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Calcaneal fractures: Which patients benefit from surgery?

Panel discusses recent calcaneal fracture literature and how it has affected their practice.

Issue: September 2006

BySteven Douglas K. Ross, MD

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The treatment of calcaneal fractures continues to be controversial. These fractures present many challenges to the treating surgeon, including bony comminution, sometimes severe soft tissue envelope involvement, and trouble regaining subtalar joint function with its very complex joint mechanics. Calcaneal fractures, unlike tibial plateau or tibial pilon fractures, involve displacement of the entire bone, thus making reconstruction particularly difficult because there is often no foundation upon which to build.

Last month in part one of this two-part round table, we gathered a group of experts in the field to discuss some of the recent literature and how it has changed their practice. They discussed how they decide which patients are good surgical candidates, how fracture pattern or classification influences operative approach and how much fixation is necessary. The discussion also covered the use of small incision surgery for repairing these injuries.

In part two of this virtual round table, our experts review the case of a 25-year-old man injured in a head-on auto collision.

Ross: I would like to have your comments on the following case.

This is a 25-year-old man who was injured in a head-on auto collision. He suffered chest and abdominal injuries that required emergent surgery. His orthopedic injuries included a left femoral condylar fracture that required operative treatment and an injury to his right foot.

The right foot was swollen and ecchymotic with deep fracture blisters on the medial hindfoot but was not open. At 10 days after injury when you are asked to see him. Attached are the films. Questions:

1. What treatment would you recommend?

a. Can this do well with closed treatment? Why or why not?

b. How would you classify the fracture and how does this help you?

c. If you choose surgery, what are your criteria for when? What approach? What type of fixation and why?

d. What type of immobilization? When would you allow weight-bearing? When would you start range of motion?

e. What would you expect his prognosis to be?

Sanders: In response to your photos, this is a simple, Sanders 2B, but this is essentially a fracture dislocation with the entire facet intact, except for a far lateral fragment that I cannot see. The joint is fractured at the B line but this is non-displaced. More importantly, like a fracture dislocation, the ankle ligaments are torn, and the recoil has pulled the ankle out of the mortise.

I cannot tell much about the peroneal tendons but they may be dislocated as well. The patient needs an open reduction and repositioning of the posterior tuberosity. This procedure cannot be performed closed because the tuberosity is wedged, with an open surgical correction of the joint, which appears to be depressed even though it is non-displaced.

Then the ankle ligaments must be repaired, and the peroneal tendons should be restored in their groove.

The approach is a standard L-type lateral approach with the patient in the lateral position. Everything else is straightforward. I use an Ace-DePuy calcaneal plate, standard lag screws for the joint, Mitek G2 anchors for repair of both the ankle ligaments and the peroneal tendon sheath. Postoperatively, the patient should spend 3 weeks in a cast, 9 weeks in a boot and stocking, and should not weight bear for 3 months.

Prognosis is good over all, but the patient may develop “sprain pain” at his ankle laterally if the subtalar joint gets stiff because the eversion will be through the ankle, and the ligaments are already torn and scarred.

Thordarson: In response to your first question, in my opinion, this case would do poorly with closed treatment due to the varus tilt of the ankle mortise and the obvious calcaneofibular abutment, in addition to the severe overall malalignment of the posterior tuberosity.

I typically use the Sanders classification and this would be a Sanders Type 2B with a split in the central portion. However, I believe it is also important to add that there is gross malalignment of the posterior tuberosity with calcaneofibular abutment leading to ankle malalignment.

In choosing surgery, I would wait until the swelling is down, there is no evidence of full-thickness skin slough beneath the medial fracture blister, and there is clearly wrinkling of the lateral hindfoot skin with eversion and dorsiflexion of the hindfoot.

I would do a lateral extensile L-shaped approach and use an Ace perimeter plate, as this is my preferred fixation method, and I believe it would be adequate for this injury.

I do not personally use locking plates for calcaneal fractures because they add bulk and it is difficult to know whether I’ve achieved adequate purchase with a screw when placing them in or near comminuted bone.

For postoperative immobilization, I would place this patient in a splint for approximately 2 to 3 weeks until the wound is completely healed, then I would start range-of-motion exercises. Weight-bearing would be delayed 8 to 10 weeks.

His prognosis would be fair. With ORIF, hopefully he would have an overall normal calcaneal morphology with, in general, one-third to one-half normal subtalar motion. He would hopefully have a relatively uninvolved ankle once the lateral calcaneofibular interval was decompressed.

Buckley: Because of the amount of displacement, this man requires ORIF (at the right time). He has marked disruption and when he goes to the operating room for his initial operative care for his femur, he should have a closed reduction of his calcaneus to help with soft tissue management.

He is lucky this is not an open fracture but it might become open if it is left much longer. Repair is achievable with closed manipulation only but it is possible to do a limited external fixation to pull the tuberosity beneath the subtalar joint and to remove the pins and allow the soft tissues to settle down until the heel is ready to operate on.

This fracture classification is relatively straightforward because it has a single fracture line into the joint surface.

This is Sander’s type 2B but is accompanied by a marked tuberosity displacement. This makes it somewhat more difficult to handle but it is still a Sander’s 2 by the classifications that we use. This classification helps me immensely because it helps with treatment of the joint surface, but it doesn’t really plan what I will do with the foot operatively.

I currently operate on about 70% of the heel fractures that come to me. The other 30% are elderly or unwell patients or non-compliant people who do not require surgery. This man is young and has a marked displacement of his calcaneus that mandates operative care. He needs to ensure that he stops smoking if he is a smoker. In addition to our initial wound and fracture care, he must keep the foot elevated.

I would do the surgery within the first 15 days because after that the position is poor. He needs surgery to reduce the tuberosity beneath the hindfoot within the first 2 days. I would use lateral operative approach.

The amount of comminution beneath the joint surface means that he is a good candidate for a locking plate, which would maintain tuberosity height and length. It will not be maintained without locking plates or other means of fixation, such as multiple threaded K-wires. Often when there is a large hole I also use the bone substitute that harden (Norion).

I do not immobilize the calcaneal fracture after surgery. I start immediate motion. These fractures, however, have a tendency to collapse, so I do not start weight-bearing until 10 weeks. Range of motion will be started immediately.

This man should do well because his hindfoot joint is not badly injured. With accurate reduction and maintenance of such with no varus and maintenance of height, this man should score around 7 or 8 out of 10 on an oral analogue scale, with 10 being perfect. This is based on published literature.

Carr: I would recommend surgical treatment, because this is guaranteed to do poorly with nonoperative treatment. He has a fracture dislocation of the calcaneus with varus of the talus in the ankle mortise.

Nonoperative treatment would result in a deformed foot with poor weight-bearing mechanics. Additionally he has disruption of the peroneal tendons with avulsion fractures of the distal fibula. This would result in dislocated peroneal tendons that further compound a poor result with nonoperative treatment.

This is classified as a fracture dislocation. This helps me because I know the calcaneal body is dislocated laterally beneath the fibula and constitutes an absolute indication for surgery, in my opinion.

Associated problems seen with fracture dislocations include varus of the talus in the ankle mortise, and in some cases entrapment of the flexor hallucis longus in the fracture site. This later problem can produce a checkrein deformity of the big toe.¹

For the surgical timing, I would wait for the medial blister to heal. This will take an additional 10 to 14 days.

I would not immobilize the foot to allow motion and help care for the blister. Once the blister is healed, I would perform surgery with a medial and lateral approach.² If he had a full-thickness contusion under the medial fracture blister, then I would use a small lateral approach only. The lateral approach would have to be slightly longer than I normally use to allow repair of the peroneal tendons.

Fixation would consist of medial column screws and perhaps a 2.7 mm antiglide plate on the superomedial fragment. If it weren’t for the peroneal tendons, this approach would be sufficient for this fracture pattern (assuming the posterior facet has no displaced fragments). Laterally, a 2.7 mm or 2.0 mm plate is used to bridge the tuberosity to the anterolateral fragment.

In this case, the joint may not require fixation but if it shows displacement, it is reduced and fixated with an appropriately sized screw: 3.5 mm to 2.0 mm. Extra long minifragment screws are required and are made by numerous manufacturers. I repair the peroneal tendons by stabilizing the sheath — most likely with sutures placed through drill holes in the fibula or suture anchors.

Postoperatively, I would place the patient in a bivalved short leg cast for 2 weeks. At 2 weeks, he would then be started on range of motion exercises. Weight-bearing would proceed at 6 weeks guided by pain and his other orthopedic injuries.

The prognosis for this injury is very good, especially if the posterior facet is non-displaced as the one CT scan indicates. I would anticipate an AOFAS foot score to be 85+. The need for later surgery with this injury is remote.

Ross: As you can see from the postoperative reduction films (page 42), the patient was treated with ORIF, the incision was above the peroneals and the lateral ligaments and peroneal tendon sheath were also repaired.

The most proximal screws on the plate were placed through the small stab incision. The reduction was assisted by the femoral distractor placed percutaneously on the medial side. What are your thoughts about this approach and the outcome? The fragment on the medial side (on Harris view) was, of course, under the deep fracture blister.

Would you have approached that at the time of this original surgery? When would you have started active range of motion? What determines when you start weight-bearing? Is it fracture stability, X-ray evidence of fracture healing, a predetermined time or something else?

Buckley: This is an interesting approach for a difficult fracture. The biggest problem that we see now that people are trying to do minimally invasive surgery is that they fail to reduce the joint. Do you have a CT demonstrating that you have reduced the joint? Have we assurance that the plain film actually shows that the joint is perfectly reduced?

Each of your techniques look very good. The medial side would have been reduced through the lateral approach, but I would have used an extended lateral approach. I would have started range of motion on the first day. Weight-bearing usually waits between 8 and 12 weeks. It is certainly is a combination of everything, fracture stability and fracture healing and the type of fracture (the lower Sanders types are mobilized full weight-bearing much quicker).

Sanders: Where is the postoperative CT? Otherwise, the body looks reduced on the lateral, with an appropriately placed DePuy plate. I cannot tell about the joint reduction. Kocher incision used, that is OK, HLA view shows a bit of residual varus. A CT scan is mandatory.

Carr: The approach is fine, although the peroneal tendon exposure does not provide extensile exposure.

The medial side has a piece flipped out at a 90º angle to the tuber. It is hard to say based on descriptions alone whether or not I would have done a medial approach because that is based on the soft tissues. Fragments can impinge on the nerve but may be left alone if they are not causing symptoms. I start active ROM at 2 weeks when the wound is healed. I start touch down weight-bearing at 2 weeks if the bone-screw purchase is good. Weight-bearing is then progressed at 6 weeks as pain allows.

I would start weight-bearing based on fracture stability at the time of fixation, X-ray evidence of fracture healing, as well as the usual time frame for bone healing. I agree with Dr. Sander’s remarks, although the tuberosity appearance may be a projectional one.

Ross: One of the advantages of the sinus tarsi approach for calcaneus fractures is that you have an excellent view of the articular surface reduction. I do not routinely obtain a postoperative CT scan because I am able to fully visualize the articular surface at the time of surgery and postoperatively the information would not change my treatment. Finally, what is your rehabilitation protocol and expected outcome and how is it affected by patient factors?

Buckley: These are many factors that most influence outcome. This was determined by our multicenter, prospective, randomized trial. As I noted earlier, younger patients do better than older patients when treated operatively, women do better than men and workers’ compensation patients do less well, regardless of treatment. Our randomized control trial demonstrated that patients who had more medical illnesses and problems with smoking had higher infection rates. Patients who were marginal surgical candidates with complications did less well and patients with multiple complications also did poorly.

This answers your question that says that those treated operatively do the best if there are no complications, but nonoperatively treated patients are the next best group.

Those that are treated with operations but have complications are usually less well than those who have nonoperative care. Finally there is the group that has poor decision making for nonoperative care and they do the least well of all patients because if they get complications with nonoperative care then they end up with the least good outcomes.

Sanders: I tell patients that postoperatively they can expect to improve considerably within 6 months, but that they will not be able to run and will have difficulty with uneven ground. They should, however, do well with flat surfaces, be able to play golf, swim and bike and, of course, participate in the great American pastime of shopping.

Unfortunately, many of my patients are construction workers, and this injury limits them to work on the ground, as ladders and roofs can be dangerous for them. Many will require a job modification or a change of profession altogether.

Ross: Calcaneal fractures continue to be associated with ongoing treatment innovation as demonstrated by the thoughts presented by our four guests.

I want to thank each of you for your participation in this symposium and look forward to your continued work to help everyone in the orthopedic community to have a better understanding of these difficult fractures.

For more information:

• Orthopedics Today was unable to determine whether Drs. Buckley, Carr, Ross and Sanders have a direct financial interest in the products discussed in this article or if they are paid consultants for any companies mentioned. Dr. Thordarson is a paid consultant for DePuyACE.
• Carr JB: Complications of calcaneus fractures: entrapment of the flexor hallucis longus: case report. J Orthop Trauma. 1990;4:166-168.
• Carr JB. Surgical treatment of intra-articular calcaneal fractures: a review of small incision approaches. J Orthop Trauma. 2005 Feb;19(2):109-17.