calcaneal fracture presentation pptx.ppt
- 1. CALCANEAL FRACTURE DR BIPUL BORTHAKUR PROFFESOR AND HEAD DEPARTMENT OF ORTHOPAEDICS ASSAM MEDICAL COLLEGE DIBRUGARH , ASSAM
- 2. Introduction • Most common tarsal bone fracture • 1-2% of all fracture • 60-75 %of them intraarticular displaced fracture • 10% have a/w spine fracture • 90% in young men
- 3. ANATOMY • 4 articulating surface -3 superior and 1 anterior • Superior surface articulate with the talus 1. Posterior facet 2. Middle calcaneal facet 3. Anterior calcaneal facet • Anterior surface :-triangular surface articulate with cuboid
- 4. ANATOMY • Lateral surface Flat and subcutaneous Peroneal tubercle for attachment of the calcaneofibular ligament centrally
- 5. anatomy • Medial surface Concave from above to downward Presence of a shelf like projection of bone called sustentaculum Tali
- 6. anatomy • Medial side : - perforating branch of posterior tibial artery • Lateral side :- by calcaneal artery branch of posterior tibial artery
- 7. MECHANISM OF FRACTURE • INTRAARTICULAR FRACTURE Axial loading Fall from height Motor vehicle accident • Calcaneal tuberosity fractures Poor bone quality/osteoporosis Recurrent microtrauma due to peripheral neuropathy
- 8. MECHANISM OF FRACTURE • Calcaneal stress fracture Increase physical activity • Anterior process fracture Twisting injury Avulsion injury of bifurcate ligament
- 10. FRACTURE LINE • Primary fracture line Created by the impact of talus on calcaneum Run from posteromedial to anterolateral • Secondary fracture line Additional cracks that develop as a result of the primary fracture These lines often radiate from the primary fracture line and can extend into other parts of the calcaneus. • Castant fragment specific part of the calcaneus that remains relatively stable and undisplaced, even when the rest of the bone is fractured. It's called "constant" because it remains in a constant position, unlike other fragments that may be displaced.
- 12. Extraarticular fracture ANTERIOR PROCESS OF CALCANEAL THE SUSTENTACULUM TALI
- 13. Extraarticular fracture • FRACTURE OF THE CALCANEAL TUBERSITY
- 14. INTRA ARTICULAR FRACTURE • ESSEX –LOPRESTI CLASSIFICATION TONGUE TYPE DEPRESSION TYPE • Posterior Tuberosity NOT attached to Posterior Facet • Not amenable to Essex- Lopresti percutaneous reduction technique • Posterior Tuberosity attached to Posterior Facet • May be amenable to Essex-Lopresti percutaneous reduction technique
- 15. INTRA ARTICULAR FRACTURE • SANDERS CLASSIFICATION TYPE 1:- nondisplaced OR displacement <2mm Type 2:- 2 articular piece from single fracture line TYPE 3:- 3 articular piece from 2 fracture TYPE 4:-4 or more articular piece
- 17. INTRA ARTICULAR FRACTURE • BEAVIS CLASSIFICATION based on fracture of tuberosity Type 1:- sleeve fracture Type 2:- beak fracture Type 3:-infra bursal fracture
- 18. CLINICAL EVALUATION • HISTORY Mechanism of injury Associated injury • COMORBIDITIES Diabetes Peripheral vascular disease
- 19. CLINICAL EVALUATION • SYMPTOMS Pain Swelling Inability to bear weight Gross deformity Open fracture
- 20. CLINICAL EVALUATION • Physical examination o Inspection Ecchymosis Shortened widened heel May have apparent varus deformity Open skin lesion or fracture Posterior heel skin compromise Tenting ,ecchymosis, lack skin blanching with tuberosity fracture
- 21. CLINICAL EVALUATION • Palpation Diffuse tenderness to palpation Lack of cord continuity in avulsion fracture Lack of posterior heel skin blanching with tenting fracture Assess compartment syndrome presence of Langer's lines and skin wrinkles suggests skin is appropriate for surgical intervention
- 22. CLINICAL EVALUATION • Strength Decreased ankle plantarflexion strength with avulsion fractures • Neurologic assess for neurologic compromise due to swelling • Vascular assess peripheral pulses severe peripheral vascular disease may preclude surgical treatment due to poor wound healing potential
- 23. RADIOLOGICAL EVALUATION • RECOMMENDED VIEW AP LATERAL OBLIQUE • OPTIONAL VIEW BRODEN HARRIS AP ANKLE
- 24. Broden’s view • For posterior facet • 45 degree internal rotation • Foot in neutral position • 4 x ray bean at 10,20,30,and 40 degree
- 25. HARRIS VIEW • Visualizes tuberosity fragment widening ,shortening and varus positioning • Place the foot in maximal dorsiflexion and angle the x ray beam 45 degree
- 26. Displaced Posterior Facet Flattened Bohler’s Angle Bohler’s Angle XRAY MEASUREMENTS • Tuber angle of böhler is composed of 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 25-40 degrees • Severity (lower Bohler’s angle) correlates with outcome
- 27. XRAY MEASUREMENTS • Crucial angle of gissane is formed by two strong cortical struts extending laterally: • One along the lateral margin of the posterior facet and the other extending anterior to the beak of the calcaneus. • Normal 120-145 degrees • Change in angle indicates change in relationship between posterior, medial, and anterior facets Critical Angle of Gissane
- 28. CT SCAN • INDICATION GOLD STANDARD SHOULD PERFORMS 2-3 CUTS VIEW • 30 –DEGREE SEMICORONAL Posterior And Middle Facet Displacement • AXIAL DEMOSTRATES CALCANEOCUBOID JOINT INVOLVEMENT • SAGITTAL Demonstrates TUBERSITY DISPLACEMENT
- 29. MRI • INDICATION diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis
- 30. TREATMENT
- 31. GOAL OF CALCANEAL FRACTURE TREATMENT Restoration of congruency of posterior facet of sub talar joint Restoration of height of calcaneus Reduction of width of the calcaneus Decompression of sub fibular space available for peroneal tendon Realignment of tuberosity into a valgus position Reduction of calcaneocuboid joint if fracture
- 32. NONOPERATIVE INDICATION RELATIVE CONTRAINDICATION MINIMALLY DISPLACED EXTRAARTICULAR FRACTURE DISPLACED INTRA ARTICULAR FRACTURE INVOLVING THE POSTERIOR FACED NONDISPLACED INTRAARTICULAR FRACTURE ANTERIOR PROCESS FRACTURES WITH >25 INVOLVEMENT OF CALCANEOCUBOID ARTICULATION ANTERIOR PROCESS FRACTURE WITH <25 INVOLVEMENT OF CALCANEOCUBOID ARTICULATION DISPLACED FRACTURE OF CALCANEAL TUBERSITY CALCANEAL FRACTURE WITH SEVERE PERIPHERAL VASCULAR DISEASE ,INSULIN DEPENDENT DIABETES MELLITUS ,MININIMALY AMBULATOTORY ELDERLY PATIENTS FRACTURE –DISLOCATION OF CALCANEUS OPEN FRACTURE OF CALCANEUS
- 33. NONOPERATIVE TREATMENT • CONSERVATIVE LIMB ELEVATION ACTIVE MOVEMENT OF TOE ICE PACKS APPLICATION BELOW KNEE LIGHT WEIGHT CAST FUNCTIONAL BRACE FOR 4-6 WEEK PERIOD NON WEIGHT BEARING FOR A FURTHER 2 WEEK
- 35. OPERATIVE TREATMENT TIMING OF SURGERY • Surgery within 3 week of injury • Surgery should not be attempted until swelling in the foot and ankle has adequately dissipated as indicated by a positive wrinkle test
- 36. COMPOUND CALCANEAL FRACTURE MANAGEMENT All type I Type II with medial wound •Type II with non medial wound All open type IIIA All open type IIIB ↓ ↓ ↓ Delayed orif Ex..Fixation/ percutaneous fix Delayed reconstruction
- 37. OPEN CALCANEAL MANAGEMENT IN CASUALTY • Wound irrigation with 0.9 % nacl saline • Tetanus prophylaxis • Antibiotic prophylaxis • Skin closure with stay suture • Splint application
- 38. OPEN CALCANEAL MANAGEMENT IN OT •Wound debridement •Open reduction •External fixation
- 39. External fixation • 2 plan • Circular external fixator
- 40. EXTERNAL FIXATION • MEDIAL FRAM CAN BE PLACED TEMPORARILY TO PRESERVE LATERAL SOFT TISSUE FOR EXPOSURE AFTER SOFT TISSUE HEEL • CAN ALSO BE DEFINITIVE TREATMENT TO GET OVERALL MORPHOLOGY SUBSEQUENT LIMITED EXPOSURES CANBE DONE LATERALLY FOR ARTICULAR REDUCTION /FUSION
- 41. EXTERNAL FIXATION PLACE OF SCHANZ PIN MEDIAL CUNEIFORM MEDIAL DISTAL TIBIA MEDIAL CALCANEAL TUBERSITY REDUCE TUBERSITY HEIGHT LENGTH ANGULATION
- 42. OPERATIVE TREATMENT PERCUTANEOUS OR MINIMALLY FIXATION ORIF VIA EXTENSILE LATERAL APPROCH ORIF VIA STA ORIF VIA MEDIAL APPROCH ORIF OF ANTERIOR PROCEESS FRACTURE OPEN REDUCTION COMBINED WITH SUBTALAR FUSION
- 43. PERCUTANEOUS OR MINIMALLY INVASIVE FIXATION •Potential pitfall Inadequate appreciation of fracture fragment Inadequate instrument to effect reduction •Prevention Preop planning Availability of adequate instrument
- 44. ORIF VIA THE EXTENSILE LATERAL APPROACH • this approach provide wider exposure of calcaneal allowing following 1. Better visualization of the fracture 2. More accurate reduction 3. Stabilization with plates and screws • SURGICAL STEP 1. Patient positioning: Lateral decubitus position with the affected side up 2. Incision: A longitudinal incision is made along the lateral aspect of the foot and ankle, approximately 8-10 cm in length 3. Dissection: Soft tissues are dissected, and the peroneal tendons are retracted 4. Exposure: The lateral wall of the calcaneus is exposed, and the fracture is visualized 5. Reduction: The fracture is reduced, and temporary K-wire fixation is used to hold the reduction 6. Plate and screw fixation: A calcaneal plate and screws are applied to stabilize the fracture 7. Closure: The incision is closed in layers, and the wound is dressed
- 46. ORIF VIA THE EXTENSILE LATERAL APPROACH • Potential pitfall Limited by quality and condition of soft tissue envelope • Prevention Preop planning Availability of adequate instrument Wrinkle sign present Avoid microcirculatory compromise
- 47. ORIF VIA SINUS TARSI APPROACH • sinus tarsi incision may additionally be utilized for direct visualization of the posterior facet articular surface • percutaneous screws are placed more plantarly from calcaneal tuberosity into the anterior process, and beneath the displaced posterior facet fragments
- 48. ORIF OF ANTERIOR PROCESS FRACTURE • Potential pitfall Inadequate appreciation of fracture fragment Inadequate exposure for cc joint reduction • Prevention Preop planning Availability of adequate instrument Reduction should be completed under direct visualization
- 49. ORIF VIA PERCUTANEOUS APPROACH • Inadequate reduction and/or loss of reduction of the articular fragments may occur in a significant number of cases • In conclusion, minimally invasive and/or percutaneous techniques should be reserved for relatively simple tongue-type fracture patterns
- 50. ORIF VIA MEDIAL APPROACH • NO CONTROL OVER THE POSTERIOR FACED SIMPLE TWO PART EXTRAARTICULAR MEDIAL WALL BLOW OUT • HORIZONTAL INCISION HALF WAY BETWEEN THE TIP OF THE M.MAND THE SOLE • THE NEUROVASCULAR BUNDLE IS CAREFULLY RETRACTED • THE ABDUCTOR HALLUSUS MUSCLE RETRACTED DOWNWARD • DAMAGE TO CALCANEAL BRANCH OF POATERIOR TIBIAL NERVE (25%CHANCE)
- 51. OR COMBINED WITH SUBTALAR FUSION • Potential pitfall Maintenance of calcaneal height and length for fusion • Prevention Preop planning Availability of adequate instrument Availability of structural
- 52. CLOSURE TECHNIQUE • Minimal soft tissue handling • Use Pop –off absorbable sutures • Which are hand –tied moving towards the apex of the wound • Nonabsorbable interrupted nylon suture are placed using the allgower- donati technique
- 53. POST OP FOLLOW UP • MONITORING AND PAIN CONTROL • LEG ELEVATED AND OUTPUT MONITORED OVERNIGHT • PATIENT DISCHARGE WITH SPLINT OR SLAB • AFTER 1WEEK - CAST APPLY • AFTER 2-3 WEEK-CAM BOOT • AFTER 2-3 WEEK ANKLE ROM EXERSISE STARTS IF WOUND HEALED • WEIGHT BEARING STARTS AFTER 10-12 WEEK
- 54. Complications • Wound problems • Apical wound necrosis • Infection
- 55. Late complication Subtalar joint pain Osteomyelitis Peroneal tendinitis Heel spur Arthritis of calcaneocuboid & talonavicular joint. Nerve entrapment Widening of heel
- 58. Calcaneal fracture treatment algorithm
- 59. PRGNOSIS • Depends on Articular involvement Degree of displacement Number and size of bone fragment Associated injuries Timeliness and quality of treatment Age and overall health Complication
- 60. Thank you
Editor's Notes
- #43: POSITIONING DISIMPACT AND REDUCE LARGER TUBERSITY FRAGMEMT THROUGHT POSTEOLATERAL HEEL CORRECTION OF DEFORMITY CONFIRM PIN POSITION ON LAT,AP &AXIAL VIEW ADVINCE PINS ACROSS THE FRACTURE PERCUTANEOUS THREADED SCREW 6.5CAN BEOVER AGUIDE PIN TO MAINTAIN REDUCTION STA IF JOINT VISUALIZATION REQUERED SUPPLIMENT FIXATION 3.5 mm SCREW SLINTING THE EXTRENITY IN MILD PLANTERFLEXION POSITION
- #44: The incision starts approximately 2 cm above the tip of the lateral malleolus, just lateral to the Achilles tendon. This line is continued vertically toward the plantar surface of the heel. It is connected to a line drawn at the junction of the lateral foot and the heel pad—typically when compressing the heel, a crease will appear in this region the two drawn lines form a right angle, this is replaced with a gentle curve heel. The incision is started at the proximal part of the vertical limb, becoming full thickness once the calcaneal tuberosity is reached. The knife should be taken “straight to bone” at this level, with care taken not to bevel the skin. As the knife rounds the corner, pressure is relaxed and a layered incision is developed along the plantar aspect of the foot
- #46: The incision starts approximately 2 cm above the tip of the lateral malleolus, just lateral to the Achilles tendon. This line is continued vertically toward the plantar surface of the heel. It is connected to a line drawn at the junction of the lateral foot and the heel pad—typically when compressing the heel, a crease will appear in this region the two drawn lines form a right angle, this is replaced with a gentle curve heel. The incision is started at the proximal part of the vertical limb, becoming full thickness once the calcaneal tuberosity is reached. The knife should be taken “straight to bone” at this level, with care taken not to bevel the skin. As the knife rounds the corner, pressure is relaxed and a layered incision is developed along the plantar aspect of the foot
- #48: LATERAL DECUBITUS WITH TOURNIQUET A 3cm INCISION OVER ANTERIOR PROCESS ELEVATION OF EDB DIRECT REDUCTION OF ANTERIOR PROCESS WITH VISUALIZATION OF THE CC JOINT REDUCTION CONFIRM WITH X RAY FIXATION CAN INCLUDED 3.5 mm SCREW OR PLATE DEPENDING ON BONE QUALITY AND COMMINUTION
- #51: POTIONING DRAPE ILIAC CRESTIF AUTOGRAFT REQUIRED EXTENSILE OF STA Extensile of STA reduction of Calcaneal length and alignment should be achieved Decorticating of posterior facet to direct vision, autograft or allograft as needed Structural graft if height cannot be maintained Two large percutaneous screw from tuberosity into talus Confirmed position on c-arm