Calcaneal Fracture Case

presentation

MR A. C. MAGEZA
MBChB (UZ); FCS
Orth (ECSA)
Introduction

• Most commonly injured tarsal bone

• 17% open
• Axial loading e.g fall from a height, motor vehicle crash
• Poor outcomes - 40% complication rates
• Associated w other injuries
•

-vertebral frx, calcanocuboid joint extension, contralateral calcaneal frxs

• Good pt selection in-order to get good results w operative management
The patient

• 50 yr old Chinese
• Smoker
•

• >20cig per day for >25yrs

• Construction worker
• Fell off a height ±4m
The patient

• Painful swollen rt foot

• Backache
• Unable to mobilize
• Urinary retention
The patient

• Stabilized per ATLS protocol

• Head to toe exam
•

• Tender in the lumbar

region
• Altered sensation L4 - S3
• Reduced power(4/5)
Investigations

• Bohler’s angle =
15 (20-40)
•

• Gissane’s angle
= 162 (<130)
Investigations

SANDERS iii
Investigations
Investigations
Management

• Strict bed rest

• Urinary catheter
• Lumbar corset
• Elevate limb on 2 pillows
• Opioid analgesia
• Quit smoking
•

Pt Compliance = Zero
Management

• Refused lumbar sx
(under the neurosurgeons)
•

• Agreed to ORIF calcaneus

•

• Surgery at day 14
Post-Operative X-rays
 Post Operative

• Bohler’s angle = 28
(20-40)
•

• Gissane’s angle =
115 (90 - 130)
Follow-up

Day 21 -just before stitch removal

Day 5 - in the ward
Complications

• Wound complications (10-25%)  
- increased risk in smokers, diabetics, and open injuries

• Subtalar arthritis 
• Lateral impingement with peroneal irritation
• Damaged FHL

- at risk with placement of lateral to medial screws

• Compartment syndrome (10%)
Discussion

Management options

Non Operative

Operative

CRPP

ORIF
Nonoperative

◦ cast immobilization with NWB for 6 weeks 

▪ calcaneal stress fractures

◦ cast immobilization with NWB for 10 to 12 weeks

▪ small extra-articular fracture (<1 cm)

▪ Sanders Type I (nondisplaced)
▪ anterior process fracture involving <25% of calcaneocuboid joint
▪ comorbidities (smoker, diabetes, PVD)
Operative
Closed reduction with percutaneous pinning
▪ minimally displaced tongue-type fxs
▪ large extra-articular fractures (>1 cm)

ORIF
▪ displaced tongue-type fractures  

▪ large extra-articular fractures (>1 cm displacement)

- urgent if skin is compromised

Discussion - outcomes

Factors associated with a poor outcome    

▪ age > 50
▪ obesity
▪ manual labor
▪ workers comp
▪ smokers
▪ bilateral calcaneal fractures
▪ multiple trauma
▪ vasculopathies
▪ men do worse with surgery than women
Take home

• Most commonly injured tarsal bone

• 17% open
• Axial loading e.g fall from a height, motor vehicle crash
• Poor outcomes - 40% complication rates
• Associated w other injuries
•

-vertebral frx, calcanocuboid joint extension, contralateral calcaneal frxs

• Good pt selection in-order to get good results w operative management