calcaneal fractures by dr.waleed maher ali - minia university 2011
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Transcript of calcaneal fractures by dr.waleed maher ali - minia university 2011
بسم الله الرحمن الرحيم
�م� قالوا ل �َك� اَل� ِع� اَن �َح� ْب ُس��َك� �َن �ا ِإ �َن �م�َت �اَل� َم�ا ِع�ل �ا ِإ �َن ل�َح�ِك�يم� �يم� ال �َع�ل �َت� ال �َن صدق الله العظيمَأ
سورة البقرة (32آية )
ANATOMICAL CALCANEAL PLATE IN MANAGEMENT OF DISPLACED INTRA-ARTICULAR CALCANEAL FRACTURES
By
Waleed Maher Ali
MB, B.CH, RESIDENT OF ORTHOPEADIC SURGERY & TRAUMA FACULTY OF MEDICINE - MINIA UNIVERSITY
Thesis submitted in partial fulfillment of Requirement of M. Sc. degree in Orthopeadic& Trauma
Faculty of MedicineORTHOPEADIC SURGERY & TRAUMA Dept.
UNDER SUPERVISION OF
Prof. Hussein Abdel- Salam NazimPROFESSOR OF ORTHOPEADIC SURGERY &
TRAUMA FACULTY OF MEDECINE EL-MINIA UNIVERSITY
Dr. Ahmed Saleh Abdel-Fattah
ASSISTANT PROFESSOR OF ORTHOPEADIC SURGERY & TRAUMA FACULTY OF MEDICINE
MINIA UNIVERSITY
Dr. Mohamed Yehia HassanLECTURER OF ORTHOPEADIC SURGERY & TRAUMA FACULTY OF MEDICINE MINIA
UNIVERSITY
I would like to express my deep gratitude to the spirit of ..
Prof. Hussein Abdel- Salam Nazim
who patiently followed up and corrected the thesis, helping this work to come to light in proper form. Thanks for his continuous guidance.
Also I would like to express my deep respect to
Dr. Ahmed Saleh Abdel-Fattah , who helped and guided me in very hard
times in this work.
I would like to express my special thanks to ..
Dr. Mohamed Yehia Hassan,
who helped me in choosing the subject of this thesis and who kindly helped me with his valuable advice and great effort.
I would like to thank ..
Dr. HATEM GALAL ZAKIASSISSTANT PROFESSOR OF
ORTHOPEADIC SURGERY & TRAUMA –ASSUIT UNIVERSITY
For accepting to discus my thesis , giving us sharing time in his very
busy schedule and traveling to reach our university
I WOULD LIKE TO THANK
Prof. Dr. Mohamed ElshafaeiThe Head of the our Department of
Orthopedic surgery and trauma
I would like to thank our staff members in
orthopedic surgery and trauma dept. who
helped me so much by their experience
and guidance.
The calcaneus is the most frequently fractured
tarsal bone, accounting for 60% of all tarsal
injuries, and represents 2% of all fractures and
75% of calcaneal fractures are intra_articular.
Are bilateral in 5-9% of patients .
Incidence of associated injuries
such as compression fractures of
the lumbar and/or dorsal spine is
10% .
These fractures are complicated
by a compartment syndrome in
10% of cases.
Is to evaluate the results and
efficacy of the anatomical
calcaneal plate in treating
displaced intra-articular calcaneal
fractures .
ANATOMY OF THE CALCANEUS
1-BONY ANATOMY:
The calcaneus is the largest of the
tarsal bones It is irregularly cuboidal in
form, having its long axis directed
forward and lateralward
THE MEDIAL SURFACE
THE LATERAL SURFACE
On the superior aspect are three articular
surfaces: the posterior, middle, and anterior
facets. The posterior is the largest and is
convex. The middle one, which is slightly
concave, is situated on the sustentaculum tali.
The anterior facet, also slightly concave.
THE SUPERIOR SURFACE
2-RADIOLOGICAL ANATOMY
BÖHLER'S ANGLE
formed by drawing two lines. The first
is drawn from the highest point on the
anterior process to the highest point on
the posterior facet. The second line is
tangential to the superior edge of the
tuberosity. The normal value of Böhler's
angle is 25 to 40°.
THE CRITICAL ANGLE OF GISSANE
is the angle formed by the intersection
of a line drawn along the dorsal aspect
of the anterior process of the calcaneus
and a line drawn along the dorsal slope
of the posterior facet. The normal value
of Gissane's angle is 120 to 145°.
Lateral radiograph of the normal calcaneus. Lateral radiograph of the calcaneus shows compression (light blue arrows) and traction (yellow arrows) trabeculae,with the neutral triangle (brown triangle) in between with sparse trabeculae. The thickened cortical or thalamic portion of the bone supporting the articular facets is shown (T).
3 -Attachments & Relations:
4 -ARTICULATIONS:
TALOCALCANEAL JOINT )SUBTALAR JOINT( :
Lateral talocalcaneal ligament.
Medial talocalcaneal ligament.
Interosseous talocalcaneal ligament.
Cervical ligament
TALOCALCANEONAVICULAR JOINT
It is regarded as two joints, i.e. the anterior
part of the 'subtalar' joint and the
talonavicular joint.
CALCANEOCUBOID JOINT
at the same level as the talonavicular joint
and, together, they represent the transverse
tarsal joint.
5 -SURGICAL ANATOMY
The sural nerve runs about 3 cm above
the tip of the lateral malleolus.
The tendon of flexor hallucis longus
running under the sustentaculum tali of
the calcaneus.
BIOMECHANICS
The calcaneus contributes to :
The posterior aspect of the longitudinal
arch.
Supporting the talus.
Sharing in weight bearing.
Transmitting body weight to the ground
and creates a strong lever for the
muscles of the calf.
BIOMECHANICS OF SUBTALAR JOINT
Subtalar Joint
Subtalar Joint Motion
Axis of motion
passes obliquely
from posterolateral
aspect of calcaneus
through the neck of
the talus .
42° from transverse
plane
16° from sagittal
plane
Pronation of the
Subtalar joint
calcaneal abduction,
eversion and dorsiflexion
.
Supination of the
Subtalar joint
calcaneal adduction,
inversion and plantar
flexion
MECHANISM OF INJURY
intra-articular calcaneus fractures are usually the result of a fall from a height or an motor vehicle accident.
High-energy axial load, the talus is forced downward into the calcaneus
primary fracture line, or separation fracture, marked 1, runs from the critical angle of Gissane to the medial wall, dividing the calcaneus in the coronal plane. An additional fracture line is often seen extending from the anterior process to
the tuberosity 2
The shear fracture splits the calcaneus into the anteromedial (or sustentacular) and posterolateral (or tuberosity) fragments. The compression fracture runs in the coronal plane, with the anterior limb running through the critical angle of Gissane and the posterior limb extending either horizontally toward the tuberosity as a tongue type fracture (red line) or more vertically, just posterior to the posterior facet, as a joint depression type fracture (blue line).
CLASSIFICATION :
Essex-Lopresti (British Journal of Surgery 1952):
1- joint depression type
2 – tongue type
SANDER’S CLASSIFICATION
DIAGNOSIS:
Plain x-rays :
Lateral radiograph
Anteroposterior radiograph of the foot
Harris axial radiograph of the heel Patient
supine, foot maximally dorsiflexed, beam
45°cephalad
Oblique/Broden’s view
Brodén’s view
The articular surface
of the posterior
facet
CT
Coronal View
Sagittal View
Sanders type II A
Sanders type III AC
Sanders type IV
COMPLICATIONS
Early complications:
Significant Swelling
can develop
healing problems .
Compartment
Syndrome
Late complications:
chronic foot pain
difficulty with
certain types of
footwear
arthritis
TREATMENT
Calcaneus fractures are among the most difficult fractures to operatively reduce and internally fix.
Methods: Closed reduction, with elevation of the foot,
compression dressing, and early motion. Percutaneous reduction techniques such as
Essex-Lopresti . Open reduction and internal fixation as
popularized by Palmer et tal . Primary arthrodesis.
This prospective study was carried
out from December 2008 to July 2010 in
emergency section of our Department of
Orthopedic Surgery and Traumatology in
Minia University Hospital . We treated 30
patients with displaced intra articular
calcaneal fractures with anatomical plate
Age and sex: The age of the patients ranged between
22 and 40 years with the mean age 31 year , there were 18 cases below 31 years (60%) and 12 cases above 31 years (40%) . There were 22 males (73%) and 8 females (27%) .
Affected Side: The left side was affected in 10 patients
(33%), while the right was affected in 14 patients (47%) and it was bilateral in 5 patients (20%)
Mechanisms of Injury 25 cases were due to fall from hieght
)83%( and 5 cases were due to motor vechile accident )17%(
Classification systems: According to Essex-Lopresti there were 20
cases with joint depression type and 10 cases
with tongue type . According to Sander’s 18 (60%) type-II
fracture 8 cases (26%) were type III fractures and 4 (14%) cases were type IV fracture .
INCLUSION CRITERIA
Sanders types II or III .
Age 20 to 45.
Closed inra articular calcaneal
fractures.
Available for folloaw up for at least 2
years after surgeury.
Sanders types I or IV .
Medical contraindications to surgery,
Previous calcaneal pathology (infection,
tumor ) .
Open calcaneal fractures.
Injury greater than 3 weeks old .
Extra- articular fractures .
EXCLUSION CRITERIA
ANATOMICAL CALCANEAL PLATE
ADVANTAGES
Low-profile, 1.2 mm thickness may reduce
the potential for peroneal tendon irritation
and facilitates soft-tissue closure .
Reduced profile helps to simplifiy
intraoperative contouring
Calcaneal Plate’s Y-arm provides structural
support for joint depression fractures
K-wire holes allow for provisional stabilization
and verification of reduction
Central hole permits increased screw
angulation to allow for precise fixation of
sustentacular Tali
All plates are available in 50mm, 60mm and
70 mm lengths .
SURGICAL TECHNIQUE
Preoperative Planning :
Clinical examination of the affected
and contra-lateral limb .
Vascular examination .
Examination of the spine .
RESULTS
Criteria Grade Functional Results
no or mild pain, unlimited activities of
daily living and work, no difficulty with
walking on various surfaces, no use of
walking aids and normal range of motion
of STJ.
Excellent
moderate pain, slight limited activities
of daily living and work, slight difficulty
with walking on various surfaces, no use
of walking aids and slight decrease
range of motion of STJ.
Good
Severe pain, limitation of walk, work ability and decrease STJ motion usage of aids
Fair
Severe pain, Complete stiff STJ . Poor
FUNCTIONAL RESULTS
RADIOLOGICAL RESULTS
According To Bohler And Gissan’s Angle
Case one
Age: 25
Sex: Female
Classification: Type IIC , Joint Depression.
The affected side: RT
Mechanism of trauma: FFH
CASE PRESENTATION
POST OPERATIVE
6 MONTHS POST OPERATIVE
Case two
Age: 28
Sex: male
Classification: Type IIIAB, tongue-type .
The affected side: Lt
Mechanism of trauma: FFH
CASE PRESENTATION
Preoperative
POST OPERATIVE
6 MONTHS POST OPERATIVE
CASE PRESENTATION
Case Three
Age: 35
Sex: Male
Classification: Type IIIBC, Joint Depression
type .
The affected side: Lt
Mechanism of trauma: FFH
PRE OPERATIVE
As regard pre operative assessment of
our patients we agree with Leung et
al.that standard lateral, axial, and
internal oblique radiographs are not
adequate for the assessment of the
subtalar joint and CT is needed for
almost all fractures to detect the extent
and type of the fracture .
As regard the surgical approach used in
our study is the extended lateral
approach in all cases popularized by
Benirschke and Sangeorzan . The
merits of this approach involve the
inclusion of the peroneal tendon and
sural nerve with the flap, which helps
to minimize the risk of injury to these
structures.
The clinical outcome for 10 (33%) of the
30 feet was excellent and 15 (50%)
was good . 3 feet (10%) had a fair
result, and 2 were considered to have
had poor ; of these one feet, needed a
subtalar arthrodesis
The radiological resuls are 80% had
anatomical reduction, 13 % had near
anatomical reduction and 7 % had
failure of treatment. And thus we
consider 93% of cases are satisfactory
results and only 7% of cases are
unsatisfactory
Benirschke and Sangeorzan 2004(25 cases)
The bony results were five excellent (17.8%),
nine good (50.0%), two fair (11.1%), and two
poor (11.1%). .
The functional results were excellent in
(21.9%) patients, good in (43.7%), fair in
(12.5%), and poor in (21.9%).
(Zhongguo Xiu Fu 2008 reported on ( 50 cases)
The results were excellent and good in (88
%) , fair in (5%) and poor in (7%).
The results of Christoph are better
than our results this is due to the fact
that some of our patients were not
compliant during the follow up period
either by missing their follow up
appointments frequently or by starting
weight bearing too early before we
advise them to do so.
DISCUSSION OF COMPLICATIONS
Study Our Study Buckley et al 2002
Geel, Christoph 2005
Subtalar osteoarthritis
56% 65% 73%
Compartment syndrome
6% 28% 33%
Wound infections
12% 21% 25%
Pain 75% 84% 63%
As regard post operative complications
in our study, Injury of the sural nerve
has been reported in 3 cases (10%) ,
Infections , wound breakdown and late
deep infections occur in 30% of cases
and Subtalar osteoarthritis occurred in
6 cases (20%).
The focus of current treatment is on operative
methods, with the goal of restoring not only
articular congruency but also the shape and
alignment of the calcaneus and this can be easily
achieved by using the anatomical plate.
A lateral approach with use of an extensile
incision appears to be associated with the fewest
soft-tissue complications .
Intra operative fluoroscopy to obtain
Brodén’s, lateral, and axial radiographs
is strongly recommended to ensure an
anatomical reduction.
Thank
you