For calcaneal fractures, approach and fixation decisions rely on soft tissue healing potential

Calcaneal fractures can be very problematic to heal, with serious consequences to patients’ quality of life. However, when choosing an approach and fixation, success is not simply a matter of achieving a well-aligned reduction. Joris Hermus (Maastricht University Medical Center, the Netherlands) and Aleksas Makulavicius (Vilnius University Hospital, Lithuania) recently met to discuss the problem of how to choose approaches and fixation techniques that match patient characteristics. Here, they also speak of visualization options.

Makulavicius opened by emphasizing that, for calcaneal fractures, the surrounding tissue is a matter of major concern: “These fractures occur in a very sensitive area surrounded by soft tissue, which is very unforgiving. Normally, the fracture site is a soft tissue injury with a broken bone inside.”

As calcaneal fractures often tend to have high-energy causes—traffic accidents or falls from ladders, for example—they not only present serious challenges on their own, but also tend to accompany other traumatic injuries. Therefore, the trauma surgeon’s initial job may be simply to correct the most serious displacement and close open wounds, then wait to perform the definitive surgery. In addition to minimizing infection risk, this relieves the pressure on the surrounding soft tissue, where necrosis can quickly set in.

Complications and treatment

Complications such as infection, soft tissue necrosis, or even simply overtaxing the patient’s ability to heal can greatly increase recovery time. Therefore, both surgical approaches and fixation techniques must be weighed against the complication risks they entail.

“Treatment choice depends on soft tissue healing potential. For an otherwise healthy patient with reasonably robust soft tissue, we can be more aggressive. Conversely, if there are soft tissue problems, or the patient’s general status or cooperativity level is poor, our approach will have to be more conservative. For example, we need to think about smaller incisions, percutaneous techniques, and less invasive fixation. Non-operative treatment is normally reserved for non-displaced fractures or non-compliant, elderly, or high-risk patients with multiple contraindications regarding surgery. After calcaneus surgical treatment, infection can be disastrous.”

Makulavicius also summarized the main radiographic tools used for diagnosis and planning. For an intraarticular fracture, an initial x-ray will usually be enough to choose an Essex-Lopresti classification—that is, whether it is a joint-depression or tongue-type.

To plan treatment, though, more information is necessary. For that, either 2-D or 3-D CT scans will allow better understanding and the use of a Sanders classification. The number of fracture lines on the posterior articular surface plus one will determine the Sanders number: Calcaneus fracture without displacement is type 1; one or two lines indicate, respectively, types two or three; and three or more lines are classed as type 4.