August 2017 Journal Club (CALC FRACTURES)

[SLCpod]

Journal club overview:

- An article will be selected and posted each month. Please PM me an article you are interested in. Please keep them as recent as possible.
- We will discuss how we can use what we learned from the selected article in practice and perhaps share some clinical experiences (remember not to disclose specific patient information)

This is open to DPM's, students and pre-pods!! All are invited.

This month we will be taking a look at fractures of the calcaneus. I found two articles that I think will be beneficial to students. The first article addresses proper acute management of calcaneal fractures. It does a decent job of giving a brief overview of some classification systems and what should be done in the ED. What would you add to this article?

The second article compares the L-shaped lateral approach vs a sinus tarsi approach for reduction and fixation. If students are able to quote this paper or some of the references in the paper, directors will be impressed. For residents and those who have been practicing, which approach do you prefer? Why?

Calcaneal fractures_A possible MSK Emergency.pdf

Open reduction lateral vs sinus tarsi.pdf

NEXT MONTH: EXTERNAL FIXATION TECHNIQUES

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[dtrack22]

I still base my approach on fracture pattern and time of presentation (for the most part). Sanders 2 and many 3's with mild to moderate displacement that I can get to the OR within 1-2 weeks typically get a sinus tarsi approach/plate. Severely displaced Sanders 3 and all 4's get lateral extensiles once soft tissue is appropriate and assuming there aren't significant conorbidities that would make them a non operative candidate. More often than not, delayed presentations get extensile incisions as well. My extensile approach and post-op protocol is very systematic/rigid which I got from my residency program. We did not have anywhere near the older literature reported instances of wound complications so I didn't change much outside of a few cost saving things related to drain management. I have used ex fix on occasion (one of which hopefully will be published if I ever get around to it) but I can't imagine it ever being my go to fixation choice (sorry Dr. Dayton).

IMO the folks that don't do lateral extensile for any calc fx just aren't comfortable with the approach and/or the prospect of dealing with the potential complications. I admittedly have a problem with people who "only do" MIS or sinus tarsi approaches, because they always end up the xrays like the one attached. This particular surgeon did the patient no favors by putting metal into a malreduced calc. It was a waste of everyone's time and money. The podiatrist even admitted it was an old injury and that fracture lines had to be recreated. Open it up and put the calc back together correctly or don't do anything.

There are 100 other variables that I and hopefully everyone else take into consideration when deciding when/how to fix or not fix a calc. The above is about as quick/general as I can make a few aspects of my decision making process.

 

[SLCpod]

Great post! Thanks for the pearls.

 

[Adam Smasher]

I find the expression "possible emergency" to be a little vacuous, just like getting rear-ended in your car is a "possible emergency." Really, for ANY broken bone, you either wait a 10-14 days for the edema to go down (look up: "wrinkle test") or you operate right away. And you operate right away if there is some compromise in the soft tissue-either open fracture or skin tenting (Fig 3a in the article), unless you want to operate right away because the timing is perfect (you're already on call and an OR is available).

A great article for the students/residents is Carr's 1993 paper on the pathoanatomy of calc fx in CORR. Pay attention to the coronal plane and sagittal plane deformations that occur and the fracture lines that result.

 

[I post PRN]

I agree with dtrack, anyone that "only does" anything has a major ego problem and can't see the realty if certain things.

My management of calc fractures is very similar to described above, my approach is dependent on fracture pattern, sanders class.