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Nonextensile Techniques for Treatment of Calcaneus Fractures


Indications

  • Displaced intraarticular calcaneus fractures

  • Simpler patterns

  • Early fixation

  • Patients at high risk for wound healing complications with extensile approaches including smokers, diabetics, and those with medical comorbidities

Indications Pitfalls

  • Inexperience with calcaneus fracture reduction techniques

  • Fractures treated beyond 2–3 weeks

Indications Controversies

  • Which fractures are best suited for this treatment?

  • Can this technique be used for all fracture types?

Examination/Imaging

  • Computed tomography scan images demonstrate a displaced comminuted intraarticular calcaneus fracture ( Figs. 38.1 and 38.2 ).

    FIG. 38.1

    FIG. 38.2

Treatment Options

  • Nonoperative treatment

  • Percutaneous fixation (see alternative technique at the end of this chapter)

  • Surgical fixation using a lateral extensile approach

Surgical Anatomy

  • The calcaneus will be approached just distal and above the peroneal tendons along the lateral aspect of the subtalar joint ( Fig. 38.3 ).

    FIG. 38.3

Positioning

  • The patient is placed in the lateral position with the injured extremity up and at the end of the operative table ( Fig. 38.4 ).

    FIG. 38.4

Positioning Pearls

  • Care should be taken to pad the peroneal nerve of the down leg.

  • A positioning foam pillow or blankets may be used to elevate the operative extremity to improve the ability to obtain C-arm images.

  • The C-arm monitor is positioned on the opposite side of the table for ease of viewing.

Positioning Pitfalls

  • Be sure the end of the table is radiolucent.

Positioning Controversies

  • Prone position or lateral positioning may be used for bilateral injuries.

  • C-arm may provide better images, but the mini-C-arm produces less radiation and can be operated by the surgical team.

Portals/Exposures

  • The incision begins 1 cm below and 1 cm distal to the tip of the fibula and is typically 3–4 cm in length ( Fig. 38.5 ).

    FIG. 38.5

  • Elevate the peroneal tendons off the lateral wall of the calcaneus sharply.

  • The peroneal tendons are sharply released at the peroneal tubercle.

Portals/Exposures Pearls

  • Sinus tarsi fat may be removed to improve visualization.

  • The lateral subtalar joint capsule may be sharply incised from inside the joint to improve visualization.

  • Removing hematoma using a small suction tip, or micropituitary rongeur will improve visualization and ease reduction.

Portals/Exposures Pitfalls

  • Care should be taken to avoid injury to the peroneal tendons in the posterior portion of the incision.

  • Injury to the sural nerve should be avoided.

Portals/Exposures Equipment

  • Small retractors

  • Irrigation

  • Sharp knife

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