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Marie Williams, DPM, DHL
Director, Podiatric Medical Education
Aventura Hospital and Medical Center
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Male Speaker: The last speaker, probably the best one we’ll have of the day, is Dr. Marie Williams, who’s been a dear friend of mine for many years, comes from the nice, warm state of Florida. She is the Director of the Division of Podiatry and Program Director for Podiatric Medicine and Surgery Residency at Aventura Hospital and Medical Center in Aventura, Florida. I have worked with Dr. Marie Williams on many, many meetings and did a lot of research and work with her, with acellular dermis and it’s just an amazing thing to spend time with Marie in laboratory and in on the lecture platform. Today, we have asked her to talk about calcaneal fractures. And I believe that you’ll find this to be most informative. So, please welcome, Dr. Marie Williams.
Marie Williams: Thank you. So the lecture I was asked to give was to plate or not to plate. I love this subject. I’ve been doing calcaneal fractures for a very long time. It’s one of the things that I find fun. So when the orthopedic surgeon hears that from me, they go, “Well, then, you can do them because there’s nothing fun about a calcaneal fracture.” So we’re going to understand the different types of mechanisms of injury, understand the different types of fixation, and truly look at the options that you have with external fixation. The point here is there’s so much about calcaneal fractures that says, you don’t have to do anything but cast them. You don’t have to do anything but plate them. You shouldn’t open them. You shouldn’t leave them unopen. There’s a lot of controversy, right? So, I just want to go over a couple of things. So, why should we operate? Bohler states, “Fractures of the calcaneal should be treated like other fractures, exact reduction must be made and reduced fragments must be fixed and positioned until bone union has occurred. And during the period of fixation as many joints as possible should be exercise.” Now, that’s a great statement for fractures. But when you have an egg that breaks and then you have to put it back together, it could be a little more difficult. That’s how I look at the actual calcaneal fractures. Remember that we’re always looking for anatomic reduction stable internal fixation, preservation of the blood supply and early active mobilization. The truth is, is that calcaneal fractures are 2% of all the fractures, 16% of all the major tarsal injuries and 75% of these fractures are intra-articular when you have them. So, it’s not a huge problem that you’ll see in your practice every day. I can tell you like Dr. Trippel [Phonetic] says when someone comes in with a second toe, hammer toe dislocation and they want their toe pretty and straight, fast and easy, you just sweat. When someone comes in with a calcaneal fracture, I can tell you that they’re going to be bad. Sounds funny, right? But, you know, they’re bad injuries so I always say, “I’m going to try to help you better but your chance of fusion is very high.” So it’s a very different concept to look at. These fractures come between 30 and 50 years of age, usually, 45, because usually, it’s the men, they’re on their ladders, putting their lights up for Christmas or they’re doing something, hammering nails into the wood, high up, trips falls of a ladder. Sometimes it’s actually someone from hikes, athletic people, not the elderly, usually. You know, they say three to 50 feet mean average of 14 feet, sometimes they get the kids, let’s say that they were jumping over a fence, because someone was running after them and you get the idea and then they fall on their heels and then they are stuck. So, I have those types of people too. Spinal injuries are common, the dorsal, lumbar spine, T12 to L4. One is the most commonly involved. Don’t forget to look for that when you see someone with a calcaneal fracture. Radiographically, the most important point here, the CT is your goal. Standard 3D CT is excellent for being able to see your fragments. You know, a lateral X-ray on a calcaneal fractures sometimes doesn’t look so bad. And then you get your 3D reconstruct CT and you go, “Oh, my goodness. Wow, there’s so many fragments here and now what I’m going to do?” So, I really I like looking at the CT scans because you get a good idea, good feel for how disrupted the calcaneous is, how the posterior facet is affected and jammed into the body of the calcaneous where there’s disarticulation between the calcineacuboid joint and how much the talus is jamming into the posterior facet of the calcaneous. It’s important.
Sanders actually has a whole classification, type 1 to 4. Type 1 being a nondisplaced posterior facet regardless of the number of fracture fragments or fracture lines. Type 2 is one fracture line in the posterior facet and two other fragments. Three is two fracture lines in posterior facet with three fragments. And four is the comminuted fracture with more than three fracture lines. And when you start to see that, here’s the situation where I used to have an orthopedic surgeon who used to come in and jam the foot altogether like he was, you know, just smash everything together and you say, “Okay, put him in a cast.” That would be like that’s your procedure. He says this is going to work. And he used to make me laugh because I used to follow these patients and some really did work, some really didn’t and it had no rhyme or reason. But the classifications are important. I mean rows and extra-articular classification and there’s several of them. And usually when you have a rogue classification, it’s an extra. Articular fracture, there’s usually an avulsion type fracture of the posterior heel not affecting the joint, and sometimes it’s simple to fix with a screw or something simple, right? When you start to get into the Essex-Lopresti type fractures, the tongue-type, and then there’s also the joint depression type, you may have to do something a little bit more advanced than just slapping it together with some cast material or and/or just one screw because there are several lines or fragments. The type of fracture depends on the sagittal plane position of the foot on impact. The tongue-type is usually a plantar grade, due to a plantar grade of the foot with impaction and the joint depression is usually the foot being dorsiflexed upon impaction. We just see a lot of times in car accident victims. The primary fracture line results from the lateral process of the talus driven into the calcaneous. And on the frontal plane, the fracture extends to the plantar cortex and device the calcaneous into the anterior and posterior fragments. And that’s important because you definitely need the sustentaculum tali being in good alignment when you start to fix calcaneal fractures. Just a little picture of the basic joint type and tongue type fractures so you get a better concept of what’s happening. But remember the driving forces, the talus through the calcaneous causing the lateral wall to blow out and also to create more fragments. Palmer and Bordeaux, they’ve written lots of articles on calcaneal fractures, when to fix, when not to fix, whether it’s good to fix or internal fixation versus external fixation. I’ve read a lot of their articles. And take home point on all of that is it’s really going to be within the surgeon’s hands that the outcomes are not so great in the overall picture. Fusion is sometimes the end result anyway. But the frontal plane angle is not always seen. The initial fracture is vertically sheared fracture and device the calcaneous into a medial and lateral component. When you have a medial component, the sustentaculum tali and the medial fragment of the posterior facet is one portion in the lateral, segment is the lateral. The lateral aspect or the lateral segment of the posterior facet and the two were on these two areas of what you’re trying to correct. The lateral portion of the posterior facet impacts into the body with secondary fracture lines. And anteriorly, the crucial angle fracture at the anterior edge of the posterior facet, it separates them from the neck. So you can see there’s like lateral wall blowout and you can see that on CT. Secondarily, the lateral fracture of the base of the major facet allows complete separation and impaction of the lateral portion, and you’ll see why that’s important later when you go to fix this or tempt to fix this. The tailor body is one of your driving forces, tailored body with the lateral portion of the posterior facet driven into the trabecular substance of the body of the calcaneous. And if you don’t fix that, no matter what kind of beautiful plate you have or super screw or anything, it’s not really going to make a difference. The medial to lateral expansion causes another sagittal plane fracture into the wall and you have a CC joint disruption, and the proximal calcaneocuboid joint is supinated. So you either have supination or pronation involved in the calcaneocuboid joint and that needs to be evaluated. Treatment, you have the typical compression, ice, elevation. Some of our orthopedic surgeons in our trauma area now that I’m in a trauma hospital, they don’t believe in compression but I believe 100% in ice and compression and Jones compression dressings and just making sure that these fractures don’t create a lot of swelling. ORIF, external fixation and primary fusion are also treatment options. This is actually done early. I did this in 1988. This was a pin to plaster. So you took this big Steinmann Pins, crisscross them into the calcaneal fracture, there it is.
And then we just put a nice big plaster cast and we said, “Okay, good, we’ll see you in about four weeks. We’ll change your cast, we’ll see you in another four weeks and we’ll pull those pins.” That patient is not exciting and it’s not wow by the big plates and X-fix but this patient probably would do just as well with that as nice big plate and fancy surgery. So, that’s just one old option, right? Don’t forget your Jones compression and ice plates. I just love this picture and I don’t know whose plates they are because I just took a lot. I mean we have plates, plates, plates, and if this slide was like the way I had at once with all the plates, you’d see thousands of plates. Go walk around outside and you’ll know that every single company now has really fancy nice calcaneal plates. My thing that I love is what you see right there, a couple of pins, some bars, and external fixation, pin to bar system and I don’t care which one do you use. I just love this and I’ve been doing it for a long time and let me tell you what. There’s tubes, there’s distracters, there’s clamps and there’s pin to rod, there’s adopters and they can be carbon or dynamic compression tubes. So there’s a whole bunch of components and now there are several companies that have these systems. I like to talk to you about the open reduction and internal fixation. You’re going to put them prone or in a lateral decubitus position, by tourniquet that’s big, long L incision right down to bone, making nice flap. You might use K-wires to hold those flaps. There are some things that I will talk to you about regarding that but the lateral wall is reflecting laterally. You get a stair elevator and use that to really pull your posterior facet out of the tuber of the calcaneus, which is really important. Then you also want to make sure that you align the lateral wall back in towards the sustentaculum tali so you’re actually reducing the lateral wall blowout. Subtalar joint is rebuilt by realigning the fracture fragments to the stable medial sustentaculum area and the middle facet. They’re usually wires. They can use [indecipherable] [12:13]. You can use screws, light screws and you’re going from medial to lateral constantly reducing that fracture. What is important is that you want to use Steinmann Pins to manipulate that fracture out of varus if you see it, distracted and forcibly avert the foot. The lateral wall blowout, you want to say, “Okay, what makes the ideal plate.” Because remember that one of the biggest areas of dehiscence is a lateral wall. That incision will break down many times so you want to use a low profile locking and unlocking plate with variable angles. That’s really an ideal plate and good compressive forces. I’m going to run through the plates because I really want to get to the external fixator, which is what I do 99.9% of the time on most all fracture. So, post operatively, you’re going to keep them non-weightbearing until you see radiographic evidence of healing. This is adjusted a couple of pictures. This guy actually jumped off of a platform, 12 feet, landed on one foot and then landed on the other. So you had a bilateral calcaneal fracture with one ankle dislocation. Here is the calcaneous. It’s in several pieces. It actually was an open fracture as well. We start to clean out that fragment. We’ve taken that nice big flap. You’re going to open the flap, use your pins or suture to hold that flap open and now nice plates being placed on that. There’s a little old and fashion spider plate there that was helped because the bone is so soft, to stop that screw from driving through the bone. Your whole idea is now to fixate the plate to the lateral wall to reduce the lateral wall and reduce the pain that you get around the perennials. The other thing that we did because we had to stabilize not only the calcaneous but we also put an external fixator on to stabilize the ankle because it was dislocated and now we have a calcaneal fracture with an ankle dislocation on one side and he had the calcaneal fracture on the other. So I use the pin to bar system. It’s really simple. We use drains on these types of open fractures. I wanted to just show you this area here, that’s the medial blowout where sometimes you’ll be so concentrated on the lateral side, you forget that the sustentaculum tali with the high impact, the bone actually splits in half. Remember, initially we said that the bone will split medial to lateral, so look at that medial fragment. That’s important to know. In the CT scan, you can see how much of a medial displacement as well as the lateral blowout. This is a pretty significant fracture that you want to actually fix. So, open it up, here’s more of a crushed injury again to the calcaneous. We align it there but we have to align it immediately. And then what I did is I took a pin to bar external fixator system that I thought was really, really neat. You put a bar between the mid foot and the heel and then run pins from the tibia and you make like an H.
Really super stable fixation. You can get stability. You’re stabilizing the ankle and the foot. The disadvantage of this is that you are over the ankle and maintaining locking at the ankle joint but you definitely have a good stability medial to lateral. So from that, I learned a lot because that was early on. Early on, I did this bilaterally for this guy and he did quite well. Also, we were putting the plate in and there’s a screw that I always put a screw in from the lateral wall into the sustentaculum tali and then there’s this H frame, and then of course, here is, all wrapped up. And you kind of realized that the one area where they had the X-fix and not a lot of dissection. The wounds healed well. This is just that patient fixated. And it’s very simple. Once you put the pins in, the surgery is over because now you have the connector. It’s like a connector set or one of those connect sets where you connect the pins and the bars. You can move them around. You can pull them out. You can change them any which way you want to get length and width and also compress all at the same time. Very simple. And here it is again. This is the medial side of the foot where there was an open fracture that was closed. That healed well, but you can see medial and lateral how that was. So here that is. And you can see, he also had the plate as we fixate it in many ways. I don’t want to run a time but I want to show you this. The lateral side of the [Indecipherable] [16:33], you see the whole blowout on the lateral wall. It doesn’t really look like much if I go back there but if you look at it here and you’re looking at the ankle joint, you can see all that lateral calcaneus blown out. And then you do a CT scan and you could see the fragments laterally. And now, you have a shortening. But the key thing here and what makes it easy is the sustentaculum tali is intact and once you get the lateral wall and the length of the calcaneus back, it comes much easier fixation. So, here’s another plate fixation. We’re really concentrating on the lateral wall and the sustentaculum tali. That’s a way of doing that. So you have options of plates. And as I said, if you walk around outside, you would see tons and tons of plates. Here’s a very comminuted fracture although in this X-ray, it doesn’t look as bad. You could tell that there’s several fragments of bone. When you look at the CT, this is really, really what tells you the story. You can see the medial displacement lateral wall blowout. And you do have someone of a stable sustentaculum tali in the other slides. And we put a plate and screws on that. And here’s another one, plates and screws, and here’s another one plates and screws but why external fixation? Well, the frame is placed on externally. It’s attached easily with percutaneous wires and very little soft tissue dissection. And you can do it for temporary reduction and/or long term fracture treatment. And I really find this to be my now standard of care from my calcaneal fractures. Trauma, it has advantages of minimum bone loss, minimum blood loss. It’s really fast and easy, sometimes it’s there just to stabilize until the patient is more a minimal to a more internal treatment and you can get effectively early range of motion. So there is some advantages. The disadvantages, it’s only relatively stable. There’s no absolute, no way bearing. Later, you might have to go back in and do another procedure and you remember there’s always chance for pin-tract infections and issues. This is just a couple samplings of how I would do this fracture. I used the tube for distraction. In this picture, I used wires and couple bars. I get distraction to the lateral wall and also stabilize the calcaneus to the cuboid. And here, I used a transfixing pin medial to lateral because of the medial, actually, the disruption of the medial, sustentaculum tali and an open fracture immediately. And just with the few pins and bars, we were able to stabilize that fracture. And here’s another, I have a whole bunch of this and my reps love it because they go, wow, you have all kinds. I just fixed it as I go. You know, I make it up as I go. There’s no rules except that your pins, you place them into the bones, you’re doing a couple of things. A, you want to get sustentaculum tali a screw fixation from a lateral to medial to make sure the bone is attached to the sustentaculum tali. B, you want to get length of the calcaneus and you want to actually get the calcaneus out of varus and/or valgus and you want to reduce the [Indecipherable] [19:48] that happen. So, those little bars, you can just pull them into place and take care of the fracture all very simply. Here’s some more another little construct that I used for calcaneal fracture that was simple.
Here, the ankles freely movable and the fractures not going anywhere. People don’t really walk on these either they get little freaked out because it looks big and bulky but really, it’s only two or three, three pins. My surgical approached, this is most important as you see, I’m using a freer device. I’m lifting up the posterior facet. I do this under C-arm. Once the posterior facet is lifted up, I make a small incision. That’s me raising it up. Once it’s raised up, I put a cannulated screw from lateral to medial into the sustentaculum tali. These two pins are actually giving me length to my fracture. And that actually will take that fracture and that fracture, same fracture and realign it with that device. It doesn’t take long to do. It saves a lot of OR time, pin-to-bar system that I think is quite easy and very, very stable. The post-op care is really, really simple as well. So there’s one type. Here it is now with the fixated or often the screw in place and you can see we’ve realign the posterior facet and the middle facet and gotten the joint back in alignment. I don’t worry so much about the body of the calcaneus, that will always fill. Here’s another one where you use a transfixing pin, medial to lateral and then you can use a Steinmann Pin to help get that fracture fragment elongated and taken out of varus or valgus. So you have an anatomically straight heel and then you can put your pins in. The way I put the pins in, I put one in the talus, sometimes I put one in the cuboid, but definitely one in the calcaneus, and then I’ll start to build around those pins. The key is to put the pins in and then build around them. Here’s a case where you have the lateral wall blowout. You have small fragment of the sustentaculum tali, which you’re not going to fix. Well, you’re definitely going to take the calcaneans, get the length back and you’re going to run the pins from medial to lateral, I’m sorry, from lateral to medial and fixate that so that you have stability to that heel. You’re also going to bring the heel down and get a realignment posterior facet. So here you go, it’s juts a picture of simple, simple pins. You can see here where we put the three pins in, very stable. I can pull the calcaneus into position and then I use a screw across to get the sustentaculum tali fixed. And here it is. There’s a screw in place and you can see here where now the bone and the joint are realigned just with a few pins and bars. Post-operatively, this is the patient. This is about eight weeks post-op and still healing, has a good posterior facet the heel itself is out of varus and valgus, which I like. Here’s another one where the bone is quite comminuted. Medial and lateral, the actual length of the calcaneus needs to be gotten so I used this. The pins with this tube and angulation to that tube and what I used is the tube, which is a distractor and I dialed out the amount of length I wanted. Once I did that then I re-fix the rest of the pins. That’s the tube in place with the four pins. And this gentleman has four range of motion, very little pain, very little swelling. He has one little small incision, so I’m not worried about incision. I’m not worried about soft tissue compromise and I have good alignment. What’s the worst thing can happen? He is going to have osteoarthritis at the subtalar joint and now he has a good alignment for a better fusion, but that sort of my end goal. Just real quick on this last case, severely comminuted. This is pretty bad case where you go, “Now what you do you do?” You didn’t realize that the whole medial aspect was an open fracture with the bone sticking out medially and laterally. So we used a transfixing pin in the heel and I used two pins on the lateral side, one on the medial side. And I did something like that. And she also had an ankle fracture, so we have percutaneous screws in the medial. But here now she has four range of motion in the ankle joint and very little post-op care. And you can see here how the pins are placed and the bars medially and laterally. I just show this picture as a last thing thought. The picture on my left, and I don’t know if it’s on your right because I’m always backwards as a left-handed person, but the picture on my left and the picture on my right. The picture on the left, both feet, patient had bilateral calcaneal fractures. The picture on the left was fixated with an external fixator and the picture on the right was left alone. And I can tell you that the side that wasn’t fix with a little external fixator was more painful post-op and long term than the one that was fixed because we took the valgus out of the heel and realigned it.
So, there are some references for you. I thank you for your time. I know I went over a little bit but it’s my passion. This is one of the things that I love to do when someone asked me to talk about calcaneal fractures. I can spend a lot of time on it and I can show you a thousand pictures of all my constructs. So, if you have any questions, feel free to find me, I’ll be here tomorrow as well. Thanks for staying. Have a great night. See you soon.