REVIEW PAPER


https://doi.org/10.5005/jp-journals-10040-1214
Journal of Foot and Ankle Surgery (Asia Pacific)
Volume 9 | Issue 2 | Year 2022

Emergent Management of Tongue-type Calcaneal Fractures: Technique Tips


Maegan Shields1, Richard Buckley2, Christopher D Balso3, Amir Khoshbin4, Aaron Nauth5, Timothy Daniels6, Mansur Halai7

1,4-7Department of Surgery, St Michael’s Hospital, University of Toronto, Toronto, Canada

2Department of Surgery, University of Calgary, Calgary, Canada

3Department of Surgery, Western University, London, Ontario, Canada

Corresponding Author: Richard Buckley, Department of Surgery, University of Calgary, Calgary, Canada, Phone: +1 4036307741, e-mail: buckclin@ucalgary.ca

ABSTRACT

The aim of this report is to aid the trauma surgeon with some technique tips to aid with maintaining and obtaining reduction of these complex tongue-type calcaneal fractures. This will be conveyed via two case examples (high- and low-energy fracture patterns), each requiring different principles of fixation.

How to cite this article: Buckley R, Halai M, Shields M, et al. Emergent Management of Tongue-type Calcaneal Fractures: Technique Tips. J Foot Ankle Surg (Asia Pacific) 2022;9(2):61-66.

Source of support: Nil

Conflict of interest: None

Keywords: Calcaneus, Emergency, Open reduction

INTRODUCTION

The tongue-type calcaneal fracture was described by Essex-Lopresti in 1952.1 These fractures extend into the subtalar joint with a secondary fracture line, which runs posteriorly through the calcaneal tuberosity. This secondary fracture line is the defining feature. Significantly displaced fractures of this type are orthopedic emergencies as there is potential for skin compromise along the posterior heel.2-4 The aim of this report is to aid the trauma surgeon with some technique tips to aid with maintaining and obtaining reduction of these complex fractures. This will be conveyed via two case examples (high and low energy fracture patterns), each requiring different principles of fixation.

CASE 1: HIGH-ENERGY POLYTRAUMA CASE

A 52-year-old female with a past medical history significant for depression and polysubstance use presented to the hospital after jumping 30 ft. She sustained multiple orthopedic injuries and a right-sided calcaneal tongue-type fracture (Fig. 1). While the calcaneal fracture was not open, there was a skin blanching over the insertion of the Achilles tendon at initial examination. This was mildly relieved by plantar flexion of the ankle and application of a dorsal slab, which we recommend as the first course of action for damage control orthopedics (DCO) in this scenario. The patient was taken to the operating room at 23:00 urgently address the right os calcis with impending skin compromise. She was positioned supine on a regular radiolucent operating table.

Figs 1A and B: Preoperative imaging demonstrating tongue-type calcaneal fracture with displacement causing impending skin compromise. (A) Preoperative X-ray prereduction and sagittal cut CT; (B) Postreduction attempt demonstrating tongue-type calcaneal fracture with minimal improvement in displacement and displaced fragment causing pressure and blanching of the posterior heel skin. This slab was changed to a dorsal slab by the orthopedic team. Each figure is named and described in the ppt presentation

An Essex-Lopresti type maneuver was used,5 which will now be described. The “tongue” (posterior tuberosity) fragment was attempted to be reduced percutaneously with a nonthreaded 2.8 mm K-wire (Fig. 2A). This was irreducible percutaneously, as is usually the case due to the depression of the posterior facet into the body of the calcaneus. Accordingly, a small 3 cm sinus tarsi incision was made. The posterior facet depression was elevated using a Howarth elevator, which unlocked the fragment (Fig. 2B) allowing the large K-wire (which was inserted from the opposite side through the posterior tuberosity) to lever the fragment and act as a joystick to facilitate reduction (Fig. 2C). Note, this is a two-handed maneuver and requires the tuberosity to move counter-clockwise (for a right foot) and the posterior facet to be elevated. Once reduced, the tuberosity fragment was then stabilized percutaneously with nonthreaded 2.5 mm K-wire into the talus and then one through the anterior process into the calcaneocuboid joint (Fig. 2D). This was found to be stable under live fluoroscopy and determined adequate without the need for replacement with screws. As the patient was polytraumatized, this is an efficient manner to stabilize the fracture and relieve the skin, especially in DCO. Had our patient been more stable, we would recommend introducing fixation into the calcaneus after using this reduction technique. This would be through the sinus tarsi incision, using a mini fragment plate to connect the anterior process to the posterior tuberosity. Finally, we recommend splinting with approximately 20° of plantar flexion. If the patient had poor bone quality, we would recommend using two wires for the tuberosity manipulation to spread the load and to avoid cut out of the screws. Wires were removed after 8 weeks in the outpatient clinic (Fig. 3). This technique is especially useful in the polytraumatized patient where time is of the essence in a DCO setting, and the soft tissues will not tolerate larger incisions.

Figs 2A to D: Intraoperative fluoroscopic images demonstrating the Essex-Lopresti reduction technique. (A) Intraoperative fluoroscopic images demonstrating failed attempted percutaneous closed reduction. (B) Sinus tarsi approach with Howarth elevator used to mobilize depressed fragment. (C) Addition of K-wire used to joystick plantar fragment while Howarth elevates the posterior facet. (D) Fracture reduced and stabilized with 3 K-wires

Figs 3A and B: Postoperative X-rays. (A) Postoperative X-rays of tongue-type calcaneal fixation immediately postoperative and (B) at 6 months postoperative once pins have been removed

CASE 2: LOW-ENERGY CASE

A 60-year-old female with a past medical history significant for rheumatoid arthritis on biologic therapy presented to the emergency department. She thought she had sprained her ankle but presented with an avulsion-type calcaneal fracture (Fig. 4). On presentation, she had a clear deformity to her calcaneus. Her skin was dark and tented. She was taken to the operating room (OR) urgently in order to prevent further skin compromise.

Fig. 4: Preoperative X-ray demonstrating avulsion tongue-type calcaneal fracture. Preoperative X-ray in lateral position

She was positioned in the “recovery position” where the patient is placed in the lateral decubitus position, with the surgical side down. The lower half of their body is rotated into a prone position, while the upper half of the body is supported in a well-padded lateral position with the aid of a inflated bean bag6 (Fig. 5). An open approach was used, using the vertical limb of the extensile lateral approach. As has been previously suggested, care was taken to protect the skin edges, sural nerve, and to have full thickness skin flaps.7 The fracture was fragmented and therefore part of the posterior tuberosity was excised, given the piece was too small for fixation. A Strayer release was done to lengthen the gastrocnemius and advance the Achilles tendon onto the remaining calcaneus. The Achilles tendon was attached using a 5 mm suture anchor with the limbs brought out medial and lateral to the Achilles and taken 5 cm proximal from the insertion. Care was taken to ensure that all the knots were buried and facing anterior. The fracture was reduced using a 5 mm partially threaded cannulated screw into the plantar bone and buried under the Achilles tendon. Finally, the fracture is neutralized with a mini-fragment (2.4 mm) T plate (Fig. 5). We believe this neutralization to be vital, as these low velocity cases occur with poor bone quality and are essentially fragility fractures, making a singular screw likely to pull out and fail. Excellent hold was demonstrated through a full arc of motion under fluoroscopy. The wound was copiously irrigated, and 1 gm vancomycin powder was placed within the wound. The incision was closed with an interrupted vertical mattress nylon sutures, and a dorsal equinus splint was applied. This was kept on for a month with weekly skin checks.

Fig. 5: The “Recovery Position.” The patient is positioned in the lateral decubitus position with the aid of a pneumatic bean bag. However, their operative side is rotated toward the floor, with the noninjured, upper leg coming over the top

Figs 6A and B: (A) Postoperative X-ray following ORIF of avulsion tongue-type calcaneal fracture, postoperative X-ray demonstrating lateral, and Harris view of calcaneus following open reduction internal fixation with lag screw and neutralization plating of avulsion-type calcaneal fracture. (B) Harris view of calcaneus following open reduction internal fixation with lag screw and neutralization plating of avulsion-type calcaneal fracture

Figs 7A to C: (A) Screw configuration for fixation of right tongue-type calcaneus fracture. Preoperative 3D CT scan demonstrating lateral view of the right calcaneus with lateral subluxation of the posterior facet under the fibula. (B) One year postoperatively showing the lateral X-ray (C) and the Harris axial view

DISCUSSION

Tongue-type displaced intra-articular calcaneal fractures are orthopedic emergencies that require urgent intervention. Gardner et al. demonstrated a rate of soft tissue compromise in tongue-type calcaneal fractures of 21%, in a retrospective study of 139 patients.4 Soft tissue compromise was associated with delayed presentation, smoking, and increased fracture displacement.4 The fracture fragment is displaced superiorly due to the strong proximal pull of the Achilles tendon and rotated dorsally due to the plantar fascia. This superficial fracture places tension on the thin posterior skin, which may lead to tissue ischemia and necrosis.2 These injuries should be treated with immediate reduction, and either a well-padded removable posterior splint or dorsal slab with window cut out over the heel positioned in plantar flexion to allow for frequent soft tissue checks and close monitoring.8

With the increased potential for soft tissue compromise, time to surgery should be carefully considered. In patients with displaced tongue-type calcaneal fractures, De Boer et al. found a significant correlation between displaced tongue type fractures with infection, ulceration and non-union.3 Previously it had been thought that delaying surgery would decrease wound complications to allow for swelling to decrease.9 However, recent studies have not demonstrated this benefit.10-12 A study by Kwon et al. demonstrated delaying surgery increased wound complications.13 Joseph et al. performed a retrospective study examining 70 intra-articular calcaneal fractures and concluded that these fractures may be treated acutely within 72 hours with minimal wound complications and without compromising short term outcomes.14

The sinus tarsi approach is a minimally invasive approach offering less soft tissue compromise and wound complications when comparing to the extensile lateral approach. This approach was described by Smith.15 A 4-cm incision is made in line with the tip of the fibula and the base of the 4th metatarsal. Extensor digitorum brevis is seen and retracted cephalad to expose the sinus tarsi and subtalar joint. Peroneal tendons should be retracted posteriorly. A Schanz pin or large K-wire is inserted percutaneously into the posteroinferior tuberosity going from lateral to medial, which serves as a joystick to control the fragment. A small elevator is placed under the posterior facet fragment shoehorn the fragment up, unlocking it and allowing the manipulation of the tuberosity with the Schanz pin joystick. This technique is shown in (Figures 6A and B). Once an adequate reduction is obtained, the fracture is held in place with K-wires aimed toward the sustentaculum. K-wires are then used for definitive fixation, or cannulated screws may be used to secure fixation.

Open reduction and internal fixation (ORIF) allows for direct visualization to achieve optimal reduction; however, it is associated with high rates of soft tissue complications.11,16 The extensile lateral approach was previously the gold standard to allow for complete visualization of the calcaneus.7,17 However, this approach is notorious for wound complications (in the trauma setting) and may cause a delay to surgery to allow for swelling to subside. Bai et al. demonstrated a significant increase in wound complications with the extended lateral as compared to the sinus tarsi approach.17 Busel et al. demonstrated the sinus tarsi approach demonstrated adequate exposure of the posterior subtalar joint and calcaneal cuboid joint.14,18-20 Furthermore, Bai et al. demonstrated in a meta-analysis that there is a decrease in surgical time using the sinus tarsi approach over the extended lateral approach.17 Various studies examine closed reduction with percutaneous fixation (CRPF) in effort to avoid wound complications, with most in favor of the sinus tarsi approach.16,21-26

In the case of the irreducible calcaneal fracture, it is important to consider interposition of the flexor halluces longus tendon in the subtalar joint as has been previously described.15,27-30 Clawing of the great toe may offer a clue toward tendon entrapment. In this scenario, a percutaneous reduction and pinning will not be successful and either a medial approach or arthroscopic assistance is required to remove the interposed tendon.

Different surgical techniques have been proposed for managing these fractures. Pinning with K-wires may be used for definitive fixation; however, it is associated with the risk of loss of reduction through slipping of the fragments on smooth wires and possibility of protruding wires resulting in superficial and deep pin tract infections. Loss of reduction may result in residual shortening and varus malalignment. Van der Vliet et al. completed a retrospective case series comparing outcomes and postoperative outcomes of 58 tongue-type calcaneal fractures in 56 patients.31 They found an increase in wound complications in the group receiving ORIF (30%) vs closed reduction and percutaneous fixation (CRPF) (12%). There was also a higher rate of deep infection in ORIF (16%) compared to CRPF (3%). The need for revision was more frequently observed in patients with CRPF (16%) compared to (3%) of ORIF due to loss of fixation in three-fourths cases. Despite it being the largest study to date looking specifically at tongue-type fractures, this is a small retrospective review on patients failing to comment on the approach used for ORIF, nor any mention whether these differences were statistically significant. Rammelt et al. has recommended percutaneous reduction for type IIC fractures, and either open or arthroscopic assisted reduction is essential for type IIB fractures.32,33

Minimally invasive pin or screw fixation has demonstrated good results in the literature.5,26,31 As has been previously reported, the usage of large, cannulated screws (6.5-8.0 mm) for definitive fixation has been recommended.5,26 An additional cortical lag screw under the posterior articular facet into the sustentaculum may provide additional rotational stability in type IIB fractures where the sustentaculum tali fragment is typically a large fragment.34 These screw configurations are demonstrated in Figure 7. This case in Figures 7A to C demonstrates another important scenario of skin compromise. This is from a posterior facet that is dislocated laterally, placing pressure over the subfibular skin area. The use of multiple screws has benefits in enhancing rotational control, rafting the subchondral surface, and allowing a more percutaneous technique. Bacaksiz et al. suggest three parallel screws as the ideal configuration for screw configuration in a biomechanical sawbone study examining four different constructs for tongue-type IIC fractures.34 The mean force to displacement and axial stiffness of the three parallel screw constructs was significantly higher compared to two divergent screws or two parallel screws. Yu et al. discuss a novel technique using a 5.0 mm condyle bolt from a retrograde femoral nail inserted perpendicular to the tongue-type fracture line using washers on the superior and plantar surface of the calcaneus to optimize interfragmentary compression through two washers, and to prevent screw pullout in the case of osteoporotic bone.34

CONCLUSION

Tongue-type calcaneal fractures are orthopedic emergencies. Using the techniques described in this report, most of these can be dealt with efficiently using simple maneuvers, with a sinus tarsi incision. Postoperatively we recommend placing the foot into an equinus dorsal slab splint for 1 month. It is important to check the skin at 48 hours postoperatively and every week until fracture consolidation.

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