Calcaneal fracture: Percutaneous fixation of Tongue-type fracture
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Calcaneal fractures account for 1-2% of all fractures. They generally following high energy mechanisms, most commonly falls from height or road traffic accidents. The ‘rule of 10’ is useful when assessing these injuries, approximately 10% are bilateral, 10% open injuries and 10% associated with spinal injuries- usually thoracic-lumbar burst fractures.
They are in the main very significant injuries when intra-articular in nature, and require a clear understanding of the fracture anatomy, and patient factors (most importantly compliance and avoidance of smoking) as well as what can be realistically achieved with operative techniques, when forming an opinion on how to manage.
Controversy surrounds their management, in particular whether open reduction and internal fixation is ever warranted, given a not inconsequential incidence of complications related to open approaches described in some series, such as wound breakdown, deep infection and pain syndromes related to cutaneous nerve compromise. This has led to the development of less invasive techniques to reconstruct calcaneal fractures including sinus tarsi approaches and percutaneous techniques.
Overall tongue type calcaneal fractures tend to have a more favourable prognosis when compared to articular depression patterns and perhaps not surprisingly treating these injuries with percutaneous techniques also offers advantage. A recent retrospective cohort study by Quirine showed a lower incidence of wound problems and deep infection when tongue type fractures are managed with percutaneous compared to open techniques.
In essence the technique was first described by Peter Essex-Lopresti, one of the Worlds first dedicated Orthopaedic trauma Surgeons. He practiced at the Birmingham Accident Hospital, the Worlds first dedicated trauma centre, before dying at the tragically young age of 35. His work was based on observations made treating the Sixth British Airborne Division, in World War II, and is a significant landmark in improving the lives of patients with these injuries. In addition to describing the patterns of calcaneal fractures and the percutaneous technique for fixation of tongue type fractures his paper also describes a sinus tarsi approach to articular depression fractures.
The UK heel fracture trial and its accompanying headline “Calcaneal fractures: surgery provides no benefits” in the British Medical Journal(BMJ) caused significant controversy with its assertion that open reduction and internal fixation should not be recommended for displaced intra-articular fractures. The debate over this paper continues but it is certainly true that newer techniques and implants continue to develop which avoid the need for the use traditional open surgery, and are associated with a lower immediate incidence of complications.
It is also true that these fractures should be managed by surgeons and units used to dealing with large volumes of these injuries. This has been recognised for some time, and indeed was specifically reported on in 2008 by Poeze, and this is really only common sense. The median number of operations per surgeon in the BMJ study was 2 and this itself may be related to the high rate of complications, specifically a 19% infection rate, which any surgeon would deem unacceptable.
As with many aspects of complex trauma rather than didactically deciding on treatment based on a simple radiological review the decision making as to the best treatment of an individual patient relies on careful examination of the injured limb, study of the X-rays and scans and a detailed discussion with the patient as to the risks and benefits of each treatment for them in light of other factors such as smoking or medical co-morbidities. Unfortunately this patient-centred process does not lend itself to an RCT.
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Quirine M J van der Vliet 1 , Jeffrey M Potter 2 , Thirza A Esselink 3 , Roderick M Houwert 4 , Falco Hietbrink 4 , Luke P H Leenen 5 , Marilyn Heng. Open Versus Closed Operative Treatment for Tongue-Type Calcaneal Fractures: Case Series and Literature Review. J Foot Ankle Surg . Mar-Apr 2020;59(2):264-268. doi: 10.1053/j.jfas.2019.02.006.
Poetze M, Verbruggen J, Brink P. The relationship between the outcome of operatively treated calcaneal fractures and institutional fracture load: A systematic review of the literature. The Journal of Bone and Joint Surgery (Am). 2008. 1013-20.
Griffin D, Parsons N, Shaw E, Kulikov Y, Hutchinson C, Thorogood M, Lamb S. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised, controlled trial. The British Medical Journal. 2nd August 2014.
Author:Paul Fenton FRCS (Tr & Orth)
Institution: The Queen Elizabeth Hospital, Birmingham, UK.