■ Review Article

cme ARTICLE Earn Category 1 credits Open Calcaneal Fractures

STEVEN J. LAWRENCE, MD

educational objectives

As a result of reading this article, physicians should be able to: was not dictated by the authors. The over- 1. Describe the initial management for an open calcaneal fracture. all complication rate was remarkably high—Ͼ60% of patients developed 2. Describe “secondary” treatment options used in the management of this wound complications. Nine of 17 patients compound fracture. with Gustilo III type wounds developed 3. Discuss fracture subtypes associated with open calcaneal fractures. osteomyelitis or joint sepsis. Five limbs 4. Discuss common complications that may develop with treatment. were amputated for uncontrolled infec- tion; 1 limb required joint arthrodesis. Severe functional deficits and chronic pen calcaneal fractures are calcaneal fractures. Furthermore, a criti- pain resulted in most patients. After doc- uncommon, but potentially dev- cal review of the few published series umenting the poor outcomes and high Oastating traumatic hindfoot demonstrates therapeutic interventions, complication rate, the authors recom- injuries. Compound fractures comprise timings, complications, and outcomes. mend that management of the soft-tissue 3%-6% of all os calcis fractures.1,2 disruption and avoidance of infection Published series are limited in number; should be the initial treatment focus, they generally consist of multiply injured rather than fracture stabilization.3 patients referred to regional trauma cen- Isolated open calcaneal Aldridge et al4 reported 19 open os ters.3-6 A wide continuum of injury pat- calcis fractures treated over a 10-year terns have been documented with an equal fractures are relatively period. In this series, 17 fractures under- array of treatments and outcomes.3-6 rare and appear to be went some form of internal fixation, yet Although the initial, emergent treat- the overall complication rate was only ment of an open fracture-disruption has associated with multiple- 11%. The number of days to internal fix- become fairly standardized,7 subsequent injured patients with high- ation averaged 7 days post-injury (range: treatment addressing the injury’s osseo- energy injuries. 0-22 days). One patient required a below- chondral component remains controver- the-knee amputation. Four free flaps sial. A thorough review of the available lit- were performed. At 26-month follow-up, erature assists in establishing a knowledge base on this devastating hindfoot injury. A From the Division of Orthopedics, University 3 treatment protocol is proposed to provide Siebert et al reported 36 open cal- of Kentucky, Lexington, Ky. a basis for future treatment advances. caneal fractures managed over a 5-year Dr Lawrence has no industry relationships to period. In this series, a majority of the declare. Reprint requests: Steven J. Lawrence, MD, LITERATURE REVIEW patients were referred after initial care Division of Orthopedics, University of Kentucky, Few published reports detail the treat- was provided elsewhere. Specifically, in Kentucky Clinic, 740 S Limestone, Ste 401, ment and outcomes following compound 29 of 36 fractures, the initial intervention Lexington, KY 40536.

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fractures. In this series, 42% underwent some form of internal fixation. Five wounds required free flap coverage. The overall complication rate was approxi- mately 5%. Unfortunately, long-term functional outcomes were not discussed.

DISCUSSION The orthopedic literature remains con- troversial regarding the optimal manage- ment of compound calcaneal fractures. Nonetheless, considerable insight into the injury can be derived from the limited num- ber of reported series. Isolated open cal- caneal fractures are relatively rare and appear to be associated with multiple- injured patients with high-energy injuries (Figure 1). Commonly, patient resuscitation 1 Figure 1: Lateral radiograph demonstrates a severe open calcaneus fracture with talonavicular joint subluxation and extreme deformity. the average American Orthopedic Foot and Ankle Society hindfoot score was 82 points. In accordance with Siebert et al,3 the authors concluded that these open injuries be initially managed with aggres- sive wound care followed by delayed fracture stabilization.4 Heier et al5 reported 43 fractures treat- ed over a 9-year period. Various forms of stabilization were undertaken in approxi- mately 70% of cases. Approximately 25% underwent a primary arthrodesis. Six limbs were amputated. Eight flaps and 5 split-thickness skin grafts were per- 2 formed. All 8 Gustilo I type injuries fared well. Overall, a 37% infection rate was Figure 2: Clinical photograph of the wound associated with an open calcaneal fracture. reported. Furthermore, in Gustilo IIIB wounds, 11 complications developed in Lawrence and Grau6 reported 48 open is necessary prior to management of mus- 12 patients. Therefore, complication rates fractures treated over a 7-year period. The culoskeletal injuries. Following hemody- appeared to correlate to the severity of ratio of blunt to penetrating trauma was namic stabilization, a thorough wound eval- the soft-tissue injury. The authors con- 7:1. Of the blunt trauma patients, Ͼ90% uation and detailed neurovascular assess- cluded that patients with high-grade open sustained multiple orthopedic and non- ment of the limb are necessary (Figure 2). calcaneal fractures be informed of the orthopedic injuries. Two below-the-knee Hindfoot radiographs and computed tomo- likelihood of chronic debilitating pain amputations were performed as primary graphy are recommended to assess fracture and dysfunction. They should be fore- intervention. Of patients with open calca- comminution and displacement. warned that an amputation may be neces- neus fractures, 23% sustained a local neu- The fundamental tenets of open frac- sary, especially if significant complica- rovascular injury and Ͼ40% sustained ture care7 remain the cornerstone of initial tions arose.5 concomitant ipsilateral foot and ankle management for these hindfoot fracture-

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cute, and reconstructive (Table). The TABLE acute phase comprises the initial 10 days Treatment Phases and Associated Treatment following injury; the subacute follows the Phases Days Treatment acute and extends to day 21; the recon- structive stage begins at 3 weeks and con- Acute 0-10 Open fracture care (mandatory) Minimal internal fixation techniques in tinues indefinitely. appropriate fractures During the acute phase, the priority of Subacute 11-20 Minimal internal fixation or plate and screw the initial treatment is soft-tissue manage- osteosynthesis in appropriate fractures ment. Meticulous but aggressive debride- Reconstruction у21 Arthrodesis combined with other forms of reconstructive procedures ment of devitalized tissues with wound irrigation is a critical component of Note. Amputation is a potential treatment option in any phase. care—this appears to minimize the risk of complications such as deep infection. Occasionally, after open fracture care has disruptions. Tetanus prophylaxis is ed for this purpose. Overall, the severity been successfully completed, no further administered, if indicated. Emergent seri- of the soft-tissue disruption and fracture operative care is necessary, except for al irrigation and debridement is per- subtypes appear to parallel the prognosis, fracture immobilization until healing. formed and repeated every 48 hours until outcome, and complication rates. However, this is a rare occurrence. During a stable, clean wound results. Antibiotic the acute stage, due to traumatized soft- coverage with cefazolin and gentamycin TREATMENT SUGGESTIONS tissue envelope, traditional forms of plate is appropriate in most instances; however, Distinct treatment phases need to be and screw osteosynthesis are best avoid- contaminated wounds resulting from defined, as the timing of treatment may be ed. However, osseous stabilization with marine or barnyard injuries are best man- as important as the treatment type. As minimal internal fixation, such as aged with triple antibiotic coverage until Kirschner wires, percutaneous cannulated culture-based sensitivities are available. screws, or application of an external fixa- In a majority of instances, the traumat- tor, appears to be valuable while invoking ic wound can be closed primarily or sec- The goals of open a minimal increased risk of infection.6 ondarily. Closure by secondary intent is calcaneal fracture However, these techniques are generally appropriate if viable wound edges are not management include undertaken on severely disrupted frac- opposable and no exposed osseous or tures where anatomic reduction of the neurovascular structures are present. In timely healing of the soft- articular surface is not possible (Figure 3). this instance, local wound care is institut- tissue envelope without The fixation is used to circumvent superi- ed. A recent addition to nonsurgical or migration of the tuberosity fragment options is the vacuum-assisted closure,8 a infection and maintenance due to the unbridled effect of the Achilles treatment modality that promotes sec- of bony alignment. tendon. ondary wound healing by augmenting the Formal plate and screw osteosynthesis rapid in-growth of granulation tissue. In is probably best reserved for the subacute severely disrupted wounds, a free micro- phase. This time period follows stabiliza- vascular tissue transfer may be necessary, highlighted by several series,3-5 overzeal- tion of the scant soft-tissue envelope, but especially in exposed bony or neurovas- ous attempts at fracture stabilization fre- proceeds prior to bony consolidation. cular elements. In such instances, internal quently result in wound difficulties, infec- Fracture subtypes amenable to recon- fixation of the osseochondral injury tion, or both. On the other hand, delays struction were found in Ͼ60% of a large should be performed prior to the free tis- Ͼ3 weeks may be hampered by early series of open os calcis fractures (Figures sue transfer procedure. fracture healing. Delineation of specific 4 and 5).10 Therefore, many tongue-type, Means to stratify injury severity have phases is intended to guide the timing of one-, two-, and three-part fractures of the not been established. By default, the intervention for these complex injuries. posterior facet may be appropriate for Gustilo-Anderson7 and Sanders classifi- The University of Kentucky hospital’s delayed reconstruction in the subacute cation9 schemes have been applied, either experience with open os calcis fracture phase (Figures 6 and 7). singularly or in combination, by most management has been reported previous- The third, or reconstructive, phase clinicians to describe the injury patterns. ly.6 Considerable value exists in dividing extends beyond the critical 3-week “frac- Neither scheme, unfortunately, is intend- treatment into three phases—acute, suba- ture repair” period; therefore, open reduc-

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Figure 3: CT of the hindfoot demonstrating a As recommended by Heier et al,5 all severely comminuted posterior facet of an open patients should be forewarned that exten- calcaneal fracture. This sive and protracted series of staged surgi- severe chondral injury cal procedures may be necessary. They precludes surgical should understand that chronic pain and reconstruction. ambulatory dysfunction are relatively common, especially with high-grade injuries. Unfortunately, disastrous out- comes may result despite appropriate treatment. The exact role of limb amputation for high-grade open calcaneal fractures remains controversial. Sound clinical judgment is necessary to predict whether a series of complex reconstructive proce- dures will likely result in a more func- tional outcome than amputation. This pro- cedure may be necessary in any of the three treatment phases. Circumstances such as severe fracture comminution with 3 articular damage, combined with adjacent ipsilateral foot and ankle injuries, neu- rovascular defects, advanced age, severe patient compliance issues, or severe sys- temic medical comorbidities may favor ablative surgery.

SUMMARY Open calcaneal fractures can be man- aged with an array of treatment tech- niques and result in a wide range of out- comes. Due to the fracture’s relative obscurity, the optimal form of interven- tion remains controversial. Consequently, 4 5 treatment for these hindfoot fracture-dis- ruptions continues to evolve. Timing of Figure 4: Lateral photograph demonstrating a tongue-type fracture with secondary articular involvement. Figure 5: Semi-coronal plane CT cut through the posterior facet, demonstrating a two-part fracture of the intervention may be a key factor in posterior facet. decreasing complication rates. The goals of open calcaneal fracture management include timely healing of the soft-tissue envelope without infection and tion and internal fixation of a comminut- this phase with a subtalar arthrodesis maintenance of bony alignment. Un- ed calcaneal fracture with a disrupted sub- (Figure 8). Arthrodesis may be undertak- fortunately, restoration of joint congru- talar joint should not be attempted in this en with minimal risk during this phase, as ence may be impossible. Unsatisfactory phase. Open reduction and internal fixa- the soft-tissue condition has stabilized, outcomes may result from neurogenic tion of the body of the os calcis combined the risk of infection is no longer a con- pain, infection, malunion, arthrosis, and with arthrodesis is recommended.9 cern, and consolidation of multiple bony impingement. Future advancements Additionally, fractures with non-recon- tuberosity fracture fragments has begun, in treatment are anticipated and will structible (у4-part) fractures of the poste- facilitating a “compression” arthrodesis depend on an improved understanding of rior facet are probably best treated during of the subtalar joint. this devastating orthopedic injury.

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6 7

Figure 6: Lateral radiograph of the hindfoot following open reduction and internal fixation of an open calcaneal fracture. Open reduction and internal fixation followed serial irrigation and debridement. Formal plate and screw osteosynthesis was undertaken on day 11. An extensile lateral incision with a low-profile plate and screw fixation was used. Figure 7: A Harris view of the hindfoot following open reduction and internal fixation demonstrating excellent restitution of calcaneal height and the medial column of the os calcis.

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