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Nonoperative Care of Os Calcis Fractures Convertir en PDF Version imprimable Suggérer par mail

Richard E. Buckley, M.D., FRCSC
Foothills Medical Center
Calgary, AB

I always get asked about the discussion of the nonoperative side of calcaneal fractures (never the operative side). This is not a problem because I have treated many hundreds of patients nonoperatively with calcaneal fractures. Since the results of our large prospective randomized multicentre controlled clinical trial have been published, we have been able to provide better care for patients, as we have taken some good steps in the management of os calcis trauma1.  

Figure 1


There is obviously a role for nonoperative treatment of calcaneal fractures. This is carefully outlined in the Canadian Orthopaedic Trauma Society article1. Nonoperative indications include:

  1. Patient indications
  2. Limb indications
  3. Fracture indications

It is imperative that the trauma surgeon make decisions based on the patient and not "the fracture". It is lots of fun to operate on calcaneal fractures, but usually it is not the fracture care that matters, it is the patient who makes the difference.

Reasons to treat patients nonoperatively include:

  1. Older age group (>50)
  2. Medically unwell (example: diabetic)
  3. Heavy smoker
  4. Compliance issues (lack thereof)
  5. WCB patients (Reference 1 shows they "all" do poorly on outcome scales)

Reasons to treat patients nonoperatively (limb):

  1. Soft tissue cover poor, or soft tissue not yet ready for surgery (large fracture blisters)
  2. Vasculopathy
Figure 2

Reasons to treat patients nonoperatively (fracture):

  1. Extra-articular fractures (posterior facet not involved in fracture)
  2. Non displaced intra-articular fractures of the posterior facet
  3. Displaced intra-articular calcaneal fracture with little loss of Böhlers angle (if the angle is more than 15°, the patient will do well regardless of care)

There are many fractures that will do well operatively and they include all of the things other than what I have mentioned, including young age group, simple fractures that are displaced, good soft tissues, compliant patients who are non WCB, and who are medically well (not smoking). The essence of the treatment of this particular fracture is the recognition of patient characteristics. If the patient is a poor candidate, there is no reason to proceed with surgery, because literature indicates that if complications arise after operative care, then the patient was better served by nonoperative treatment. Patients with certain fractures are best treated operatively and this will provide the best possible outcome. A large percentage of cases are treated best nonoperatively, with fewer chances of complications and good long-term results; very near the same results as patients who are treated operatively2. It is noteworthy that our average long-term outcome was no more than 70 out of 100 on a 100 point scoring scale regardless of which group the patients were in, operative or nonoperative.

Figure 3
Should nonoperative treatment fail with patients who are marginal surgical candidates, then a simple distraction bone block arthrodesis (one single operation done somewhat later after you have got to know the patient) will salvage the patient. This produces nearly the same result as with a patient who has been treated operatively or nonoperatively with a good result3.

The example that I have provided with pictures shows an initial CT, a two year CT and the clinical results of a patient treated nonoperatively (Figures 1, 2 and 3 respectively). This patient was in his 50's and got back to doing most everything he had done before injury with excellent results. This is an excellent topic for a debate because in fact there is no right answer. Patients need to be reviewed very carefully and demographically split into those patients who will perform best with operative or nonoperative treatment, given the surgeon's and institution's capabilities.



References

  1. Buckley R., Tough S., McCormack R., Pate G., Leighton R., Petrie D., Galpin R. Operative compared with Nonoperative Treatment of Displaced Intra-articular Calcaneal Fractures, A prospective, randomized, controlled multicenter trial, JBJS(AM),Vol 10, pp 1733-1744, 2002

  2. Howard, Buckley R., McCormack R., Pate G., Leighton R., Petrie D., Galpin R. Complications Following Management of Displaced Intra-articular Calcaneal Fractures: A Prospective Randomized Trial Comparing Open Reduction and Internal Fixation with Non-operative Management. Journal of Orthopaedic Trauma, Vol 17, pp 241-249, 2003.

  3. Csizy, Buckley R., Tough S., Leighton R., Smith J., McCormack R., Pate G., Petrie D., Galpin R. Displace Intra-articular Calcaneal Fractures-Variables predicting late subtalar Fusion, Journal of Orthopaedic Trauma, Vol 17, No 2, pp 106-112, 2003.

 

 
 
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