Calcaneum fracture- pathoanatomy & various fracture pattern.

DR. GIRISH MOTWANI Consultant Foot & Ankle surgeon (Paediatric & Adult)

1)Sushrut Hospital, Research Centre & PostGraduate Institute of Orthopaedics, Nagpur west

2)Aman hospital,Nagpur east

3)South point clinic, Nagpur south

Qualifications o MS orthopaedics (Gold medalist)

o Fellowship in Foot & Ankle ortho(university of Alabama at Birmingham ,USA)

o Fellowship in paediatric ortho(B.J.wadia hospital for childrens ,Mumbai)

o Certification in Ankle sports medicine(Northwestern university ,Chicago,USA)

Calcaneum fracture

“The man who breaks his heel bone is done “

• 2 % of all fractures• Most commonly fracture tarsal bone.

• 60 % of tarsal fracture• 75 % are displaced intraarticular fracture.

Calcaneum fracture

ANATOMY• TUBEROSITY serves as attachment for achillis tendon & plantar

fascia.

• ANTERIOR PROCESS1.Articulates with cuboid (CC joint).2.Origin for extensor digitorum brevis muscle belly.

• SUSTENTACULUM TALI1.Support middle facet of talus.2.Fulcrum for FHL tendon.3.Close relationship with posterior tibial nerves &

terminal branches of tibial nerve.

ANATOMY

• POSTERIOR FACETSupport the talar body

• ANTERIOR & MIDDLE FACETS“Form the sustentaculum tali constant fragment”Bear more weight per unit area than the posterior facet.

NORMAL FUNCTION OF SUBTALAR JOINT RELIES ON RESTORATION OF THE RELATIONSHIP OF THESE

JOINTS

Anatomy

• POSTERIOR FACET slopes downward posteriomedially.

• Difficult to visualize intraoperatively.

• Must be awake to avoid intraarticular screw placement.

POSTERIOR FACET

MEDIAL (SUSTENTACULUM)

LATERAL

Vascularity

1. lateral calcaneal artery(LCA) – Br. Of peroneal A 2. lateral malleolar artery(LMA) – Br. Of anterior tibial A 3. lateral tarsal artery(LTA) – Br. Of dorsalis pedis A The lateral calcaneal artery appeared to be responsible for

“majority of the blood supply to the corner of the flap” and, because of its proximity to the vertical portion of the

typical incision, it appeared most likely to be injured from inaccurate placement of the incision.

LCA

ANATOMY

• More than just a bone.• Thin soft tissue envelop.• Multiple structure at risk.• Sural nerve & posterior tibial tendons at particular risk with lateral dissection.

•How does a displaced intraarticular calcaneum fracture disrupt normal anatomy?

HIGH ENERGY AXIAL LOADING( MVA, FALL FROM HEIGHT)

LATERAL PROCESS OF TALUS DRIVEN INTO ANGLE OF GISSANE, ACTS AS WEDGE

Primary fracture line from anteriolateral to posteriomedial

PRIMARY FRACTURE LINE

AMF

PLF

Secondary fracture line runs in one of two planes,depending on direction of force

1)beneath the facet exiting posteriorly in Tongue-type fracture

2) behind the posterior facet in Joint depression fractures 

SECONDARY FRACTURE LINE dectates whether there is joint depression or tongue-type fracture

SECONDARY FRACTURE LINE dectates whether there is joint depression or tongue-type fracture

NO ESSEX LOPRESTI

TECHNIQUE FOR JOINT

DEPRESSION TYPE

CONSTANT FRAGMENT -Sustentaculum

Location of this fragment and the density in this area are critical For reduction and fixation of calcaneal fracture

SUSTENTACULUM

Typically maintains Its relationship withTalus via interosseousLigament & medial joint capsule

Coronal Axial Sagittal

Pathoanatomy of calcaneum fracture

Broden’s view

• Positioning

20° IR view (mortise)

10°-40° plantar flex

Demonstrating the articular surface of the posterior facet.

Harris axial view• Very difficult to obtain in the acute setting• 45° axial of heel• 2nd toe in line w/ tibia

Assess varus/valgus -- Normal »10° valgus –

Joint displacement

Tuberosity angulation

Heel width.

• Bohler’s angle• 20-40

• Gissane’s angle• 95-105

Lateral view

Lateral view

Sander’s classification

Sanders R, Fortin P, DiPasquale T et-al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin. Orthop. Relat. Res. 1993; (290): 87-95. Pubmed citation

It is based on the coronal CT scan which shows the widest under-surface of the posterior facet for the talus.

1)number of intraarticular fracture lines and 2)their location on semicoronal CT images.

Sander’s classification

Sanders R, Fortin P, DiPasquale T et-al. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin. Orthop. Relat. Res. 1993; (290): 87-95. Pubmed citation

 ”This classification is useful not only in understanding typical fracture patterns of the calcaneus, but also in predicting outcome.

As you move from type 1 to type 4 injuries, expected outcomes are progressively worse”

Sander’s classification

“We conclude that, despite the popularity of the classification system of Sanders for intra-articular fractures of the calcaneum, there is a high degree of variability and inconsistency in its interpretation with only a fair to moderate agreement among its users. Our aim is neither to advocate this system nor to undermine it, but to highlight its shortcomings so that caution is exercised in its usage and interpretation.”

Published 14 January 2005

Consistent features

• There is significant variability in the fracture pattern of displaced intraarticular calcaneal fractures however there are 3 consistent features…

1) sustentaculum typically remain attached to the talus.2) The anterior process translates dorsally.3) The tuberosity translates laterally,displaces superiorly

(pull of achillis),rotates into varus and shortens into the fracture.

Extraarticular calcaneal fracture

Medial process fracture

Anterior processfracture

Verticle tuberosityfracture

Avulsion fracture at EDB attachment

ANTERIOR PROCESS OF CALCANEUM FRACTURE

SUSTENTACULUM TALI FRACTURE Tuberosity avulsion fracturesDue to axial loading and inversion

Usually treated conservatively with non weightBearing or fixed by screw

Associated FHL tendon injury

• Achilles avulsion• Wound problems• Surgical urgency

─ Lag screws or tension band

Take home message…..

•  When calcaneum fracture occurs, the heel can widen, shorten, and become deformed. Consider all pathoanatomical features of fracture to evaluate its complex geometry.

• Although there is significant variability in the fracture pattern of displaced intraarticular calcaneal fractures, always look for 3 consistent features – sustentaculum,anterior process & tuberosity varus.

• Defining calcaneal fracture in different xray views & CT scan is crucial part in its management.

THANKS