Abstract OBJECTIVE:
To assess radiological outcome of management of calcaneal fractures.  METHODS:
The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised data of calcanealfractures managed between February , 2008 and February, 2014 Cases were identified through medical records, and X-rays were reviewed through digital radiology archive. Bohler\\u27s angle, Gissane\\u27s angle, calcaneal height and width were assessed digitally on pre-operative and post-operative X-ray images.  RESULTS:
Of the27 patients, only 1(3.7%) was female. The cause of fracture was fall from height 15(56%), road traffic accidents 7(26%) and bomb blasts5(19%). Tongue type fractures were 16(59%) and 11(41%) were joint depression type. There was a significant mean increase in Bohler\\u27s angle (p0.05 each).  CONCLUSIONS:
Measurable improvement in anatomical parameters is possible with surgery, which is a prerequisite for good functional results

Abdul Muhammad, Zehra

Ahmad, Tashfeen

Humayun Matin, Bilal

Quadri, S. A.

Tariq Malik, Azeem

English

eCommons@AKU

eCommons@AKUDepartment of Surgery Department of SurgeryNovember 2015Calcaneal fractures: an audit of radiologicaloutcome.Tashfeen AhmadAga Khan University, tashfeen.ahmad@aku.eduZehra Abdul MuhammadAga Khan University, zehra.abdul@aku.eduBilal Humayun MatinAga Khan UniversityAzeem Tariq MalikAga Khan UniversityS. A. QuadriAga Khan University, talal.aqueel@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surgPart of the Surgery CommonsRecommended CitationAhmad, T., Abdul Muhammad, Z., Humayun Matin, B., Tariq Malik, A., Quadri, S. (2015). Calcaneal fractures: an audit of radiologicaloutcome.. JPMA: Journal of Pakistan Medical Association, 65(11), S-171-S-174.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/147IntroductionCalcaneal fractures account for 1-2 % of all fractures inadults1,2 and are uncommon in children,3,4 yet they tendto be the most commonly fractured bone in the footwhich has an impact on daily activities and causeshighmorbidity. Approximately 75% calcaneal fractures areintra-articular5 and most commonly happenafter high-energy trauma to the heels such as fall from height, roadtraffic accidents (RTAs)6 and, to a lesser extent, avulsionfractures or by direct blow. Though less commonlyinjured, being one of the weight-bearing bones, it tendsto have a large impact on functionality if not treatedappropriately. Although undisplacedfractures aregenerally managed non-operatively, there is a recenttrend towards operative management comprising openreduction and internal fixation (ORIF) or minimallyinvasive fixation.7-10Data on internal fixation of calcaneal fractures in Pakistanis scarce. The current was planned to determine theextent of improvement in radiological parameters withinternal fixation of calcaneal fractures.Materials and MethodsThe retrospective study was conducted at Aga KhanUniversity Hospital (AKUH), Karachi, and comprised dataof calcaneal fractures managed between February, 2008and February, 2014. Data for calcaneal fractures wasdrawn from patient's medical records with the help ofInternational classification of Diseases version-9 (ICD-9)codes. Patients who were lost to follow-up or had lessthan a 6 -week follow-up, and who had incomplete dataor unclear X-rays to permit satisfactory measurementswere excluded. Fractures were classified according toEssex-Lopresti classification (Table-1).11 Radiologicaltreatment outcomes comprised Böhler's angle, Gissane'sangle, calcaneal height12 andwidth that wasmeasured onlateral and axial views of plain radiographs taken asroutine care preoperatively, postoperatively and at lastfollow-up visit. Normal Bohler's angle was considered 20°-40°13 and Gissane's angle 130°-145°.14The widest distance between displaced lateral andmedialcortices was then measured and a line was drawnperpendicular to both lines and measured as thecalcaneal width.ResultsA total of 54 cases of calcaneal fractures were identified ofwhich 27(50%) didn't meet the inclusion criterion. Thefinal study sample, as such, stood at 27(50%). The overallmean agewas 38 years, and all except 1(3.7%) weremales.The cause of fracture was fall from height 15(56%), RTA7(26%) and bomb blasts 5(19%). Tongue type fractureswere 16(59%) and 11(41%) were joint depression type. Allfractures were comminuted with 10(37%) being open and17(63%) being closed (Table 2).Surgical management accounted for 80%cases comparedto 20% that were managed conservatively by closedVol. 65, No.11 (Suppl. 3), November 201529th Pak Orthocon 2015 S-171Department of Surgery, Aga Khan University, Karachi, Pakistan.Correspondence: Tashfeen Ahmad. Email: tashfeen.ahmad@aku.eduORIGINAL ARTICLECalcaneal fractures: An audit of radiological outcomeTashfeen Ahmad, Zehra Abdul Muhammad, Bilal HumayunMatin, AzeemTariq Malik, Talal Aqueel QuadriAbstractObjective: To assess radiological outcome of management of calcaneal fractures.Methods: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised data ofcalcaneal fractures managed between February , 2008 and February, 2014 Cases were identified through medicalrecords, and X-rays were reviewed through digital radiology archive. Bohler's angle, Gissane's angle, calcaneal heightand width were assessed digitally on pre-operative and post-operative X-ray images.Results: Of the27 patients, only 1(3.7%) was female. The cause of fracture was fall from height 15(56%), road trafficaccidents 7(26%) and bomb blasts5(19%). Tongue type fractures were 16(59%) and 11(41%) were joint depressiontype. There was a significant mean increase in Bohler's angle (p<0.001) and mean decrease in calcaneal width(p=0.023). Gissane's angle and calcaneal height increased marginally (p>0.05 each).Conclusion:Measurable improvement in anatomical parameters is possible with surgery, which is a prerequisite forgood functional results.Keywords: Calcaneal fracture, Essex-Lopresti classification, Imaging, Radiology, Articular fracture, Surgicaltechnique. (JPMA65: S-171 (Suppl. 3); 2015)reduction and cast/splint application. Surgicalmanagement comprised of K-wire, percutaneous screws,semitubular plate (Figure-1), and, more recently, calcaneallocking plates (Figure-2). Mean follow-up was 16±2.5weeks (range: 6-22 weeks).There was a significant mean increase in Bohler's angle(p<0.001) and mean decrease in calcaneal width(p=0.023) (Table-2). Gissane's angle and calcaneal heightJ Pak Med Assoc (Suppl. 3)S-172 29th Pak Orthocon 2015Figure-1: (A-F) Pre-operative (A-lateral,B-axial) and post-operative (C-lateral,D-axial) X-rays and the measurement (E-lateral,F-axial) method (b=Bohler's angle;g=Gissane'sangle,h=height, w=width). Post-operative final X-rays showing healed fracture with increase in Bohler's angle and reduction in Gissane's angle, increase in height and decrease in width.Fixation of the body has been done with semitubular plate and the sustentacular fragment with latero-medial lag screw.Table-1: Essex-Lopresti Classification of Calcaneal Fractures.11Extra-Articular Fractures (25%)Intra-Articular Fractures (75%) Tongue fracture Primary fracture line through posterior facet Secondary fracture line: Runs straight back to the posterior border of the tuberosity from the crucial angle (ofGissane) This produces one large posterior, superior and lateral fragment It can be displaced, "like a see-saw, down at the front and up at the back" The displaced key fragment can be maneuvered using the long lever The fragment may be flexed by the continuing pull of the Achilles tendon Joint depression fracture Primary fracture line through posterior facet Secondary fracture line Runs across the body just behind the joint, and deviates dorsally to exit the bone justposterior to the articular facet, creating a fragment separate to the tuberosity -thethalamic portionWhich contains the major portion of the posterior articular facet of the calcaneus This also acts in a see-saw fashion, down at the front and up at the backMore common than the tongue fracture The displaced fragment buried in the bone can only be reduced by an open approachTable-2: Fracture characteristics (n=27).Characteristic NumberMechanism Fall 15Road traffic accident 7Bomb blast 5Type Closed 17Open 10Classification Joint depression 11Tongue type 16increased marginally (p>0.05 each).DiscussionData is limited from this part of the world on calcanealfractures, especially regarding radiological outcome. Astudy15 reported functional outcome to be 48% good toexcellent and 52% fair to poor, but these are combinedresults of ankle and foot fractures. Similar results havebeen reported by others, and the high rate of fair/poorresults is generally attributed to severity of fractures,making it difficult to restore normal anatomy. Calcanealfractures generally occur from axial loading. As the talusdrives into the calcaneus, the force results in jointdepression, the body fragment bursts so that themediolateral width increases, and calcaneal height isreduced, resulting in reduced pitch which makes thegastro soleus slack and thus weak. Subtalar joint articularsurface involvement is often the reason for pooroutcomes, as it results in stiffness and pain on heelinversion and eversion, thus adversely affecting gait.Although conventional radiographs are good to assessthe angles and dimensions, congruity of the subtalararticular surface is only partially evident on the lateralfilm. Thus, computed tomography (CT) scan has become amethod of choice, and Sanders has developed hisclassification based on coronal CT scan appearance.16 Dueto cost, CT scan was not done in many of our patients,hence Sanders classification was not used. In the absenceof CT scan, Broden's view is a practical method to assesssubtalar articular surface. This is done in anterior-posterior(AP) direction with the ankle rotated internally by 30°-40°,taking four exposures at 10°, 20°, 30° and 40° cephalad tilt.This view can be obtained intraoperatively usingfluoroscopy.Recently, emphasis is being placed on surgicalmanagement aimed at correction of calcaneal height inorder to restore calcaneal pitch, anatomical reduction ofthe subtalar joint under direct vision and rigid fixation.7-10This is on the pretext that functional results will improve,and several studies have shown good outcome withsurgery. Our study focussedon surgical outcome in termsof improvement in radiological parameters reflectinganatomic restoration. The results showed improvement inBohler and Gissane's angles and calcaneal width, and anon-significant increase in calcaneal height. Moreover,the improvement was sustained over time, and the lastfollow-up X-ray showed minimal loss of correction.However, operative management has its owncomplications. Thus, hematoma, woundmarginal necrosisand infection are well-known complications withconventional extensile approach, thus recently modifiedextensile and minimally invasive (sinus-tarsi) approachesare gaining popularity.17Being a retrospective study, our study has somelimitations. We could not correlate radiological withfunctional outcome as this is best done prospectively.Many patients did not have complete set of X-rays in ourdigital archive; some may have had X-rays done outsidewhich could not be included in the study. Furthermore,the cases included had beenmanaged non-operatively aswell as operatively; the data presented regarding changein measurements pertains to the operated cases.Outcome of non-operatively managed cases is best donethrough analysis of function which, as described above,was beyond the scope of the present study.We recommend careful assessment of pre-operative X-rays to recognise the different parameters which requireVol. 65, No.11 (Suppl. 3), November 201529th Pak Orthocon 2015 S-173Figure-2: (A-D) Pre-operative (A-lateral, B-axial) and post-operative (C-lateral, D-axial) X-rays. Fixation has been done with calcaneal locking plate having obliquelyaligned screw slots for the subarticular bone below the posterior facet (these screwsalso catch the medial sustentacular fragment as seen on the axial view), and slots forthe anterior process and posterior tuberosity.Table-3: Radiological outcome.(Mean ± SD).Pre-operative Post-operative Last follow-upBohler angle (°) 15±7 23±9* 23±7*Gissane Angle (°) 115±27 121±7 120±8CalcanealWidth (mm) 50±10 45±10# 45±9#Calcaneal Height (mm) 42±6 44±4 43±5* p<0.01; # p<0.05correction during surgery of calcaneal fractures, andplanning of the operative procedure accordingly.Operative fixation may be by closed reduction andpercutaneous K-wire or screw fixation, open reductionand reconstruction/semitubular/locking plate fixation, ormore recently, calcaneal locking plate, and choice ofprocedure and approach is dependent on fractureconfiguration and skin condition. Our results confirm thenotion that surgical correction can restore anatomyconsiderably, and can be expected to improve outcomes.ConclusionMeasurable improvement in anatomical parameters ispossible with surgery, which is a pre-requisite for goodfunctional results, and the improvement is sustained untilhealing.References1. Zwipp H, Rammelt S, Barthel S. [Calcaneal fractures - the mostfrequent tarsal fractures]. Ther Umsch 2004; 61: 435-50.2. Slätis P, Kiviluoto O, Santavirta S, Laasonen EM. Fractures of thecalcaneum. J Trauma 1979; 19: 939-43.3. Schindler A, Mason DE, Allington NJ. Occult fracture of thecalcaneus in toddlers. J Pediatr Orthop 1996; 16: 201-5.4. de Beer JD, Maloon S, Hudson DA. Calcaneal fractures in children.S Afr Med J 1989; 76: 53-4.5. Brauer CA, Manns BJ, Ko M, Donaldson C, Buckley R. An economicevaluation of operative compared with nonoperativemanagement of displaced intra-articular calcaneal fractures. JBone Joint Surg Am 2005; 87: 2741-9.6. Järvholm U, Körner L, Thorén O, Wiklund LM. Fractures of thecalcaneus: a comparison of open and closed treatment. ActaOrthop Scand 1984; 55: 652-6.7. Rajkumar P, Henderson AA. Surgical treatment of displaced intra-articular fractures of the os-calcis. Foot Ankle Surg 2003; 9: 3-6.8. Clare MP, Sanders RW. Open reduction and internal fixation withprimary subtalar arthrodesis for Sanders type IV calcaneusfractures. Tech Foot Ankle 2004; 3: 250-7.9. Zwipp H, Rammelt S, Barthel S. Calcaneal fractures - openreduction and internal fixation (ORIF). Injury 2004; (35 Suppl 2):SB46-54.10. Kocis J, Stoklas J, Kalandra S, Cizmár I, Pilný J. [Intra-articularcalcaneal fractures]. Acta Chir Orthop Traumatol Cech 2006; 73:164-8.11. Essex-Lopresti P. Themechanism, reduction technique, and resultsin fractures of the os calcis. Br J Surg 1952; 39: 395-419.12. Böhler L. Diagnosis, pathology, and treatment of fractures of theos calcis. J Bone Joint Surg Am 1931; 13: 75-89.13. Gissane W. Discussion on "Fractures of the os calcis". Proceedingsof the British Orthopaedic Association. J Bone Joint Surg Am 1947;29: 254-5.14. Qiang M, Chen Y, Zhang K, Li H, Dai H. Measurement of three-dimensional morphological characteristics of the calcaneus usingCT image post-processing. J Foot Ankle Res 2014; 7: 19. doi:10.1186/1757-1146-7-19.15. Sarfraz AH, Masood F, Awais SM. Study of occurrence,demography and pathomorphology of ankle and foot fracturesand evaluation of the treatment outcome of calcaneal fractures.Ann King Edward Med Uni 2014; 20: 96-103.16. Sanders R, Fortin P, DiPasquale T,Walling A. Operative treatment in120 displaced intraarticular calcaneal fractures. Results using aprognostic computed tomography scan classification. Clin OrthopRelat Res 1993; 290: 87-95.17. Hsu AR, Anderson RB, Cohen BE. Advances in surgicalmanagement of intra-articular calcaneus fractures. J Am AcadOrthop Surg 2015; 23: 399-407.J Pak Med Assoc (Suppl. 3)S-174 29th Pak Orthocon 2015

Calcaneal fractures: an audit of radiological outcome.

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Calcaneal fractures: an audit of radiological outcome.

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