Calcaneus Fracture

The calcaneus is the bone that most frequently fractures the tarsus, 75% of fractures are intraarticular and its treatment continues to be the subject of debate today. The aim of this update is to highlight the points of controversy, as well as to clarify the consensus, especially in the treatment of intra-articular fractures, and to describe the management of the main complications.

Epidemiology

90% of fractures occur in young men (20-45 years) and most of them occur in the work environment, with the resulting socio-economic impact. Regardless of the method of treatment used, calcaneal fractures are highly disabling injuries.

Fracture Mechanism

The "typical" mechanism usually occurs after high-energy trauma, such as falls from a height of more than one metre, in which the astragalus is inserted like a wedge into the calcaneus, fracturing it; or less frequently after traffic accidents. The pattern of fracture lines and the degree of comminution are, to some extent, variable and depend on a number of factors, including the position of the foot at the time of impact and the overall bone quality of the patient.

The primary fracture line crosses the posterior subastragaline and creates 2 separate fragments: anteromedial (generally not comminuted, encompasses the sustentaculum tali, which is usually in place attached to the astragalus by the strong interosseous ligaments, and the deltoid ligament) and posterolateral (sometimes comminuted, encompasses the posterior tuberosity, which typically displaces superiorly creating articular incongruence, laterally creating heel widening and forward shortening the heel). Secondary fracture lines, according to Essex-Lopresti, are produced while the deforming axial force continues, distinguishing 2 types of fracture:

Tongue type fracture:

the second fracture line comes from the top of the first line backwards along the longitudinal axis of the calcaneus.

Joint depression:

the second line of fracture comes out of the same place as the previous one, but ends just behind the joint veneer. More frequent than tongue fracture.

When the projectile fired by a firearm hits the skin and the muscles located below it, due to the elasticity of the fibers that compose both tissues, a depression is produced with elongation of the tissues, which finally, when the projectile defeats the resistance they oppose to its advance, are perforated leaving a circular or ovoid wound of the lips directed towards the interior of the skin. In most cases, the orifice is smaller in diameter than the projectile, varying according to the type of warhead, speed, movements of the projectile (rotational and mutation), the depth at which the nearest bone plane is located, the orientation of the muscular fibres, the sonic waves and the turbulence that follow the projectile, the position and angle of incidence of the projectile on the skin, etc.

When the resistance of the skin is overcome, a blunt perforating wound is produced that has particular characteristics that can be observed at the level of the edges.

Diagnosis

Clinical: heel pain and swelling, retrofoot deformity and functional impotence for support. Ecchymosis in the arch of the foot. Appearance of flicthens that condition the timing of surgical treatment (important measures against edema and elevation of the limb in these fractures). Occasionally, there is dislocation or subluxation of the peroneum, neurovascular compression of the posterior tibialis or interposition of the flexor hallucis longus tendon between the fragments (leaving the first finger in a fixed flexion position).

Per image: 3 simple x-rays:

1. Lateral X-ray of foot and ankle: we measure the following angles:

2. Böhler angle: determined by the intersection between a line running from the posterior tuberosity of the calcaneus to the posterior articular facet of the calcaneus-astragaline, and another from this point to the anterosuperior calcaneus end. It is considered normal between 25°-40°. Its value is reduced in proportion to the level of elevation of the posterior tuberosity and/or sinking of the thalamus, unequivocal signs of the presence of a fracture.

3. Critical or crucial angle of Gissane: it is the one that we can measure in the intersection between a line parallel to the surface of the thalamus and another parallel to the anterior average articular surface of the calcaneus. Its normal value is 95-105° and its decrease reflects the presence of a compression fracture.

Treatment

Initial handling

Immobilization with well cushioned bandage, anti-inflammatory measures (local ice, nonsteroidal anti-inflammatory) and limb elevation.

Surgical treatment.

The basic objectives of surgical treatment are as follows:

1. Restore the Böhler angle.

2. Restore the normal width and length of the calcaneus.

3. Anatomical reduction of the articular surfaces, especially of the subastragaline joint.

4. Restore the biomechanics of the retrofoot and gastro-oil complex.

If you need recommendations or help in orthopedic surgery and traumatology do not hesitate to contact me.

Dr. Leopoldo Maizo - Orthopedic Surgeon

If you want to read more I invite you to visit my page:

• https://drmaizo.com

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Posted from my blog with SteemPress : http://drmaizo.com/2018/10/10/surgeons-case-calcaneus-fracture/

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