Calcaneal fracture: Open reduction and internal fixation; percutaneous fixation

Open reduction of calcaneal fracture

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  Administer preoperative antibiotics and apply a tourniquet.

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  Place the patient in a true lateral position and use the lateral approach.

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  Carry the incision directly down to the periosteum of the lateral wall with no blunt soft tissue dissection in the midportion of the wound. The sural nerve may cross the incision at its proximal and its distal end, so soft tissue dissection should be done in these areas to avoid cutting the nerve ( Fig. 47.1 ).

  

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  Gently retract the flap while performing subperiosteal dissection along the lateral wall. It is essential to follow the contours of the blown-out lateral wall and not stray into the soft tissues to avoid damage to the peroneal tendons. These tendons should be contained in the flap. Elevate the entire flap in one piece and hold it out of the way with a Kirschner wire placed longitudinally into the fibula, one from lateral to medial in the talus and one into the cuboid. Bend these wires back to retract the flap, which does not need to be touched again for the remainder of the procedure ( Fig. 47.2 ).

  

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  Expose the entire lateral wall of the calcaneus distally to the calcaneocuboid joint.

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  Carry the dissection above and below the peroneal tendons at the level of the calcaneocuboid joint if necessary. This extensile lateral approach exposes the lateral wall of the calcaneocuboid joint and posterior facet. Reduction of the tuber-sustentacular fragment is done indirectly.

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  When the exposure is completed, remove the lateral wall and place it in a secure place on the back table for later replacement; this fragment blocks direct observation of the posterior facet. Do not reduce the posterior facet immediately, because room for the piece must first be created.

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  When a fracture line separates the anterior process from the sustentacular fragment, reduce this part first to allow better exposure of the relationship between the medial part containing the sustentacular fragment and the lateral part with the posterior facet and tuberosity ( Fig. 47.3 ).

  

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  Reduce the tuberosity to the sustentacular fragment with manipulation of a large threaded Steinmann pin placed into the tuberosity fragment from either lateral to medial or directed posteriorly to correct the varus and loss of height and length; perform a provisional fixation using axially directed Kirschner wires introduced from the heel into the sustentacular fragment ( Fig. 47.4 ).

  

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  With the bone now out to length from these two reduction maneuvers, turn attention to the depression of the posterior facet, reducing it to the intact medial piece and holding it with provisional fixation ( Fig. 47.5 ).

  

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  Obtain intraoperative radiographs to assess overall reduction.

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  A large defect often remains in the substance of the calcaneus beneath the reduced posterior facet. If good stability of the fracture and secure internal fixation are obtained, this defect may be accepted, or bone graft or bone cement can be used to fill the void.

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  Reduce the lateral wall along the outer edge of the posterior facet and perform fixation, which should take advantage of the known anatomy. The thickened bone in the thalamic portion, which supports the posterior facet, provides the most reliable fixation in most instances.

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  Insert small cortical lag screws (3.5 mm) into the sustentacular fragment to maintain the reduction of the posterior facet. Apply a lateral plate that extends from the anterior process of the calcaneus into the most posterior aspect of the tuberosity. The plate helps maintain a neutral alignment of the calcaneus. When contouring the plate, be careful not to fix the heel in varus. Obtain an intraoperative axial view to confirm neutral alignment before application of the plate ( Fig. 47.6 ).

  

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  When possible, direct screws from the plate into the sustentacular fragment for maximal fixation. Place the most anterior screw into the subchondral bone supporting the calcaneocuboid articular surface. Place the most posterior screw into the thickened bone at the posterior aspect of the calcaneus. Contour the plate into a “frown” shape (concave plantarly) and fill the remaining holes ( Fig. 47.7 ).

  

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  Close the flap over a deep drain. Apply a short-leg splint.