What is the step-by-step procedure for treating a calcaneal (heel bone) fracture using plating?

Step-by-Step Procedure for Calcaneal Fracture Plating

The surgical treatment of calcaneal fractures using plating involves a systematic approach with careful attention to anatomical reduction and stable fixation to optimize functional outcomes and minimize complications.

Preoperative Assessment and Planning

1. Radiographic Evaluation:

   • Standard three-view ankle radiographs (anteroposterior, lateral, and mortise views)
   • CT scan to assess fracture pattern and articular involvement
   • Evaluate Böhler angle (normal: 20-40°) and Gissane angle (normal: 120-145°)
   • Classify fracture using Sanders classification

2. Patient Selection Considerations:

   • Assess for risk factors for wound complications:
     • Diabetes (increases risk 3.4 times)
     • Smoking (increases risk 1.2 times)
     • Open fractures (increases risk 2.8 times)
   • Multiple risk factors significantly increase complication rates

Surgical Procedure

1. Patient Positioning and Preparation

• Position patient in lateral decubitus position with affected side up
• Place a bump under the ipsilateral hip
• Prep and drape the foot and ankle in sterile fashion
• Apply tourniquet to the thigh

2. Approach

• For most displaced intraarticular fractures, use a lateral approach:
  • L-shaped lateral incision (lateral utility incision)
  • For less invasive approach, consider sinus tarsi approach
  • Ensure incision is not directly over the fibula to avoid peroneal tendon injury

3. Exposure

• Develop full-thickness flaps
• Protect the sural nerve and peroneal tendons
• Retract the peroneal tendons superiorly
• Expose the lateral wall of the calcaneus

4. Fracture Reduction

• Insert Schanz pin into the tuberosity fragment for manipulation
• Reduce the tuberosity fragment to restore calcaneal height and length
• Reduce the sustentaculum tali fragment (usually remains attached to the talus)
• Reduce the posterior facet with attention to articular congruity
• Temporary fixation with K-wires

5. Fixation

• Apply appropriately contoured calcaneal plate to the lateral wall
• Secure plate with screws:
  • Place screws in the tuberosity fragment
  • Place screws in the sustentacular fragment (may require fluoroscopic guidance)
  • Place subchondral screws to support the posterior facet
• Consider bone grafting for significant bone defects

6. Wound Closure

• Perform two-layer closure with meticulous attention to soft tissues
• Consider drain placement based on surgeon preference
• Apply sterile dressing and splint

Postoperative Management

1. Immediate Postoperative Care:

   • Elevate the extremity
   • Monitor for compartment syndrome
   • Administer appropriate pain control

2. Immobilization and Weight-bearing:

   • Non-weight bearing for 6-8 weeks
   • Apply short leg cast or removable boot
   • Begin early range of motion exercises if fixation is stable

3. Follow-up:

   • Regular radiographic assessment at 3 weeks and at cessation of immobilization
   • Assess Böhler and Gissane angles to confirm maintenance of reduction
   • Progressive weight-bearing based on radiographic healing

Special Considerations

• For highly comminuted fractures, primary subtalar arthrodesis may be preferable
• For open fractures, consider external fixation or delayed internal fixation
• For minimally displaced fractures, consider percutaneous fixation techniques
• For patients with multiple risk factors for wound complications, consider less invasive approaches or non-operative management

Expected Outcomes

• Successful anatomical reduction correlates with improved functional outcomes
• AOFAS scores of 88-99% can be achieved with proper technique
• Restoration of normal Böhler and Gissane angles is associated with better clinical results

Potential Complications

• Wound complications (25% overall, 21% requiring surgical intervention)
• Infection
• Malunion or nonunion
• Subtalar arthritis
• Peroneal tendon irritation
• Sural nerve injury
• Chronic pain

The surgical approach should be tailored to the specific fracture pattern, with the goal of anatomic reduction of articular surfaces and restoration of calcaneal height, width, and alignment to optimize functional outcomes.