Case of the week #15
Mr is a 47 year old gentleman who fell off a ladder, a height of nearly three metres, two years ago. He was working interstate at the time. He sustained a comminuted, intra-articular fracture of the calcaneum (a 'Sanders IV' using the Sanders classification).
He was initially managed in the local Emergency Department as per Early Management of Severe Trauma principles. In particular, a careful examination of his spine as well as a lumbar spine x-ray was performed as 5% of people with a calcaneal fracture also have a lumbar spine fracture. Up to 17% of calcaneal fractures are open, with skin laceration down to bone and extensive associated soft tissue injury. This is due to the axial loading that occurs with this injury.
Mr F presented to Dr Amy Touzell two weeks following his injury, having been non-weight bearing in backslab for transfer back to Victoria. We repeated his x-ray which demonstrated flattening of Bohler's angle and increased angle of Gissane (see below).
The axial x-ray of his calcaneum demonstrated significant lateral wall comminution (see below).
The management of calcaneal fractures remains controversial. The traditional, open 'L-shaped' incision is associated with a high wound complication rate due to the tenuous blood supply and angiosome distribution in the lateral side of the heel. More modern techniques have evolved, including the sinus tarsi approach and arthroscopic-assisted fracture fixation. These techniques have a lower wound complication rate, but calcaneal fractures as still associated with high morbidity and high rates of post-traumatic arthritis of the subtalar joint. A recent Cochrane review has suggested a high complication rate with surgery, but higher rate of subsequent subtalar fusion for post-traumatic arthritis with initial non-operative management.
The risks and benefits of operative versus non-operative management was discussed with Mr F. In particular, he was a heavy smoker at the time which increased his risk of wound complications and non-union. Subsequently, the decision was manage to manage this fracture non-operatively. He was partial weight bearing in a boot for a further four weeks, and commenced weight bearing six weeks after his injury.
Six months after his injury, Mr F still had ongoing pain and a palpable, painful 'click' on the lateral side of his ankle. His physiotherapist was concerned about peroneal tendon instability and referred him back to see Dr Touzell. A CT and dynamic ultrasound of his ankle confirmed that his physiotherapist was absolutely right, and the peroneal tendons were getting caught on the displaced lateral wall of the fracture, which had malunited (see below).
Mr F had been unable to walk due to the painful click in his ankle, and had stopped smoking a few months prior with ongoing support from his General Practitioner and encouragement from his Physiotherapist. The option of surgery was discussed. Most of Mr F's symptoms were arising from the painful click of peroneal tendon instability rather than subtalar joint arthritis, so the decision to proceed with stabilisation of the tendons, without treating the subtalar joint, was made.
Intra-operatively, it was noticed a large 4cm lateral bone fragment had displaced the peroneal tendons causing the painful click. This bone fragment was removed, and the tendons stabilised using intra-osseous anchors to stabilise the peroneal tendons back behind the fibula.
Mr F commenced weight bearing in an ankle brace two weeks post-operatively and at his six-week review his painful click had resolved.
Ten months after surgery, Mr F describes a dull ache in his ankle at the end of the day but relatively pain-free during the day, and was no longer talking any analgesia. He is unable to run or kick a football with his affected foot. However, he has an unlimited walking tolerance and no longer has the painful click with movement of his ankle. He is aware he may still need a subtalar joint fusion to treat post-traumatic arthritis of his subtalar joint, but hopefully this will be delayed until well into the future.
Calcaneal fractures are high-energy injuries associated with poor outcomes, both with operative and non-operative management.
Always examine the lumbar spine in a patient who presents with a calcaneal fracture due to the increased risk of spinal fractures with this injury.
Many patients with a calcaneal fracture develop post-traumatic arthritis of the subtalar joint, which can be treated surgically with a subtalar fusion if non-operative treatment (strengthening, injections and shoewear changes) is not successful.
Peroneal tendon instability is an uncommon complication of non-operative treatment of calcaneal fractures.