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 requires careful preoperative planning, appropriate patient selection, and meticulous surgical technique to achieve optimal outcomes in terms of morbidity, mortality, and quality of life.

Preoperative Assessment and Planning

1. Radiographic Evaluation:

   • Standard three-view ankle radiographs (anteroposterior, lateral, and mortise views)
   • Weight-bearing radiographs if possible to assess fracture stability
   • CT scan to evaluate fracture pattern and guide surgical planning
   • Assess Böhler angle (normal 20-40°) and Gissane angle (normal 120-145°) 1

2. Patient Selection Criteria:

   • Evaluate for risk factors that increase wound complications:
     • Diabetes (relative risk 3.4)
     • Smoking (relative risk 1.2)
     • Open fractures (relative risk 2.8) 2
   • Consider alternative treatments in high-risk patients with multiple risk factors

3. Fracture Classification:

   • Determine if fracture is intra-articular or extra-articular
   • Sanders classification for intra-articular fractures
   • Assess displacement and comminution

Surgical Procedure

1. Patient Positioning and Preparation

• Position patient in lateral decubitus position with affected side up
• Apply tourniquet to thigh
• Prep and drape the foot and ankle in standard sterile fashion
• Elevate the leg on a padded support

2. Surgical Approach

• Lateral Approach (most common for plating):

  • Make an L-shaped incision starting 1-2 cm proximal to the tip of the lateral malleolus
  • Continue the incision distally and horizontally toward the calcaneocuboid joint
  • Reflect the full-thickness flap to expose the lateral wall of the calcaneus
  • Protect the peroneal tendons and sural nerve during dissection

• Sinus Tarsi Approach (less invasive alternative):

  • Make a 3-4 cm oblique incision over the sinus tarsi
  • This approach is suitable for most displaced intra-articular fractures 3
  • Provides access to the posterior facet while minimizing soft tissue complications

3. Fracture Reduction

• Elevate the depressed posterior facet fragment:

  • Create a cortical window in the lateral wall (if not already present from fracture)
  • Use a bone tamp or elevator to lift the depressed articular fragments
  • Consider using an inflatable bone tamp for less invasive reduction 4
  • Temporarily fix with K-wires

• Restore calcaneal height, width, and Böhler's angle:

  • Apply a distractor if needed to restore height
  • Use bone clamps to compress the primary fracture lines
  • Verify reduction under fluoroscopy

4. Bone Grafting (if needed)

• Fill any void beneath the elevated articular surface with:
  • Autograft (iliac crest or local bone)
  • Allograft
  • Synthetic bone substitute

5. Fixation

• Apply an appropriately contoured calcaneal plate to the lateral wall:

  • Position the plate to support the posterior facet
  • Secure with screws, starting with the talar neck region
  • Add additional screws to stabilize the sustentaculum tali
  • Place screws in the anterior process and tuberosity
  • Verify screw placement with fluoroscopy to ensure they don't penetrate joints

• For highly comminuted fractures:

  • Consider locking plates for better fixation in osteoporotic bone
  • Add additional small fragment screws as needed

6. Wound Closure

• Perform meticulous hemostasis
• Irrigate thoroughly
• Close in layers:
  • Deep layer with absorbable sutures
  • Skin with non-absorbable sutures or staples
  • Consider drain placement in high-risk cases
  • Apply sterile dressing and splint

Postoperative Management

1. Immediate Care:

   • Elevate the extremity
   • Apply ice to reduce swelling
   • Administer appropriate pain management
   • Prophylactic antibiotics as indicated

2. Mobilization Protocol:

   • Non-weight bearing for 6-8 weeks
   • Boot walker after initial immobilization
   • Progressive weight bearing starting at 8-12 weeks based on radiographic healing

3. Follow-up:

   • Regular radiographic assessment at 3 weeks and at cessation of immobilization
   • Clinical evaluation of wound healing and fracture stability
   • Assess Böhler and Gissane angles to confirm maintenance of reduction 1

4. Rehabilitation:

   • Begin ankle range of motion exercises when wound healing permits
   • Progressive strengthening and proprioceptive training
   • Return to full activities at 4-6 months depending on healing and function

Potential Complications and Management

• Wound complications (occur in approximately 25% of cases) 2:

  • Minor: treat with local wound care and antibiotics
  • Major: may require surgical debridement or flap coverage

• Subtalar arthritis:

  • May develop despite anatomic reduction
  • Manage with NSAIDs, orthotics, or subtalar fusion if severe

• Malunion:

  • May require corrective osteotomy if symptomatic

Special Considerations

• For severely comminuted fractures, primary subtalar arthrodesis may be preferable 5
• Consider less invasive techniques for high-risk patients
• Conservative treatment is appropriate for non-displaced fractures or when local conditions make surgery inadvisable 5

The success of calcaneal fracture plating is highly dependent on achieving anatomical reduction of the articular surface and restoration of calcaneal height and width, which correlates with improved functional outcomes as measured by the American Orthopaedic Foot and Ankle Society (AOFAS) score 1.