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Calcaneal fractures are one of the most disabling
injuries. The fracture is often the least of their problems. Sources of post-injury pain can be varied all leading to chronic
pain and a dysfunctional foot. Whether it be sural neuritis, peroneal tendonitis, altered plantar fatpad, widened heel, tarsal
tunnel, or simply post-traumatic arthritis.
Acute injuries often develop severe edema and ecchymosis which often
lead to fracture blisters which can often put patients at risk for wound problems and infection. Thus there is no rush to
operate. Often it can take as long as 3 weeks before the heel is ready for surgery.
Majority of surgeons are utilizing
the standard extensile lateral approach; unfortunately, many surgeons are setting patients up for wound necrosis by not placing
their incision properly - needs to run along the achilles tendon.
Patients need to understand that calcaneal fractures
can take 6-8 months to get back to working any type of labor intensive job. They will need to understand that as high as
50% of those who have surgery will develop enough pain to warrant a subtalar fusion or require plate removal.
Two distinct
patterns:
- Joint depression of the posterior facet
- Tongue
Additional fracture patterns:
- Posterior tubercle
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Sustentaculum tali
- Anterior calcaneus
- Calcaneal beak
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Fracture blisters on medial ankle
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Extensile lateral approach with a drain
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Hopefully, no one will have as bad as injury as this. This is the worst calcaneal frcature that
I have ever had to treat. What a mess!
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Calcaneal fractures all need to have a CT-SCAN to identify the fracture fragments for pre-surgical
planning.
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The bright white edges are the subchondral plate. These are the pieces that we can fix. Obviously,
there is some voids which will require bone grafting.
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Typical fracture that we see after falling off a ladder
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Two-part posterior facet fracture
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Brodens view showing provisional reduction of the posterior facet
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Depuy calcaneal fracture plate
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Axial view reveals reduction of the fracture. Important for detecting any varus or valgus.
This
particular patient lost his life in Iraq. He died defending his country and was proof that even calcaneal fracture patients
can return to the highest level of activity - 82nd Airborne Paratrooper.
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