Calcaneum burst fracture in multiple trauma patients: an analysis of 31 cases

Purpose of the study We analyzed calcaneum burst fractures in multiple trauma patients and propo se a management scheme. Material and methods In a retrospective study, we isolated 23 patients with 31 calcaneum burst f ractures. All were stage V in the Duparc classification. We call them "pied de mine" fractures as they resembled those described in military reports. Half of them (16 cases; 54%) were open fractures, All patients suffered mul tiple injuries and 12 had a psychiatric history. These fractures were assoc iated with spinal fracture in 17 cases (73%) and half had neurologic defici t, limb fracture in 16 (73%), and pelvic fracture in 12 (52%). The most fre quent associated foot injuries were a talus fracture in 9 cases (29%) and C hopart displacement in 16 cases (32%). Clinical evaluation used the Marylan d foot score, foot print and radiologic evaluation with lateral retrotibial view. Results Mean follow-up was 35 months. Mean Maryland foot score was 62.7 and 13 case s were pain free. Pain was due to conflict with the lateral malleolus, bony plantar thorns, medial malleolus and subtalar osteoarthritis. Orthopedic s hoes were used 11 times, The other patients used sports shoes. Subtalar mob ility was most frequently absent (23/29 cases, 2 amputations). Fool print s howed 13/16 flat feet; 6 thorns were indirectly visible. Two patients had r etraction toes and were initially treated by external fixation. Radiologic evaluation showed 23/29 complete subtalar arthrodeses, 23/29 migration of t he great tuberosity, often (17/23 cases) associated with varus angulation. Eleven patients needed subsequent surgery: 5 for arthrodeses and 6 for rese ction of bony thorns. Rate of complication was high, especially for open fr actures: 2 infections for 15 closed fractures, and 8 infections (50%) for 1 6 open fractures with 2 cases of chronic osteitis. Secondary amputation was required in 2/31 cases due to sepsis. Treatment propositions For closed calcaneum burst fractures, it is better to wait one week before osteosynthesis. This delay is used to decrease edema with limb elevation an d compressive bandaging. Skin tension due to trauma is increased by edema a nd osteosynthesis gives a high risk of wound disunion. We recommend reducti on and Y-plate fixation even for burst fracture. Reduction must lower the t uberosity and correct the varus. After surgery, subtalar spontaneous arthro desis is usually observed in a good position. Any bony plantar thorn must b e resected. For open calcaneum burst fracture, the risk of sepsis is high. First treatm ent is debridement, stabilization and external fixation with antibiotic the rapy. Stabilization should improve vascularization and facilitate internal fixation. The external fixation can be placed on the medial side to free th e lateral approach to the calcaneum. Flap repair can be performed after one week when skin tension has subsided and areas of necrosis controlled.