Fractures of the calcaneus can cause long-term disability if not treated properly. While the best treatment method is controversial, operative treatment via open reduction internal fixation may provide better outcomes than non-operative treatment by restoring anatomy and preventing malunion. However, operative treatment also carries risks of wound complications. Treatment must be individualized based on the injury pattern, patient characteristics, and surgeon experience to weigh the risks and benefits of operative versus non-operative management.
2. Introduction
“…the man who breaks his heel bone is
done.”
- Cotton and Henderson, 1916
“…results of crush fractures of the os calcis
are rotten.”
- Bankhart, 1942
3. Introduction
• High potential for disability
─ Pain
─ Gait disturbance
─ Unable to work
• “Best” treatment method controversial
15. Sustentacular Fracture
• May alter ST jt. mechanics
• Most small/ nondisplaced:
─ Non-operative
• Large/ displaced
─ ORIF (med. approach)
─ Buttress plate
34. Sanders
Classification
• Based on CT findings
• # joint fragments
• 2 = type II
• 3 = type III
• 4 or more = type IV
• Subtype: L → M fx position
• Predictive of results
37. Non-op Treatment: Natural History
Nade and Monahan, Injury, 1973
• 57% long term symptoms (pain, swelling,
stiffness)
• 95% symptoms on uneven ground
• 76% broad heel
As a standard treatment …..”[results] are not
good enough and deserve further studies”
38. Non-op Treatment:
Complications
Malunion
• Varus hindfoot
─ Locks midfoot
─ Medializes “foundation” for stance
• Shortened foot = short lever arm
• Peroneal impingement/ dislocation
• Shoewear problems
45. Operative Treatment:
Natural History
• Early studies recommending non-op treatment:
─ Old ORIF techniques
─ No CT classification
─ No assessment of fracture reduction
46. Operative Treatment:
Natural History
• Initial results were poor (wound problems)
• Newer ORIF techniques improved results
─ Anatomic reduction for good result
─ Fracture severity correlates with results
─ Learning curve
47. Operative Treatment:
Rationale
• Restore anatomy
─ Shape and alignment of hindfoot
─ Articular congruency
• Return to function & prevent arthritis
• Typically, restoring articular anatomy gives
improved results if complications are avoided
48. Operative vs. Non-op Treatment
• Orthopedic literature is lacking
• No prospective, randomized studies with
longterm follow-up
49. Operative vs. Non-op Treatment
Thodarson and Krueger, F&A, 1996
• Matched set of op and non-op treatment
• Modern operative technique
• AOFAS scores: Operative= 86.7
Non-op= 55
“Operative treatment successful and preferable unless
contrainications present”
50. Operative Treatment:
Contraindications
• Diabetes
• Vascular insufficiency
• Smoker
• Severe swelling
• Open fractures
• Sanders type IV
(very comminuted)
• Elderly
• Neuropathic
• Non-compliant pt.
• In-experienced
surgeon
78. Summary
• High energy injuries
• Risk for long term morbidity
• ORIF can give good, reproducible results if
complications are avoided
• Individualize treatment
• Longterm outcomes studies are needed
comparing treatment alternatives
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Index