What is the step-by-step procedure for treating a calcaneal (heel bone) fracture using plating and K-wire (Kirschner wire) fixation?

From the Guidelines

The treatment of a calcaneal fracture using plating and K-wire fixation is a complex procedure that requires careful planning and execution to minimize morbidity and mortality, and improve quality of life. The procedure involves several critical steps, including patient positioning, surgical preparation, and fracture reduction.

Step-by-Step Procedure

• The patient is positioned laterally with the affected foot elevated on a radiolucent support, allowing for easy access to the calcaneus and minimizing the risk of complications 1.
• After standard surgical preparation, a lateral extensile L-shaped incision is made, starting 3-4 cm above the lateral malleolus, extending distally, then curving anteriorly below the fibula toward the calcaneocuboid joint.
• The full-thickness flap is carefully elevated to expose the lateral wall of the calcaneus, with attention to preserving the sural nerve and peroneal tendons.
• Fracture reduction begins by addressing the primary fracture lines, first restoring the crucial angle of Gissane and Böhler's angle, which is critical for preventing post-traumatic arthritis and chronic pain.
• Temporary K-wires (typically 1.6-2.0 mm) are inserted to hold the reduction, and the subtalar joint surface is anatomically reduced, often requiring elevation of depressed fragments.
• Once reduction is confirmed with fluoroscopy, a pre-contoured calcaneal plate is positioned on the lateral wall, and multiple screws (3.5-4.0 mm) are placed through the plate into the sustentaculum tali, tuberosity, and anterior process.
• Additional K-wires may be used for supplementary fixation of smaller fragments, and intraoperative imaging confirms proper hardware placement and fracture reduction.
• The wound is irrigated, a drain may be placed, and closure is performed in layers, with a well-padded splint applied postoperatively to minimize discomfort and promote healing.
• The patient remains non-weight bearing for 8-12 weeks, allowing for optimal fracture healing and minimizing the risk of complications, as recommended by recent guidelines for the acute care of severe limb trauma patients 1.

Key Considerations

• The timing of fracture fixation is critical, with early definitive osteosynthesis recommended within the first 24 hours to reduce the incidence of local and systemic complications, unless the patient has severe visceral injuries, circulatory shock, or respiratory failure, in which case a delayed definitive osteosynthesis may be recommended 1.
• A sequential surgical approach, such as damage control orthopaedic surgery, may be necessary in certain cases to minimize the risk of morbi-mortality, and CT scan is a key exam in detecting massive bleeding or unstable injuries 1.
• The goal of the procedure is to achieve anatomic reduction and stable fixation of the fracture, allowing for early mobilization and minimizing the risk of post-traumatic arthritis and chronic pain.

From the Research

Step-by-Step Procedure for Fracture Calcaneum by Plating and K-Wire

The treatment of calcaneal fractures often involves a combination of plating and K-wire fixation to achieve anatomic reconstruction of the calcaneal shape and joint surfaces 2. Here is a step-by-step guide to the procedure:

• Preoperative Planning: Preoperative planning and experienced fluoroscopy are crucial to successful management of calcaneal fractures using percutaneous reduction and fixation techniques 3.
• Approach: The approach may vary depending on the type of fracture, but a less invasive approach such as the sinus tarsi approach or a minimally invasive internal fixation method with a thin plate and bone grafting may be used 2, 4.
• Reduction: Reduction of the fracture can be achieved through percutaneous reduction techniques, such as using an inflatable bone tamp, or through open reduction and internal fixation (ORIF) 3, 5.
• Fixation: Fixation can be achieved using a combination of plates, screws, and K-wires. Threaded 1.575 mm (0.062 in.) Kirschner wires (K-wires) can be used for fixation post-operatively along with standard plates and screws 5.
• Percutaneous Fixation: Percutaneous fixation techniques, such as using Schanz pins and Kirschner wires, cannulated screws, arthroscopically guided percutaneous fixation, and application of bone substitute, can be used to minimize postoperative complications 6.
• Bone Grafting: Bone grafting may be used to enhance the stability of the fixation and promote healing 4.
• Postoperative Care: Postoperative care is crucial to prevent complications, such as wound breakdown and infection. Patients should be instructed to avoid weight-bearing activities and follow a rehabilitation program to promote healing and recovery.

Key Considerations

• Complications: Complications, such as K-wire infection and breakage, can occur, but the overall complication rate can be minimized with proper technique and postoperative care 5.
• Clinical Outcomes: Clinical outcomes, such as the change in the Bohler and Gissane angles and the calcaneus width after fixation, can be evaluated using scoring systems, such as the Maryland foot scoring system 4.
• Soft Tissue Complications: Soft tissue complications, such as wound breakdown and infection, can occur, but the incidence can be minimized with proper technique and postoperative care 4.