The Journal of Bone and Joint Surgery 82:225-50 (2000)
© 2000 The Journal of Bone and Joint Surgery, Inc.
Current Concepts Review - Displaced Intra-Articular Fractures of the Calcaneus*
ROY SANDERS, M.D. , TAMPA, FLORIDA
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Introduction
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Most calcaneal fractures occur in male industrial workers, making the economic importance of this injury substantial. Many authors have reported that patients may be totally incapacitated for as long as three years and partially impaired for as long as five years after the injury1,11,39,73,94,133. Although modern operative intervention has improved the outcome in many patients, there still is no real consensus on classification, treatment, operative technique, or postoperative management. In this article, the current thinking regarding the treatment of these very difficult fractures will be reviewed.
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Historical Treatment
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As early as 1908, Cotton and Wilson suggested that open reduction of a calcaneal fracture was contra-indicated27. McLaughlin agreed, likening attempts at operative fixation to the "nailing of a custard pie to the wall."76 Cotton and Wilson recommended closed treatment with use of a medially placed sandbag, a laterally placed felt pad, and a hammer to reduce the lateral wall and "reimpact" the fracture27. Although initially they were enthusiastic about this technique, by the 1920s they had abandoned the treatment of acute fractures altogether and had turned instead to the treatment of healed malunions29.
Despite the fact that Böhler11 advocated open reduction in 1931, the principal reasons for the predominance of nonoperative treatment were the technical problems associated with operative treatment. Anesthesia was not always effective, radiography and fluoroscopy were not well developed, antibiotics did not exist, and a sound understanding of the principles of internal fixation was lacking105. The resulting complications of infection, malunion, and nonunion, and the possible need for amputation, made most surgeons believe that treatment should be nonoperative.
In 1935, Conn, who was dissatisfied with standard treatment methods, reported on the use of delayed primary triple arthrodesis, with which he had excellent results26. In 1943, Gallie championed subtalar arthrodesis as definitive treatment but only for fractures that had healed42. He thought that Conn's operation involving a lateral approach and moving of peroneal tendons26 was too much operative manipulation, and he did not believe that the midfoot should be treated with an arthrodesis42. Although he never reported results (except those for one patient, anecdotally), and despite the fact that no bibliography was ever published, this technique became standard treatment for healed, malunited calcaneal fractures.
Dissatisfied with both nonoperative and late treatment of these injuries, Palmer described the operative treatment of acute displaced intra-articular calcaneal fractures in his classic work, published in 194893. He used a standard lateral Kocher approach to reduce the joint, holding up the fragment with bone graft. He stated that his patients did well and that many returned to work. Essex-Lopresti reported similar findings in 195239. He suggested that, when the articular surface was displaced, a tongue or joint-depression fragment resulted. Although tongue-type fractures were reduced with percutaneous leverage, joint-depression fractures necessitated formal open reduction and internal fixation. The results in patients less than forty years old were as encouraging as those in older patients39.
Not all surgeons were pleased with the results of reduction and fixation, however, and Dick35, in Scotland, and Harris55, in Canada, began to advocate Gallie's technique42 of subtalar arthrodesis for malunited fractures of the calcaneus as the treatment of choice for acute calcaneal fractures. They cited excellent results, with early return to work. This prompted orthopaedic surgeons in Canada to perform primary subtalar arthrodesis as the treatment of choice for acute displaced intra-articular calcaneal fractures. Lindsay and Dewar evaluated many of these patients in a long-term follow-up study73. Although more than half were lost to follow-up, the findings indicated that primary subtalar arthrodesis was being performed unnecessarily, that operative intervention was fraught with problems, and that the best results were in patients who were managed nonoperatively. As a result of that article, which received wide acceptance in the United States and elsewhere, the operative treatment of acute calcaneal fractures once again fell into disfavor. During the 1960s and 1970s, most authors continued to advocate nonoperative treatment3,5,6,24,66,74,94,96,100.
In the last twenty years, better anesthesia, the introduction of antibiotics, the AO/ASIF principles of internal fixation, and computed tomography and fluoroscopy have allowed surgeons to obtain good outcomes with use of operative intervention for most fractures105. Most fracture surgeons believe that the benefits of these improvements should also be offered to patients who have a displaced intra-articular calcaneal fracture, and a concerted effort to apply operative techniques to these fractures is again being made19,31,32,69,84,87,106,111,123,127,137. Although these extensive attempts have indeed improved the functional outcomes after displaced intra-articular calcaneal fractures, it is recognized that treatment remains challenging and can still be fraught with difficulties.
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Radiographic Anatomy
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The calcaneus transmits body weight to the ground and creates a strong lever for the muscles of the calf. Traction trabeculae radiate from the inferior cortex of the calcaneus, while compression trabeculae converge to support the posterior and anterior articular facets (Fig. 1). Soeur and Remy termed this condensation of bone trabeculae the thalamic portion of the calcaneus116. The area between these trabeculae creates a space known as the neutral triangle56.
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FIG1: Fig. 1 Radiograph showing traction trabeculae radiating from the inferior cortex of the calcaneus and compression trabeculae converging to support the posterior and anterior articular facets. The area between these trabeculae is known as the neutral triangle56.
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Two important angles are seen on the lateral radiograph of the calcaneus (Figs. 2-A and 2-B). The tuber angle of Böhler, usually between 20 and 40 degrees, is formed by two lines11. The first line is drawn from the highest point of the anterior process of the calcaneus to the highest point of the posterior facet. The second line runs tangential to the superior edge of the tuberosity. A decrease in this angle may indicate that the weight-bearing surface of the calcaneus (the posterior facet) has collapsed, shifting the weight of the body anteriorly. McLaughlin pointed out that reduction or reversal of this angle indicates only the degree of proximal displacement of the tuberosity and therefore the angle can be decreased in both intra-articular and extra-articular fractures, thus limiting its usefulness74,123. The second angle, the crucial angle of Gissane, is seen directly inferior to the lateral process of the talus110 and is represented by two strong cortical struts that extend laterally and form an obtuse angle39,50. The first strut extends along the lateral border of the posterior facet, and the second extends anteriorly to the beak of the calcaneus.
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Mechanism of Injury and Pathological Anatomy
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Intra-articular fractures of the calcaneus with displacement are the result of high-energy trauma, usually due to a fall from a height, with the patient's weight concentrated on the heels on landing, or to a motor-vehicle accident. The position of the foot at the time of impact, the force of the impact, and bone quality all determine the pattern of comminution as well as the location of the fracture lines. Although the exact mechanism of injury is still controversial, the findings of Essex-Lopresti39, Burdeaux17, Thorén128, and Carr23 are in general agreement.
Essex-Lopresti thought that the primary fracture line is first produced laterally by the lateral process of the talus and then travels medially39. He believed that the energy follows two separate paths: an outer and an inner path. His understanding was that, at the time of impact, the subtalar joint is forced into eversion and "the sharp outer taloid spur is driven like an axe into the crucial angle, splitting it and the outer wall of the bone along its grain."39 The inner route then consisted of the remainder of the force, which "descends through the anterior subtaloid joint on to the sustentaculum tali, which may be sheared off the inner side of the body together with the medial one-third or one-half of the posterior subtaloid joint."39 If the force continues, the fracture line can exit as far forward as the anterior process or the calcaneocuboid joint, creating an anterolateral fragment. With increased force, a secondary fracture line is created. If the foot is flat on the ground and the force is directed posteriorly, the fracture will run behind and superior to the posterior facet, resulting in a free superolateral fragment of posterior facet. Alternately, an inferiorly directed force results in a tongue-type fracture39.
More recently, Carr et al. created experimental intra-articular calcaneal fractures in eighteen below-the-knee amputation specimens22. Different weights at different heights were dropped over a guide-rod inserted into the tibial medullary canal. Two primary fracture lines were consistently observed (Figs. 3-A and 3-B). One fracture line divided the calcaneus into medial and lateral portions. In some specimens the fracture line continued into the calcaneocuboid joint, whereas in others it split the anterior facet. The other primary fracture line divided the calcaneus into anterior and posterior portions, starting laterally from the angle of Gissane and running medially. In several specimens, the fracture line ran medially, splitting the middle facet. Laterally, the fracture line ran inferiorly, either toward the plantar surface or anteriorly. Together, these two fracture lines resulted in a variety of tongue and joint-depression-type fractures and in the creation of anterolateral, superolateral, and superomedial fragments, thereby validating the work of Essex-Lopresti39 (Figs. 4-A and 4-B), Soeur and Remy116, and others135.
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FIG3-A: Figs. 3-A and 3-B: The pathological anatomy of an intra-articular calcaneal fracture, according to the description by Carr et al.22.
Fig. 3-A: Schematic drawing showing the primary fracture lines (1 and 2) and the anterolateral fragment (3).
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FIG3-B: Fig. 3-B: Transverse computed tomographic scan showing the fracture fragments. A = superomedial fragment (also known as the sustentacular or constant fragment), B = superolateral fragment (also known as the semilunar or comet fragment), C (not shown) = tongue fragment (the superolateral fragment attached to a piece of the posterior tuberosity, which includes the Achilles tendon insertion), D = anterior main fragment (the anterior half of the calcaneus), E = anterolateral fragment (the lateral wall of the anterior process), and F = posterior main fragment (the posterior tuberosity fragment).
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FIG4-A: Figs. 4-A and 4-B: Radiographs showing the fracture classification of Essex-Lopresti39.
Fig. 4-A: Joint-depression fracture. The double density indicates a split fracture of the articular surface.
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Radiographic Evaluation
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The initial assessment of the patient should include plain radiographs. If these radiographs reveal an intra-articular component to the fracture, a computed tomographic scan should be made. Many projections and detailed studies of radiographic views have been described, but most of these images are hard to interpret and difficult to reproduce4,60,116,132. When interpreted correctly, computed tomographic scans provide a wealth of data for both diagnosis and treatment. Because of the association of calcaneal fractures with spine injuries, routine radiographs of the lumbar spine also should be made58.
Conventional Radiography
Plain radiographs consist of a lateral radiograph of the hindfoot, an anteroposterior radiograph of the foot, and a Harris axial radiograph of the heel60. The lateral radiograph should confirm the diagnosis of a calcaneal fracture. Radiographs of intra-articular fractures usually show a loss in the height of the posterior facet, with a decrease in the angle of Böhler and an increase in that of Gissane, but only if the entire facet is separated from the sustentaculum and depressed. If only the lateral half of the posterior facet is fractured and displaced, a split in the articular surface will be seen as a double density and Böhler's angle will be normal (Fig. 5-A). The articular surface can be found within the body of the calcaneus; usually, it is rotated 90 degrees in relation to the remainder of the subtalar joint. The lateral radiograph also indicates whether the fracture is of the joint-depression or tongue type according to the classification of Essex-Lopresti39. The anteroposterior radiograph of the foot shows extension of the fracture line into the calcaneocuboid joint (Fig. 5-C). This radiograph provides very little information and usually may be omitted. The Harris axial radiograph of the heel allows visualization of the joint surface as well as loss of height, increase in width, and angulation of the tuberosity fragment (Fig. 5-B). Unfortunately, this radiograph is very difficult to make in the acute setting because of pain.
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FIG5-C: Fig. 5-C: Anteroposterior radiograph of the foot, showing the fracture extending into the calcaneocuboid joint.
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FIG5-B: Fig. 5-B: Harris axial radiograph of the heel. The clarity is limited because the image was difficult to make due to pain.
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Tomograms are rarely indicated, as they provide no additional information when computed tomography is available and they expose the patient to increased doses of radiation53. Deutsch et al. pointed out that tomograms may fail to show the extent of articular incongruity34. Brodén's view, however, is a reproducible means of demonstrating the articular surface of the posterior facet on plain radiographs14. This view, known as Brodén Projection I, is obtained with the patient supine and the x-ray cassette under the leg and the ankle. The foot is in neutral flexion, and the leg is internally rotated 30 to 40 degrees (Fig. 6-A). The x-ray beam then is centered over the lateral malleolus, and four radiographs are made with the tube angled 40, 30, 20, and 10 degrees toward the head of the patient (Figs. 6-B and 6-C)14. These radiographs show the posterior facet as it moves from posterior to anterior; the 10-degree view shows the posterior portion of the facet, and the 40-degree view shows the anterior portion. Importantly, these radiographs can be used in the operating room to verify the reduction of the articular surface108.
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FIG6-A: Figs. 6-A and 6-B: Schematic drawings showing the technique for making Brodén's views14. (Reproduced, with modification, from: Burdeaux, B. D., Jr.: Reduction of calcaneal fractures by the McReynolds medial approach technique and its experimental basis. Clin. Orthop., 177: 96, 1983. Reprinted with permission.)
Fig. 6-A: With the patient supine, the x-ray cassette is placed under the leg and the ankle. The foot is in neutral flexion, with the leg internally rotated 30 to 40 degrees.
Fig. 6-B: The x-ray beam is centered over the lateral malleolus and four radiographs are made, with the tube angled 40, 30, 20, and 10 degrees toward the head of the patient.
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FIG6-B: Figs. 6-A and 6-B: Schematic drawings showing the technique for making Brodén's views14. (Reproduced, with modification, from: Burdeaux, B. D., Jr.: Reduction of calcaneal fractures by the McReynolds medial approach technique and its experimental basis. Clin. Orthop., 177: 96, 1983. Reprinted with permission.)
Fig. 6-A: With the patient supine, the x-ray cassette is placed under the leg and the ankle. The foot is in neutral flexion, with the leg internally rotated 30 to 40 degrees.
Fig. 6-B: The x-ray beam is centered over the lateral malleolus and four radiographs are made, with the tube angled 40, 30, 20, and 10 degrees toward the head of the patient.
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Computed Tomographic Scanning
Computed tomographic scanning has improved our understanding of these fractures substantially and has allowed for consistent analysis of the results of treatment (Figs. 7-A and 7-B). There are several excellent review articles on this subject14,46,53,57,79,99,114,117,118.
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FIG7-A: Fig. 7-A Coronal (Fig. 7-A) and transverse (Fig. 7-B) computed tomographic scans showing a calcaneal fracture.
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FIG7-B: Fig. 7-B Coronal (Fig. 7-A) and transverse (Fig. 7-B) computed tomographic scans showing a calcaneal fracture.
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Normal Anatomy
Coronal images reveal information about the articular surface of the posterior facet, the sustentaculum, the shape of the heel, and the position of the peroneal and flexor hallucis tendons.
Transverse (axial) images provide information about the calcaneocuboid joint, the anteroinferior aspect of the posterior facet, and the sustentaculum.
Pathological Anatomy
Coronal images can be analyzed to determine displacement of the articular surface of the posterior facet and the number and location of articular fracture fragments, as these findings have prognostic importance. The calcaneal body should be evaluated for widening, shortening, and bulging of the lateral wall. The peroneal tendons should be evaluated carefully to rule out impingement. Varus shift of the tuberosity fragment also should be ruled out.
Transverse (axial) images provide information about fractures extending into the calcaneocuboid joint. Fractures at the anteroinferior base of the posterior facet (Gissane's angle) and those extending into the sustentacular fragment also can be seen. Finally, the amount of adduction of the tuberosity fragment can be determined.
The use of three-dimensional computed tomographic scanning for intra-articular calcaneal fractures was recently evaluated in several studies2,130. Although this is an interesting modality, the definition of the articular surface was not sufficient to assist in preoperative planning or to justify the costs. Vannier et al. concluded that the diagnostic value of three-dimensional computed tomography was equivalent to that of conventional two-dimensional computed tomography130.
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Classification of Fractures
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One reason why so much difficulty has been encountered in the treatment of calcaneal fractures is the surgeon's inability to successfully classify these injuries. Before the advent of computed tomographic scanning, numerous systems for the classification of calcaneal fractures were proposed39,93,100,132,133. The accuracy and utility of all of these systems have been limited by standard radiographic technique. Also, because similar fracture patterns were not analyzed, similar treatment regimens resulted in varying degrees of success. The treatment of calcaneal fractures has been greatly enhanced by the advent of computed tomographic scanning.
Classifications Based on Conventional Radiographs
In 1948, Palmer reported on two distinct types of intra-articular fractures of the calcaneus93. This description was refined in 1952 by Essex-Lopresti, who also found two distinct fracture patterns: those with a tuberosity fragment attached to the articular fragment, which he called tongue-type fractures, and those without it, which he termed joint-depression-type fractures39. Correct classification of the fracture determined the treatment but not the prognosis. Although Warrick and Bremner described various types of fractures in an atlas published in 1953, they discussed neither treatment nor prognosis132. Careful study of their findings indicates that they essentially reproduced the fracture patterns described by Essex-Lopresti. Similarly, Widen133, Arnesen5, and others44 used variations of the Essex-Lopresti classification.
In 1975, Soeur and Remy reported on their experience with calcaneal fractures116. Unique to their discussion was a classification based on the number of articular bone fragments, as determined with use of anteroposterior radiographs of the midfoot and lateral and Harris radiographs of the heel. First-degree fractures were defined as nondisplaced shear fractures with widening of the joint surface. Second-degree fractures included secondary fracture lines, resulting in a minimum of three pieces, two of which included the articular surface. Clinical radiographs in their text indicated that the posterior main fragment could be broken into as many as three fragments (lateral, middle, and medial). Third-degree fractures were so highly comminuted they could not be classified; therefore, the authors could not specify if the comminution referred to the calcaneal body or to the articular surface of the posterior facet. Although they indicated that displaced fractures should be internally fixed and that good results could be expected, they did not stratify the results on the basis of their classification.
Classifications Based on Computed Tomographic Scanning
In 1985, Segal et al. described the usefulness of computed tomographic scanning for the diagnosis and treatment of calcaneal fractures111. Although Stephenson used computed tomographic scans for a few of his patients124, Zwipp et al. were the first, to my knowledge, to integrate computed tomographic scans into a rational understanding of the injury137. The entire calcaneus was considered in their classification (Fig. 8-A). There was a total of five possible fragments, similar to the classifications of Essex-Lopresti39, Soeur and Remy116, and Carr et al.22, and fractures had two, three, four, or five parts. Although the outcomes of the operations were evaluated, no prognosis was made on the basis of the fracture classification137.
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FIG8-A: Figs. 8-A and 8-B: Classification systems based on computed tomographic scanning.
Fig. 8-A: Classification of calcaneal fractures according to Zwipp et al.137. 1 = sustentacular fragment, 2 = tuberosity fragment, 3 = subtalar joint fragment, 4 = anterior process fragment, and 5 = anterior subtalar joint fragment. The most frequently involved joint is the posterior subtalar joint, followed by the calcaneocuboid joint and the anterior subtalar joint (middle and anterior facets). (Reprinted, with permission, from: Zwipp, H.; Tscherne, H.; Thermann, H.; and Weber, T.: Osteosynthesis of displaced intraarticular fractures of the calcaneus. Results in 123 cases. Clin. Orthop., 290: 78, 1993.)
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Crosby and Fitzgibbons, in 1990, associated the clinical outcome with the type of fracture according to a classification system based on computed tomographic findings30. They evaluated displacement of the articular surface and, on this basis, categorized the fractures into three types: type I—nondisplaced, type II—displaced, and type III—comminuted. Sanders et al. developed a computed tomographic scanning classification that was based on the number and location of articular fracture fragments105,106 (Fig. 8-B). This classification was a natural progression of the fracture-pattern classification as described by Soeur and Remy116. All patients were examined preoperatively and postoperatively with computed tomography to determine the success of the reduction of the calcaneal body and the subtalar joint. The classification was found to be useful in determining treatment as well as prognosis106. The system is based on coronal computed tomographic scans. Although all coronal sections were analyzed, the section showing the widest undersurface of the posterior facet of the talus was arbitrarily used. The talus was divided into three equal columns by two lines. These lines and a third line, located just medial to the medial edge of the posterior facet, divided the posterior facet into three potential pieces: a medial, a central, and a lateral fragment. These fragments and the sustentaculum comprised a total of four potential articular pieces. All nondisplaced articular fractures, irrespective of the number of fracture lines, were considered type-I fractures. Type-II fractures were defined as two-part fractures of the posterior facet and were similar in appearance to a split fracture of the tibial plateau; three subtypes, IIA, IIB, and IIC, were based on the location of the primary fracture line. Type-III fractures consisted of three-part fractures characterized by a centrally depressed fragment, similar to a split depressed fracture of the tibial plateau or a die-punch fracture of the distal part of the radius; subtypes included IIIAB, IIIAC, and IIIBC. Type-IV fractures, or four-part articular fractures, were highly comminuted and often had more than four articular fragments.
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FIG8-B: Fig. 8-B Classification of intra-articular calcaneal fractures according to Sanders et al.105,106. Type I = nondisplaced fractures, type II = displaced fractures, and type III = comminuted fractures. (Reprinted, with permission, from: Sanders, R: Intra-articular fractures of the calcaneus: present state of the art. J. Orthop. Trauma, 6: 254, 1992.)
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Clinical Examination
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The amounts of displacement and soft-tissue disruption associated with an intra-articular fracture of the calcaneus are proportional to the force generated to produce the injury. In injuries caused by minimum force, swelling and ecchymosis are mild. Severe soft-tissue disruption occurs with higher-energy injuries and may be associated with open fractures. Open fractures may present with a slight puncture wound medially, where a spike of the medial wall of the calcaneus protrudes, or they may be substantial, with extensive soft-tissue disruption, usually laterally. With these severe high-energy wounds, talonavicular disruptions may occur, with the talar head traveling through the anterior aspect of the calcaneus. In the most severe of these fractures, the talar head protrudes through the plantar skin.
Pain is usually severe and is related to the amount of bleeding into a tightly enveloped fascia of the heel. If the patient is seen more than six hours after the injury, the lateral skin is usually so swollen that the skin creases have disappeared. Careful evaluation by palpation of the fibular malleolus should be performed to discern whether the peroneal tendons have dislocated.
Compartment Syndromes
Care must be taken to ensure that the severe pain associated with the fracture is not related to a compartment syndrome of the foot, especially in the calcaneal compartment40,89. A compartment syndrome develops when pressure increases in a closed soft-tissue space, ultimately affecting pulse pressure to the point where arterial flow is influenced. The long-term sequelae of a compartment syndrome of the foot include clawfoot deformity with permanent loss of function, contracture, weakness, and sensory disturbances40. There are four compartments—medial, lateral, central, and interosseous—within the foot. The central compartment is divided into two separate compartments by a transverse septum in the hindfoot; the superficial compartment contains the flexor digitorum brevis muscle, and the deep compartment contains the quadratus plantae muscle and the lateral plantar nerve40. The latter compartment is known as the calcaneal compartment. In addition, there is a communication between the calcaneal compartment and the deep posterior compartment of the leg89. A self-contained needle manometer system (Quikstik; Stryker, Kalamazoo, Michigan) is most commonly used to measure compartment pressures. Most authors have recommended that fasciotomy be performed when the compartment pressure rises to within ten to thirty millimeters of mercury (1.33 to 4.00 kilopascals) of the diastolic pressure40,89.
During operative treatment of a compartment syndrome of the foot, the calcaneal compartment can best be released by a separate hindfoot incision similar to that used for release of the plantar fascia40,89. The incision begins four centimeters anterior to the posterior portion of the heel and three centimeters from the plantar surface, and it is approximately six centimeters long, paralleling the sole of the foot. It may be extended proximally to decompress the entire tibial neurovascular bundle. The fascia overlying the abductor hallucis muscle is seen, directly in line with the incision. As the fascia is opened, the medial compartment is released. The abductor hallucis muscle is stripped from its overlying fascia and is retracted superiorly, revealing the dense white fascia of the medial intermuscular septum. Incision of this fascia releases the calcaneal compartment, but care must be taken to avoid the lateral and medial plantar nerves and vessels just beneath the septum. When this incision is used for release, the two dorsal incisions should be employed to release the other compartments of the foot as needed40,89.
Blisters
Blisters may appear when substantial swelling is present. They can occur anywhere about the foot, and the vesicles can be filled with either clear fluid or blood47-49,131. The blister is the result of a cleavage at the dermal-epidermal junction, and the fluid represents sterile transudate47-49,131. If the dermis retains some epidermal cells, then the fluid remains clear. If the dermis is completely devoid of epidermal cells, then the transudate becomes bloody47. In a prospective study of fifty-three feet, Giordano and Koval evaluated methods for the treatment of blisters, including aspiration, deroofing with subsequent application of Silvadene (silver sulfadiazine) cream or coverage with a nonadherent dressing, and leaving the blister intact and covered by loose gauze or exposed to the air48. Although there was no major difference in outcome among the different techniques, two patients in whom the incision had passed through a blood-filled blister had complications related to wound-healing. Varela et al. reviewed the cases of fifty-three patients retrospectively and found that two had a major wound infection secondary to an incision through the blister131. In that study, microbial evaluation of eleven ruptured vesicles demonstrated colonization with skin pathogens soon after rupture of the blister and until re-epithelialization.
On the basis of these data, incisions should be modified to avoid blistered skin.
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Treatment Options
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The treatment of displaced intra-articular calcaneal fractures can be divided into three categories: nonoperative, open reduction and internal fixation, and primary arthrodesis.
Nonoperative Treatment
Nonoperative treatment consists of early range-of-motion exercises and non-weight-bearing for approximately three months. The foot is placed in a boot, which is locked in neutral flexion in order to prevent an equinus contracture, and an elastic compression stocking is used to minimize dependent edema. Nonoperative treatment is best reserved for nondisplaced (Sanders type-I) fractures33,103. For patients who have displaced intra-articular fracture fragments, nonoperative treatment offers little chance of a return to normal function because a calcaneal malunion will develop. Of concern is the fact that a reduction of the articular surface never is obtained, the heel remains shortened and widened, the talus remains dorsiflexed in the ankle mortise, and the lateral wall causes impingement and binding of the peroneal tendons. Specific indications for nonoperative treatment include a nondisplaced fracture30,103, severe peripheral vascular disease or insulin-dependent diabetes, and other medical problems that contraindicate an operation. Specific situations in which nonoperative treatment may be required because an injury precludes early operative intervention include a severe open fracture; a life-threatening injury; and soft-tissue compromise, such as blistering and massive, prolonged edema, which may substantially delay operative treatment.
Operative Treatment with Use of a Lateral Approach
When operative treatment is elected, it should be performed within the first three weeks after the injury, before early consolidation of the fracture. Once the fracture has consolidated, it is difficult to separate the fracture fragments to obtain an adequate reduction. An operation should not be attempted until after swelling in the foot and ankle has markedly decreased. Because this may take seven to fourteen days, a variety of methods must be used to reduce edema. If the patient is seen in the emergency room, immediate elevation and application of a Jones dressing with a posterior splint is employed. Several days later, if the swelling has begun to decrease, a boot locked in neutral flexion and an elastic compression stocking can be used. Many authors have reported good results with use of a foot pump43,88,127.
The patient can be evaluated with computed tomographic scans and conventional radiographs one week after the injury. If operative intervention is indicated at that time, it may be performed as soon as the wrinkle test is positive105. This test is best performed by direct palpation of the skin over the lateral aspect of the calcaneus and by visual evaluation of this area when the patient dorsiflexes and everts the foot. If skin-wrinkling is seen and no pitting edema is evident, operative intervention may be undertaken.
The operation can be performed by placing the patient in either lateral decubitus or the prone position on a translucent table or a cardiac pacemaker insertion board (pacer board) so that fluoroscopy may be used intraoperatively. After exsanguination of the lower extremity, the tourniquet is inflated to 350 millimeters of mercury (46.66 kilopascals). The calcaneus is approached through an extensile right-angled lateral incision52,137 (Fig. 9-A). This approach minimizes the sequelae of peroneal tendinitis and devascularization of the anterior skin flap and preserves the sural nerve (Fig. 9-B).
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FIG9-A: Fig. 9-A: Photograph showing Seligson's lateral extensile approach to the calcaneus, as described by Gould52.
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FIG9-B: Fig. 9-B: The sural nerve and the peroneal tendons are protected within the full-thickness anterior flap.
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The fracture line at the level of the angle of Gissane is identified, and the thin lateral wall is lifted gently and retracted inferiorly to expose the articular fracture fragments buried within the body of the calcaneus. The superolateral fragment of the posterior facet is evaluated and rotated out from within the body, immediately decompressing the remaining fracture. Attention then is turned to restoration of the height of the calcaneus, which is accomplished by repositioning the posterior tuberosity under the sustentaculum. This is done by placing a periosteal elevator into the fracture line in the medial wall and levering the tuberosity down and shifting it medially37.
If the superolateral fragment is in two or more pieces, it can be reconstructed anatomically with use of resorbable pins (SmartPin, self-reinforced poly levolactic acid; Bionx Implants, Blue Bell, Pennsylvania). The anterolateral corner of the superolateral fragment should line up with the posterolateral corner of the anterolateral fragment so that the angle of Gissane, at the anterior edge of the posterior facet, lines up. Brodén's views are made, and the reduction of the joint is accepted or is rejected and repositioned until the surgeon is satisfied that the articular surface is anatomically reduced. Then, 3.5-millimeter cortical-bone lag screws are placed from the lateral cortex toward the sustentaculum. Attention next should be turned to the calcaneal body. The anterolateral fragment and the posterior tuberosity are realigned to ensure that the body is anatomically reduced. This may require manipulation with a Schanz pin109. A low-profile lateral plate is applied to stabilize the posterior facet, the anterior process, and the posterior tuberosity. The reduction is again verified under fluoroscopy and, if it is found to be satisfactory, a layered closure is performed (Figs. 10-A, 10-B, 10-C, 10-D, 10-E, 10-F, 10-G, 10-H and 10-I).
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FIG10-A: Figs. 10-A through 10-K: A foot that had a Sanders type-IIIBC displaced intra-articular calcaneal fracture.
Fig. 10-A: Lateral radiograph showing the displaced intra-articular calcaneal fracture.
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FIG10-B: Figs. 10-B and 10-C: Coronal and transverse computed tomographic scans indicating a Sanders type-IIIBC fracture.
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FIG10-C: Figs. 10-B and 10-C: Coronal and transverse computed tomographic scans indicating a Sanders type-IIIBC fracture.
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FIG10-G: Fig. 10-G Postoperative coronal, oblique, and transverse computed tomographic scans showing both the articular and the extra-articular reduction.
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FIG10-H: Fig. 10-H Postoperative coronal, oblique, and transverse computed tomographic scans showing both the articular and the extra-articular reduction.
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FIG10-I: Fig. 10-I Postoperative coronal, oblique, and transverse computed tomographic scans showing both the articular and the extra-articular reduction.
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While postoperative treatment may vary from surgeon to surgeon, I recommend the following regimen. The patient is kept in the hospital overnight, and a below-the-knee non-weight-bearing cast is applied before the patient is discharged. The patient returns three weeks later, at which time the cast and stitches are removed and the foot is placed back in the stocking and walking boot, which is locked at 90 degrees. The patient may begin range-of-motion exercises out of the boot at this time, but weight-bearing is not permitted for another six weeks. Additionally, the patient should wear the boot while sleeping, for approximately three weeks (six weeks postoperatively), to prevent the development of an equinus contracture. At nine weeks postoperatively, the patient may begin progressive weight-bearing while wearing the boot. The patient should be able to return to a reasonably active job by four and one-half months postoperatively (Figs. 10-J and 10-K).
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FIG10-J: Fig. 10-J Clinical photographs made one year postoperatively. The patient had resumed all activities, including tennis.
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FIG10-K: Fig. 10-K Clinical photographs made one year postoperatively. The patient had resumed all activities, including tennis.
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Primary Arthrodesis
At the present time, a primary arthrodesis is advocated only for patients who have a Sanders type-IV highly comminuted intra-articular fracture (Figs. 11-A, 11-B, and 11-C)15,105,106. After restoration of the calcaneal body and the joint surface according to the method described earlier, the remaining cartilage is removed from both surfaces of the posterior facet and an autologous bone graft is used to perform an arthrodesis. Typically, a 6.5 to 8.0-millimeter cannulated cancellous-bone lag screw is placed from the posterior tuberosity into the talar dome to stabilize the fusion. This may require removal of isolated 3.5-millimeter screws from either the side-plate or the articular reduction. The limb is placed in a non-weight-bearing below-the-knee cast for three months, after which time the patient may begin to walk, following the same regimen as described for patients who have been operated on with a lateral approach.
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FIG11-A: Figs. 11-A, 11-B, and 11-C: A foot that had a Sanders type-IV comminuted calcaneal fracture that was treated with a primary arthrodesis.
Fig. 11-A: Preoperative computed tomographic scans.
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Results of Treatment
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Treatment Before the Advent of Computed Tomographic Scanning
Closed treatment of calcaneal fractures was evaluated in at least eight large studies, which demonstrated varying rates of success and in which different methods of treatment, classification, and outcome measurement were used39,54,65,66,73,96,100,101. Simpson et al. compared the sixty-two largest studies that were performed before 1983 and cautioned against drawing conclusions on the basis of the existing literature112. Giachino and Uhthoff came to the same conclusion45. Therefore, the results of studies published before computed tomographic scanning became available are ambiguous and should be evaluated in a historical context.
Many studies using more modern methods of analysis subsequently were published. These studies can be categorized as those involving nonoperative treatment, those involving operative treatment, and those comparing operative with nonoperative methods.
Nonoperative Treatment
Crosby and Fitzgibbons utilized a computed tomographic scanning classification based on a fracture pattern involving the posterior facet in order to evaluate the results of closed treatment30. They classified small or nondisplaced fractures as type I, displaced fractures as type II, and comminuted fractures as type III. Their series included thirteen type-I, ten type-II, and seven type-III fractures. All fractures were treated with closed methods. Those authors concluded that all patients who had a type-I fracture had a good result but that most who had a type-II fracture and all who had a type-III fracture had a poor result with closed treatment, and they suggested operative treatment for these fractures.
Kitaoka et al. reviewed a series of sixteen calcaneal fractures that had been treated nonoperatively between 1980 and 198765. Unique to this study was the use of gait analysis to evaluate outcomes. Most patients had an altered gait pattern, especially when they walked on uneven ground, confirming that there was at least some persistent functional impairment.
Operative Treatment
Medial Compared with Lateral Approach
Previously, most authors focused more on restoration of the overall shape of the calcaneus and correction of Böhler's angle than on reduction of the joint39,81,82,93,126,128,133; thus, McReynolds75,76 and others17-19 stressed the importance of a medial approach for reconstruction of the shape of the extra-articular portion of the calcaneus. This approach resulted in an indirect and often incomplete reduction of the joint surface; as a result, Stephenson used a medial approach for reduction of the body and a lateral approach for reduction of the joint123-125.
Recently, Burdeaux reported on his twenty-one |
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Introduction
Historical Treatment
