Medical Legal cases: Calcaneal fractures (Fractures of the heel)

Fracture of the calcaneus, or heel bone, is the most common tarsal fracture but represents 2% of all fractures seen in adults. 70% of them are intra-articular, i.e. involving the joint. Only 2% of calcaneal fractures are open fractures.

 How does the injury occur?

Causes of fractures include fall from a height, usually 6 feet or more; motor vehicle accidents; impact on a hard surface while jumping. Avulsion injuries occur with abrupt contraction of the Achilles tendon and stress fractures can occur in athletes.

Calcaneal fractures are also associated with other fractures caused by axial loading. It is important to assess for tibial plateau fractures and vertebral injuries, which can occur in 10% of patients.

 How is the injury diagnosed?

Patients present with pain, swelling, bruising, deformity of the foot and inability to weight bear. 7% of patients with a calcaneal fracture will have a fracture of the calcaneus on the other foot.

Radiographs are indicated for any suspected calcaneus fracture. Usually a foot series, including calcaneal views are ordered.

A CT scan is usually required to assess fracture configuration, especially in intra-articular fractures. It gives more detailed views to assess the degree of displacement of the fracture. This helps with the management plan and pre-operative planning, if indicated.

MRI scan is used only to diagnose calcaneal stress fractures in the presence of normal radiographs and/or uncertain diagnosis.

 What are the management options?

The use of non-operative versus operative interventions for calcaneus fractures is controversial. Operative treatment aims to restore heel height and length; realign the posterior facet of the subtalar joint, and restore the mechanical axis of the hindfoot.

 Most extra-articular calcaneus fractures are managed non-operatively, provided that the injury does not change the weight-bearing surface of the foot. Severely comminuted intra-articular fractures may be managed nonoperatively, particularly when reconstruction is likely to be unsuccessful

Non-operative treatment involves cast immobilisation with non-weightbearing for at least 6 weeks in cases of calcaneal stress fractures.

Patients with small extra-articular fracture (1 cm) with intact Achilles tendon and undisplaced fractures or with displacement of 2mm need to remain non-weightbearing for 10 to 12 weeks. They can however begin range of motion exercises once swelling subsides.

 Operative treatment is indicated when there are large extra-articular fractures (>1 cm) with detachment of Achilles tendon and/or > 2 mm displacement. This has to be carried out urgently in cases where the skin is compromised, if there is compartment syndrome and in cases of open fractures.

Otherwise, there are no benefits to early surgery due to significant soft tissue swelling. Surgery can wait 10-14 days until swelling and blisters resolve and wrinkle sign is present.

 Patients with certain co-morbidities such as diabetes, peripheral vascular disease and smokers tend to have a poorer outcome. Surgical outcome generally correlates with the number of intra-articular fragments and the quality of articular reduction. Other factors associated with a poor outcome are:

• age > 50
• obesity
• manual labour
• smokers
• bilateral calcaneal fractures
• multiple trauma
• vasculopathies
• men do worse with surgery than women
• male workers seeking compensation

 What are the restrictions associated with the injury?

Patients treated non-operatively have to remain non-weight bearing for at least 6 weeks and usually for 10-12 weeks. This is further complicated in cases of bilateral fractures and in the presence of other associated fractures. These patients may need to mobilise in a wheelchair.

After surgery, sutures are removed at 2 to 3 weeks, and patients can start early range of motion exercises once the surgical wounds have begun healing.

Supervised physical therapy may be of substantial benefit, both during the non–weight-bearing period and during the active weight-bearing recovery phase.

 What are the long-term issues with the injury?

 Prognosis is poor with a 40% complication rate.

A frequent complication of a calcaneus fracture is chronic disability due to the pain of an improperly functioning subtalar or calcaneocuboid joint.

Wound complications can occur in 10-25% of cases. The risk is increased in smokers, diabetics, and open injuries.

Patients can develop subtalar arthritis, causing pain and stiffness. This is more common with non-operative management and in intra-articular fractures.

Injury or irritation to the peroneal tendon and flexor hallucis longus tendon can also cause symptoms in some patients.

Compartment syndrome can occur in 10% of patients and results in claw toes.

Malunion of the fracture can lead to loss of height, widening of the foot and heel and limited ankle dorsiflexion.

Are there are references that I need to consider?

 Fractures of the calcaneus.

Orthop Clin North Am. 2002; 33(1):263-85

Barei DP; Bellabarba C; Sangeorzan BJ; Benirschke SK

Abstract:

Displaced fractures of the calcaneous are relatively common injuries that remain a treatment enigma. Virtually all aspects of the management of calcaneal fractures are a source of debate. Contemporary imaging, reduction, and fixation techniques attempt to improve the long term results of these injuries. The complex fracture fragments displace in predictable patterns. Meticulous surgical technique, restoration of extra- and intra-articular anatomy, and obtaining rigid fracture fixation are critical to obtaining satisfactory operative results. This article extensively reviews the controversies and summarizes the current opinions in the management of displaced calcaneal fractures.

 

Interventions for treating calcaneal fractures.

Cochrane Database Syst Rev. 2000; (2):CD001161

Bridgman SA; Dunn KM; McBride DJ; Richards PJ

Abstract:

BACKGROUND: Fracture of the calcaneus (os calcis or heel bone) comprises one to two per cent of all fractures.

OBJECTIVES: To identify and evaluate randomised trials of treatments for calcaneal fractures.

SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and the Cochrane Musculoskeletal Injuries Group Trials Register were searched. We checked reference lists of relevant articles and contacted trialists and experts in the field. Date of the most recent search: October 1998.

SELECTION CRITERIA: Randomised and quasi-randomised trials comparing interventions for treating patients with calcaneal fractures.

DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, using a 12 item scale, and extracted data. Wherever appropriate and possible, results were pooled.

MAIN RESULTS: Of the six relevant randomised trials identified, four were included, one excluded and one is ongoing. All four included trials had methodological flaws. Three trials, involving 134 patients, compared open reduction and internal fixation with non-operative management of displaced intra-articular fractures. Pooled results showed no apparent difference in residual pain (24/40 versus 24/42; Peto odds ratio 0.90, 95% confidence interval 0.34 to 2.36), but a lower proportion of the operative group was unable to return to the same work (11/45 versus 23/45; Peto odds ratio 0.30, 95% confidence interval 0.13 to 0.71), and was unable to wear the same shoes as before (12/52 versus 24/54; Peto odds ratio 0.37, 95% confidence interval 0.17 to 0.84). One trial, involving 23 patients, evaluated impulse compression therapy. At one year there was a mean difference of 1.40 pain units on a visual analogue score (scale 0-10) (95% confidence interval 0.02 to 2.82) in favour of the treated group. The impulse compression group had greater subtalar movement (mean difference 14.0 degrees, 95% confidence interval 3.2 to 24.6) at three months. On average, patients in the impulse compression group returned to work three months earlier than those in the control group.

REVIEWER'S CONCLUSIONS: Randomised trials of management of calcaneal fractures are few, small and generally of poor quality. Even where there is some evidence of benefit of operative compared with non-operative treatment, it remains unclear whether the possible advantages of surgery are worth its risks. Given this it seems best to wait for the results of one large ongoing trial on open reduction and internal fixation against conservative treatment. One very small trial suggests that impulse compression therapy for intra-articular calcaneal fractures may be beneficial. More large-scale, high quality randomised controlled trials are needed to confirm these results, and to test other interventions in the treatment of calcaneal fractures.

 

Evaluation of reduction and fixation of calcaneal fractures: a Delphi consensus.

Arch Orthop Trauma Surg. 2013 Jul 28

Beerekamp MS, Luitse JS, Ubbink DT, Maas M, Schep NW, Goslings JC.

Abstract:

BACKGROUND: Postoperative radiological assessment of the quality of reduction and fixation of calcaneal fractures is essential when evaluating treatment success. However, a universally accepted radiological evaluation protocol is currently unavailable. The aim of this study was to obtain an expert-based consensus on the most important criteria for the radiological assessment of the quality of reduction and fixation of calcaneal fractures.

METHODS: The Delphi method, consisting of three rounds, was used to obtain consensus. Each round focused on four main topics of calcaneal fracture evaluation: imaging technique (38 items), anatomical landmarks (21 items), fracture reduction (16 items) and position of the fixation material (9 items). We invited ten radiologists and 44 surgeons from the USA and Europe (all calcaneus experts) to complete online questionnaires. They were asked which aspects require evaluation to determine the quality of fracture reduction and fixation. Agreement was expressed as the percentage of respondents with identical answers. Consensus was defined as an agreement of at least 80 %.

RESULTS: All experts were invited for the three Delphi rounds and 16, 18, and 15 specialists responded per round, respectively. Agreement was reached for 23/38 (60 %) items regarding imaging techniques, 20/21 (95 %) anatomical landmarks, 13/16 (81 %) items regarding fracture reduction and 8/9 items (89 %) regarding fracture fixation.

CONCLUSION: This Delphi consensus shows that more aspects require evaluation than currently used in radiological evaluation protocols. With this consensus, we provide the basis for a universal evaluation protocol to assess the radiological outcome of calcaneal fracture treatment.

Calcaneal fracture classification: a comparative study.

J Foot Ankle Surg. 2009; 48(2):156-62

Schepers T; van Lieshout EM; Ginai AZ; Mulder PG; Heetveld MJ; Patka P

Abstract:

Comparing different types of calcaneal fractures, associated treatment options, and outcome data is currently hampered by the lack of consensus regarding fracture classification. A systematic search for articles dealing with calcaneal fracture was performed, and the prevalence of use of each classification system determined. Twelve observers classified 30 intra-articular calcaneal fractures according to the 3 most prevalent classification systems; interobserver reliability (kappa [kappa] statistic) and the correlation of the system with the choice of treatment and clinical outcomes were calculated. Forty-nine conventional and 15 computerized tomographic scan classification systems were identified. The most prevalent systems were the Essex-Lopresti, Zwipp, Crosby, and Sanders classifications; and none of these showed a direct correlation with treatment, although each of these systems showed positive correlations with outcome. Moderate interobserver agreement and variability were found for the Crosby and Sanders classifications (overall kappa = 0.48), whereas interobserver reliability among radiologists was poor for the Essex-Lopresti classification (overall kappa = 0.26). Four classifications systems showed positive correlations with outcome, but no correlation with choice of treatment. The Sanders and Crosby classifications displayed comparable, moderate interobserver variability among surgeons and radiologists, and both of these systems are likely to be useful for classification of intra-articular calcaneal fractures. Level of Clinical Evidence: 5

 

 

Complications following the extended lateral approach for calcaneal fractures do not influence mid- to long-term outcome.

Injury. 2013 Jul 16. pii: S0020-1383(13)00293-3.

De Groot R, Frima AJ, Schepers T, Roerdink WH.

Abstract:

BACKGROUND AND AIM: Open reduction and internal fixation (ORIF) of intra-articular calcaneal fractures through an extended lateral approach is frequently accompanied by a high complication rate. However, ORIF currently provides the best long-term clinical results. The aim of this study was twofold: (1) to evaluate both mid- to long-term clinical and radiological results of a consecutive series treated by ORIF and (2) to determine the influence of short-term complications on long-term clinical outcome.

METHODS: Patients with a displaced intra-articular calcaneal fracture, treated with ORIF, through an extended lateral approach, in a level-2 trauma centre between 1995 and 2008 were evaluated for the study. The long-term functional outcome (American Orthopaedic Foot & Ankle Society (AOFAS), 36-Item Short-Form Health Survey (SF-36) and Visual Analogue Scale (VAS)) and radiographic results (e.g., B?hler and Gissane angle, height, width and joint reduction) were determined. Short- and long-term complications were documented.

RESULTS: A total of 57 patients matched the inclusion criteria, from which 39 patients agreed to participate in this study (68%). The median follow-up was 6.5 years (range 2-16 years). Based on the AOFAS hindfoot score, 74% of the patients had a good-to-excellent long-term clinical result. Radiological results were satisfying with a median postoperative B?hler angle of 26° and 25° at follow-up. Complications occurred in 32% of all patients; mainly wound-healing problems were noted. Short-term complications did not influence mid- to long-term clinical results (p>0.05). Anatomic reconstruction of the calcaneus was associated with improved long-term clinical results (p0.05).

CONCLUSION: Despite the high complication rate following ORIF of a calcaneal fracture, complications do not affect mid- to long-term clinical outcome. Surgical treatment should focus on restoring the anatomy. Level of evidence: Therapeutic level IV.

 

Risk factors for postoperative wound complications of calcaneal fractures following plate fixation.

Foot Ankle Int. 2013 Sep;34(9):1238-44.

Ding L, He Z, Xiao H, Chai L, Xue F.

Abstract:

BACKGROUND: A fairly high prevalence of wound complications after open reduction and internal plate fixation (ORIF) of closed calcaneal fractures via the extensile lateral approach has been reported. The goal of this study was to analyze and identify independent risk factors for wound complications among closed calcaneal fractures undergoing ORIF.

METHODS: The medical records of all closed calcaneal fracture patients who underwent ORIF from July 2005 to July 2012 were reviewed to identify those who developed a wound complication. Then we constructed a univariate and multivariate logistic regression to evaluate the independent associations of potential risk factors for surgical wound complication. Records showed 479 patients who underwent ORIF of a closed calcaneal fracture from July 2005 to July 2012. The patients were followed for 3 to 28 months, with an average follow-up period of 14.2 months. Eleven patients had bilateral fractures, for a total of 490 fractured calcanei.

RESULTS: The overall rate of postoperative wound complications following ORIF of closed calcaneus fractures was 17.8% (87 wound complications in 490 operations). With the regression model, smoking history (odds ratio, 5.79; 95% CI: 1.55 to 21.70; P = .009), diabetes mellitus (odds ratio, 6.23; 95% CI: 1.37 to 28.31; P = .018), Sanders type (odds ratio, 5.44; 95% CI: 2.02 to 14.64; P = .001), number of residents and/or fellows present during the case (odds ratio, 1.63; 95% CI: 1.06 to 2.52; P = .028), duration of surgery (odds ratio, 4.54; 95% CI: 1.46 to 14.12; P .001), estimated blood loss (odds ratio, 1.02; 95% CI: 1.01 to 1.04%; P .001), and 10 or more people present in the operating room during the entire case (odds ratio, 2.30; 95% CI: 1.79 to 2.94; P .001) were risk factors for wound complication. Tourniquet use (odds ratio, 0.02; 95% CI: 0.00 to 0.08; P .001), which was associated with a decreased risk for the development of a wound complication, was observed as a protective factor. Diabetes mellitus, Sanders type, and smoking were the strongest risk factors for postoperative wound complication after adjusting for all other variables.

CONCLUSIONS: Smoking, diabetes mellitus, Sanders type, number of residents and/or fellows present during the case, duration of surgery, estimated blood loss, and high number of persons present in the operating room during the entire case were related to an increased risk for postoperative wound complication of closed calcaneal fractures following ORIF. Tourniquet use was associated with a decreased risk for the development of a wound complication.

 

 

Intraarticular calcaneal fractures. Results of closed treatment.

Clin Orthop Relat Res. 1993; (290):47-54

Crosby LA; Fitzgibbons T

Abstract:

Thirty intraarticular calcaneal fractures were studied by computed tomography and then treated with a variety of closed methods. A classification of the fractures was devised according to the amount of displacement of the posterior facet. Follow-up evaluation showed that Type I fractures recovered function and healed extremely well. Closed treatment should be the treatment of choice for Type I fracture patterns. Type II and III fractures had unacceptable results with closed treatment. Alternate forms of treatment should be considered in dealing with more severely displaced fractures.

 

Comparison of open versus closed reduction of intraarticular calcaneal fractures: a matched cohort in workmen.

J Orthop Trauma. 1992; 6(2):216-22

Buckley RE; Meek RN

Abstract:

Seventeen displaced intraarticular calcaneal fractures treated operatively were matched with 17 nonoperatively treated displaced intraarticular calcaneal fractures among Workers' Compensation Board patients. Matching criteria included type of fracture, age, year of injury, and occupation. After follow-up averaging 6.3 years and 5.4 years, respectively, no significant differences existed between the two groups in heel pain, subtalar motion, and return to work. However, in those fractures treated operatively, the overall clinical result was better when an anatomic reduction of the subtalar joint was achieved.