory. Operative treatment of Intra—Articular fractures of the Calcaneus. OCNA Vol.26,April 1995.  203—214.     

7. Stephen Benirschke, Bruce Sangeorzan. Extensive intra—          articular fractures of the foot: Surgical management of Calcaneal  Fractures. CORR No.292, July 1993. 128—134.

8. Billie D. Burdeaux. Medial Approach for Calcaneal fractures. CORR No. 290, May 1993. 96—107.

9. Robert Soeur, Robert Remy. Fractures of calcaneum with displacement of the thalamic portion. JBJS Vol.57—B, Nov.1975. 413—421.

10. R.I.Harris. Fractures of Os Calcis –Treatment by early subtalar Arthrodesis. CORR No.30, 1963. 100—110.

11. Paul Juliano, Hoan Vu Nguyen. Fractures of the Calcaneus. OCNA Vol. 32, Jan 2001.

12. Roy Sanders. Current concepts  review—displaced intra—articular fractures of the Calcaneus. JBJS Vol. 82—A, Feb 2000.

13. Kenneth Koval, Roy Sanders. Radiological Evaluation of  Calcaneal fractures. CORR No. 290, May 1993. 41—46.

14. R.Watson Jones. Fractures and other bone and joint injuries, 1941.

15. Michael McMaster. Technique of measuring subtalar joint movement. JBJS Vol. 58—B, Feb 1976.

16. Roy Sanders, Paul Fortin, Thomas Dipasquale, Arthur Walling. Operative treatment in 120 displaced intra—articular calcaneal fractures. CORR No. 290, May 1993. 87—95.

17. Eugene M.Lance, Edward J.Carey, Preston A.Wade. Fracturesof the Os Calcis—Treatment by early mobilization. CORR No.30,1963.

18. James B. Carr. Mechanism and pathoanatomy of intra—articular calcaneal fractures. CORR No. 290, May 1993. 36—40.

19. Shahan K. Sarrafian. Biomechanics of the subtalar joint complex. CORR No. 290, May 1993.

This is a peer reviewed paper 

Please cite as: Gurdeep Singh Ratra: Management Of Fractures Of The Calcaneum

J.Orthopaedics 2009;6(1)e3

URL: http://www.jortho.org/2009/6/1/e3

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