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Charles Lombardi, DPM
Director of Podiatric Medicine and Surgery Residency
New York Hospital-Queens
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Harold: Next speaker is Dr. Charles Lombardi who did podiatric surgical residency at the same hospital I did Parkview in Philadelphia. Extremely well-trained. He is the Chief at New York Hospital in Queens, New York and Charles is going to share with you his thoughts on calcaneal fractures. So please welcome, Dr. Charles Lombardi.
Charles Lombardi: Well thank you, Harold and thank you Dr. Friedberg and Alan for inviting me. I appreciate it and inviting the residents. It’s a great turn out. Hopefully, I’m not going to speak too fast because I didn’t get a chance to edit my slides and the lectures probably longer than 15 minutes but I’m going to try to go as fast as I can. I’m going to over calcaneal fractures. Go over the etiology, mechanism of injury, operative and conservative management as I founded over the last 25-30 years. And that means that how it’s shown [Indiscernible] [01:00] a quarter been practicing much longer than that. Hopefully, I could give you some insight as to the anatomy and the structure of it and some of the difficulties I found and some of the things that I found that I work in these type of injuries. They represent 2% of fractures and 60% of all the tarsal injuries we treat. Most of the time they represent a fall from the hype but more and more we are seeing motor vehicle accidents. Motorcycle accidents that involved calcaneal fractures as well as Lisfranc’s dislocations not just tail or neck injuries. Most of these fractures like three quarters are intraocular. Just to review the anatomy, I’m sure you’re all up on it and just some important points. We want to use the pointer? Yeah, okay. Critical angle with the same, it’s important because it’s a cortical strut and that’s an area where will put some screws to put the fracture back. There is an opening the tarsal canal, you have the Bohler’s angle here that we all know how to measure on a radiographic view. And this is looking down on the calcaneus. This is lateral. This portion here is called the thalamic fragment, that’s the fragment that usually will get depressed in a joint depression injury or gets depressed in a tongue type fracture, it gets rotated into the body of the calcaneus. Here’s the critical angle of Gissane here laterally and this actually will contain part of it. Centrally as you all know in the calcaneus this is significant amount of cancellous bone. Well the cancellous bone is usually pretty soft and I know a lot of people put bone grafting materials in there after this injury. I haven’t found out to be that necessary in most patients. Occasionally you’ll have to but if you do get the cortical structures back together, you can maintain the integrity of the bones or the bone withstands and heals and ends up being stiff anyway no matter what we do but I’ll get into that later. Mechanism of injury. I think it is important that you understand it. There’s a shear component and a compression component. The historical view of Essex-Lopresti so there was the triangle facet of the lateral process of the talus access are wedged into the critical angle of Gissane. That’s partially true but for the most part it occurs first as a shearing injury. And the reason it occurs is a shearing injury is this – you can see here there’s an offloading of the talus versus the calcaneus here medially. So the talus literally suspended on the sustentaculum tali as body weight comes down on the talus and there’s offloaded weight is medial. These portions here with this being the sustentaculum get sheared off from the calcaneus because the lateral process here of the talus is actually being driven into the tali body. And because there’s nothing under, I mean the calcaneal body. If there’s nothing under here, this is going to get sheared off as you can see here. Once that happens, then the talus can further descend into the calcaneal body and cause the lateral blow up that you see. And this is out of Serafin, again same thing just showing the offloading of the talus medially and that primary shearing a force here occurring in the calcaneus and the body of the talus being driven into the calcaneus. This is looking up from above so that injury as we saw before is the primary fracture. So if you go back a slide here and here, right here we’re going to look at it from the top now. And you’ll see here this is the so-called primary fracture. What it does is it divides the calcaneus into an intermedial portion and a posterolateral portion.
If that was all that occurred then you have a two-part fracture. Generally speaking you have usually at least the three-part fracture many times more than that. Most of the time it will contain a portion of the posterior facet and will be dependent on what type of foot you have will depend on where this primary fracture line occurs and how the injury occurred. Some people may go down and fall and have an inverted foot when they land. Some people may have a more pronated foot and this primary fracture will lead or occur more lateral or more medial. We did a study of our institution a few years ago over a hundred calcaneal fractures, and we found that the more medial this primary fracture line is the more comminuted those fractures were. And generally ended up with more arthrosis. And essentially once this occurs and the talus is able to be driven into the body of the calcaneus, then you get compressive forces in the calcaneus that causes this lateral wall blow out. And this is again just another view with that again primary fracture line looking at from the back here and then from the top here. And it could occur anywhere on the surface of the talus. And that’s really where the Sanders classification comes in an arbitrary line of the tali body. It actually represents the posterior facet of the calcaneus. And this is just the CAT scan of that showing again anteromedial fragment, here’s the talus, here’s the anteromedial fragment otherwise known as the sustentaculum tali it also will go anteriorly. This is firmly attached to the talus here with ligamentous structures. This is the so-called fragment that stays where it is. This is the fragment that we put everything back to most of the time. And over 25 years except for one particular case I’ve always found it to be pretty much intact. And here I think it demonstrates it well. Here’s the body of the talus. I think you can picture this as the forces came down and cause this to shear off, this portion of the body the talus push down that thalamic portion of the posterior facet into the body of the calcaneus. And that’s the compressive force of this fracture and as that occurs the lateral blow out of the wall occurs here because this is being forced down into the body of the calcaneus under pressure. And this then blows out the lateral wall. So you have a combination of a shear injury in association with the compression injury. And of course where those secondary fracture lines or those compressive fracture lines exit will determine whether you’re going to join depression fracture or a tongue type fracture. And this is just showing how lateral wall blow out occurs. Again, sustentaculum fragment firmly attached to the talus. This is the thalamic portion gets driven into the calcaneus and as that occurs this lateral wall blow out occurs at the same time. This portion here, the tuber is being secondarily contracted by the Achilles tendon. And many times were going to equinus because of that. So that needs to be brought out of equinus as well as going into theirs which I’ll show you later. So all of these is centric loading cause the distressing injury medially and causes the sustentaculum to be sheared off from the body of the calcaneus causing a compression injury into the body. When we dealt with calcaneal fractures the first thing generally you’re going to do is you’re going to see an emergency room most of the time because they usually high velocity of the injuries. The first thing you’re going to do is get x-rays. Well you need to certainly get heel x-rays and ultimately you may end up getting the CAT scan dependent on what you find. Generally though, you can learn a lot from conventional x-rays. Just by looking at the AP and lateral, you can see there’s certainly a calcaneal fracture here lateral wall blow out. The axial view gives you a tremendous amount of information. You can see the primary fracture line. So here’s the sustentaculum medially, these are the primary fracture line going into the posterior facet. This is the tuber here that’s in varus. This is medial. This is in varus and the heel is wide. So that’s all that you can see on an axial view when you could also see the lateral wall blow out. So an axial view can give you a pretty picture of what’s going on and it also was something used intraoperatively to see that you reduce to that adequately. Either you can see just on a DP view, you can see that the calcaneal cuboid joint involvement lateral blow out as well. Probably not as imperative as the axial view but certainly useful before you determine whether you get a CAT scan. Generally speaking in our institution, a patient comes in with a calcaneal fracture. They have the CAT scan in emergency room, they will get the CAT scan immediately.
They get it at their ER stay for the most part. So and I would say I’ve been surprised sometimes that so many x-rays you see that may not look like a real bad calcaneal fracture. And then you see the CAT scan you’re surprised how significant there is some depression of the joint or displacement of the joint. A Broden’s view it’s kind of like an AP mortise view of the ankle but the – essentially it’s replicating the declination of the posterior facet. And of course in every person that maybe a little bit different and that’s why it choosily recommended to take a 10-20, 30-40 degrees. But again it gives you review of the offset of the posterior facet here. And it is easy to do with the CRM in the operating room to determine if you do have adequate reduction and you can see it here in the operating room to see that the posterior facet has been restored with this of course screw fest. Obviously when these patients well maybe not obviously but these patients should be evaluated for multiple trauma. This usually are high impact, a fall from height injuries and many times they’re associated with lumbar spine injury. The certainly the thing you don’t want to do is put patient under anesthesia be turning them on their side and then having some type of lumbar fracture or cervical fracture. CAT scan as I said gives you a real good idea of what’s going on. But you need to be vigilant and what – you need to get that semi-coronal view which is essentially a 90 degree view to the posterior facet of the subtalar joint. And you can’t depend on it being reconstituted all the time, you really need to try to make sure it’s being done that way. That’s going to give you the most information. And you can then determine how many joints are involved whether the anterior CC joint is involved, the anterior facet, the posterior facet, how many fragments there are in the posterior facet and what’s the amount of displacement. And again whether the sustentaculum fragment is still intact. Generally, we usually classify this very simply as a joint depression versus a tongue type fracture as Essex-Lopresti, we continue to do that. Extra-articular fractures, generally are just extra-articular fractures in my book whether it is displaced or not and there are certainly as extensive classification system. But for the most part we’re more concerned right now whether articular injuries and to me I find that sometimes the tongue fractures are a little more difficult to put back together than the joint depression fractures with that bears. And again this is just showing those diagrams with a primary fracture line is occurring. Intra-articular classification it really was a modification of a radiographic injury Sanders classified up using CAT scan really took an old radiographic type of classification and turned it into a classification system that I would hope that most of us are so pretty familiar with. There is European handover scheme that is certainly utilizing Europe and it is a little more detailed in terms of how many joints are involved and how many fragments there are. But in my view I think Sanders can give you a pretty good idea of what’s going on and really as I stated before, it’s based on a semi-coronal CAT scan view, it’s based on arbitrary points on under surface of the talus A, B and C. That will then break the calcaneus up into fragments or different pieces being the sustentaculum here medial and lateral. And then you describe it as being the displacement of those fractures whether it be AB, BC which fragment is displaced if they’re multiple fragments or not. So it’s a relatively simple classification system that can go on a lot of information especially if you’re speaking over the phone to someone. Of course I’m sure we’re all familiar now most of us are able to view these x-rays from our office and our iPhone without much of a description. You just need the medical record number and you can get online and look at them yourself when you get called. But same time it’s good to know these and this is just another view of them of where those lines are arbitrarily drawn. And it just gives you an idea of how many fragments there are and how much of displacement is. The physical exam when we talk about calcaneal fractures as I said there’s concomitant injuries you need to concern yourself with and you need to evaluate that.
Don’t depend on emergency room to do it although most level in trauma centers will have a trauma team, you can’t always depend on it. You always need to consider potential for compartment syndrome. Usually we’ll see ecchymosis on the plantar aspect to the heels such as here so called Mondor sign. This is probably the worst case of it that I’ve seen. We lost the heel pad and Hanson has written that the most difficult thing to treat in calcaneal fracture which is true is the heel pad. You can’t treat it. The heel pad is a very specialized structure and it’s a specialized fat structure that has shock absorption. And when it’s damaged and essentially blown out from a fall you can never, no matter what you do bring that heel pad back. You could put that fracture back perfect but many times these patients feel as though they’re walking on a rock. That’s just something that you cannot correct. Some of the things you can do simply or close reductions, you can take this tongue fractures and I’ve been doing more and more percutaneous with arthroscopies. Take this tongue type fractures, put a little scope in here laterally, try pseudo reduction put it back. I’ve done it with external fixation. Without external fixation, percutaneously. Still the standard of care in my book is open reduction of the major injuries. Generally, that involve use of plates, screws, multiple long lateral aspect of the foot. I’m just going to go through the operative technique quickly. Obviously you wanted to decide whether you’re operating or not and what type of surgery you’re doing based on the patient’s age. I’m more inclined to do percutaneous repair on patients that smoke and or elderly. There’s recent study to show that some elderly patients with calcaneal fractures can still undergo these procedures and still do well with open reduction. Obviously their occupation and activity level and of course your ability in terms of how you’ve – what experience you’ve had. I’ve had probably over about 225 or so calcaneal fractures of my career. We do see a lot of them and I still run to challenges and it’s a difficult fracture to put back on a very close space. So that needs to be determine pre-operatively. You need to realize there’s two components to the injury. There is the component that really affects the foot structure that when these fractures are displaced, you get shortening of the lateral column. If the CC joint is displaced you will see that the foot is in valgus and the heel is in varus. These are all things the total structure in the foot needs to be put back as well as the joint surfaces. Generally speaking, when you put the joints surfaces back anatomically, you can get the structure, the foot back the way it was. And again you can never return the heel pad to what it was. When do you do the surgery? Generally, it’s not an emergency and I don’t recommend you doing this emergency and there are exceptions. Generally, I usually wait five to seven days usually a minimum of three days depending on how much swelling you want the soft tissue envelope to calm down. You want the skin lines to come back. The exception would be tongue type injuries that what it does is something like this where you see the displacement. I don’t know if they comes out well but it put a tremendous amount of attention on the posterior skin here and if that’s left, it will necrose. So generally speaking tongue types especially when they’re significantly displaced and there’s tension on the skin, they need to be reduced more emergently. And that usually can be attained percutaneously. But if you’re doing the full scope in terms of opening these, it’s an expense lateral incision here. This is the plantar aspect to the foot anterior aspect to the ankle, posterior aspect that incision here is down to bone. The patients in lateral decubitus position where the thigh tourniquet. This is a full thickness flap down to bone here on the whole lateral surface of the calcaneus goes down to bone right up until the peroneal tendons here. In order to get into the CC joint here, you usually will have to pick up the peroneal tendons and sural nerve and dissect on either side. You generally don’t use any forceps on this flap, you use some silk to elevate it until you get exposure of the lateral aspect to the calcaneus. And then you put some K-wires in to hold it. So this is the flap being carried down to bone. Here’s the posterior facet. Here’s the lateral wall of the calcaneus under this red stone come out great. And here’s the two K-wires holding the flap up. Here’s the posterior facet angle of Gissane and the body of the calcaneus being reduced. Once you see everything, the first thing I usually will do is get the tuber back so this is looking out from the lateral side, you pull thalamic portion out.
Some people will put it on the back table. I tend not to. I tend to keep it attach but wrap in a sponge. You can then look at from here, you’re looking here, looking down into the primary fracture line. You can put usually a Shans pin which is a pin off the external fixation set into the tuber of the calcaneus which is in varus. Pull it out of varus, pull it out of equinus to try to reduce this primary fracture line which you can see. Once you have this reduced you can put a pin across it and hold it in position, so this is it. There’s the pin here from lateral. This is it being reduced. Once this is reduced you take pins from the posterior aspect of the tuber into the sustentaculum fragment and hold it and realignment, and then you can work from the anterior aspect to the foot posteriorly and realign the remaining joints. So this is just demonstrating that with the wires. And this is generally before you put your plate on in definitive fixation you’ll have multiple K-wires sticking out, trying to reduce some of the fracture fragments and taking – see you consider multiple K-wires here, the posterior fragments here and realignment of the joint surfaces. Once they’re realigned then you go ahead and put on your permanent fixation which is dealer’s choice. I generally will use Ascentis plate that’s usually a combination reconstruction in plate. And it’s really a custom made plate but you can use two plates here. You can use the old calcaneal plates, this is just the plate I use which is a custom made plate. What you don’t want to see is that and we’ll talk about this a second if I get to it about complications. But generally speaking what you’re doing is taking all the fragments with this plate, you’re taking the tuber, you’re taking the anterior fragment and the sustentaculum fragment. And connecting it to one internal fixation device through the screws that are holding them all in alignment. So then you could take your K-wires out. And then you close – I usually use skin staples now but you can use some type of horizontal mattress suture. I generally use this on patients a non-weight bearing for eight weeks usually at the first visit because of all the bleeding, you want to drain and usually looks macerated. Don’t be thinking it’s infected at this point. This is always what they look like, you need to dry it up. And just a few cases I’ll finish it up [Indiscernible] [22:22] okay. Joint depression calcaneal fracture here. You can see the primary fracture line offset. You can – here’s what the plate sustentaculum screws that one of the old calcaneal plates and just a reduction here with the posterior facet restoration the height of the calcaneus and with the calcaneus. Open fracture, usually when you get an open fracture calcaneus they usually medial, the open wound is medially. This gets treated like any other open fracture initial irrigation debridement. With some type of temporary fixation maybe usually with wires that’s what it look like clinically and then here’s what it look like with the CAT scan severely comminuted. Again irrigated out some type of temporary fixation usually K-wires and then later went back in, you do a lateral incision. Opened up the calcaneus and then reduced it as best we could anatomically. Here’s the lateral with Steinmann pins, wires, plates and here’s the medial incision here. What I have done a lot of in these patients that have severe comminuted calcaneal fractures, I will do a primary effusion and I do it more and more if I go in there. And I see this multiple fragments, these patients from my experience no matter how good I get these joints, they get stiff. A lot of them worker’s comp patients. They are always stiff. They’re always having pain, I will tend to fuse them if there’s a significant amount of comminution. And usually but I will reduce the calcaneal fracture, okay. I do not fuse them in site two, I will put the calcaneal fracture back, reduce it, same plate, same screws and then I’ll do primary fusion across the subtalar joint using a large bore screw or two large bore screws. Again reduction with primary fusion, this is what a bridging plate on the calcaneal cuboid joint here and two screws across subtalar joint. And just another case primary fusion. I’ve used external fixation with percutaneous reduction. This is just – you can see this is trying to hold the tuber out of varus. You can see the tension wire here, another wire holding the sustentaculum in place and then another allo wire here reducing the sustentaculum fragment to the lateral wall and the thalamic fragment. I have used medial approach. This is a medial plate. And actually you can reduce them fairly easily medially. The problem that I’ve run into medially is the constant wound problems and not just the radiograph showing that. Just one more, I’m just going to fly through this here second. We’re running out of time, sorry.
What I have been doing more and more percutaneous reductions and arthroscopic evaluation subtalar joints, this particular patient had previous peroneal tendon repair. He had a lot of scar laterally, I did not do the expense all lateral approach. Many times when you do this, you can’t get it perfectly, reduced all the fragments because you’re doing everything percutaneously. But many times you can get it adequate and this is after all the screws removed. You can see get restoration of the height of calcaneus, CC joints rid it off and the subtalar joints put back. So you can get a pretty good reduction with this and when I say arthroscopically, usually it’s foot at lateral incision you can just stick the scope in there and just flush some fluid through it. Tongue type fracture percutaneously be reduced fairly easy. I just want to sum it up at this point and say that these injuries are difficult injuries to treat. They are very fun to put back together when you get good at them but they could be very frustrating. I think that’s it on my time, right?
Harold: Yes, sir. Thank you. Thank you, Charles.