Altay State Medical University,

Barnaul, Russia

 

For injuries to supporting-motor system (SMS) the frequency of heel bone fractures is 5.7 %, among the foot fractures it reaches 60 %, with intraarticular fractures in 54.9 % of cases [1, 2]. They present the part of polytrauma (PT) in 35-43 % of cases and are accompanied by injuries to internal organs and bone fractures in other locations [3, 4]. Outcomes of treatment of heel bone fractures are worse in patients with PT compared to isolated fractures. It is conditioned by high energy character of trauma, general state of patients, greater severity of bone injury, difficulties of using traditional treatment methods and possibility of carrying out osteosynthesis only in the late period [3].

The aim of the study – to investigate the results of treatment of heel bone fractures in isolated injuries and PT. 

 

MATERIALS AND METHODS

530 patients with 626 heel bone fractures received treatment in City Clinical Hospital #1 during 2000-2012. There were 442 men (83.4 %) and 88 women (16.6 %). The age of the patients varied from 14 till 80, median – 38, interquartile range – 28-48. Among the patients the individuals of working age prevailed: employed – 258 persons (48.7 %), non-employable – 208 (39.2 %), retired – 37 (7.0 %), students – 23 (4.3 %), school children – 4 (0.8 %).

The most common causes of injuries were home accidents – 387 (73 %), industrial ones – 76 (14.3 %), road traffic accidents – 45 (8.5 %), criminal – 22 (4.2 %). Injuries after falling from low height (1-1.5 m) were noted in 183 (34.5 %) of the patients, from great height (above 1.5 m) – in 338 (63.8 %), pressing under weight – 3 (0.6 %), affray – 5 (0.9 %), turning ankle – 1. Isolated fractures were in 199 (37.5 %) patients, as part of PT – in 331 (62.5 %), among them as part of concomitant injury – 102 (19.2 %), in SMS multiple trauma – 229 (43.2 %).

According to ISS [6], non-significant PT (<17 points) was noted in 259 patients, severe PT without life threatening (17-25 points) – in 67, severe and life threatening one (26-40 points) – in 5.

Traumatic brain injuries (TBI) were noted in 86 patients (26 %), including 67 persons with brain concussion and 19 ones with brain contusion. Intracranial hemorrhage was identified in 4 patients, fractures of skull vault and base – in 7, facial bone injuries – in 1, superficial head injuries – in 5, chest and abdomen injuries – in 29 (8.8 %), pneumothorax – in 5, hemopneumothorax – in 2, diaphragm and internal abdominal injuries – in 2, kidney contusion – in 18, liver injuries – in 5, splenic injuries – in 3, intestinal injuries – in 2, omentum injuries – in 1, bladder injuries – in 1.

388 fractures of bones in other locations were found, including closed fractures – 375 (96.6 %), opened ones – 13 (3.4 %). There were 41 fractures of forearm bones, as well as humerus – 9, hip – 30, leg – 91, foot bones – 26, pelvis – 44, ribs – 16, patella – 13, spine – 117, hand – 1. Gross joint dislocations were noted in 7 patients. The fractures of single heel bone were identified in 434 patients, both heel bones – in 96. SMS superficial injuries in view of bruises and scratches of extremities were in 19 patients, opened wounds of the body and extremities – 1 patient.

There were 546 closed heel bone fractures (87.2 %) and 80 opened ones (12.8 %). Opened fractures were in 16 cases with isolated injuries to the heel bone, and in 64 cases with PT. The differences were statistically significant (p < 0.05). It indicates the severe characteristics of fractures in PT.

The classification of heel bone fractures by V.A. Sokolov (2006) [3] was used in the study. The fractures were categorized into two types: extraarticular ones (type I) and intraarticular (type II). The type I (saved foot arch) included type IA – fractures of calcaneal tuber without displacement and with displacement like “duck's bill”; type IB – fractures of processes. With the type II the fracture line entered the talocalcanean joint. The following types were separated: type IIA – two- and three-segmentary fractures of the shaft without displacement; type IIB - tongue-shaped fractures; type IIC - comminuted fracture with shortening, foot arch applanation, heel pronation and widening. The table 1 shows distribution of heel bone fractures according to the classification.

The table 1 demonstrates that injuries of type I were in 88.4 % (176 heel bones) of cases with isolated fractures, type II – in 11.6 % (23 heel bones). Conversely, the patients with PT had heel bone fractures of type I in 42.6 % (182 heel bones), type II – in 57.4 % (245 heel bones). The differences were statistically significant (p < 0.05). It indicates severe characteristics of heel bone fractures in PT.

Plaster immobilization was used in IA and IIA non-displaced fractures, skeletal traction – in IA, IB and IIB displaced fractures, external osteosynthesis – in opened fractures in case of emergency (Fig. 1-3). Osteosynthesis with plates and screws was used for IA and IIB displaced fractures in late period after skin preparation and state stabilization. Transcutaneous osteosynthesis with cannulated screws was used for IA, IB and IIB displaced fractures according to the original method [7]. Its implication is correction of fragment displacement with 6.5 mm rod-screw and subsequent fixation with cannulated screws in correct position (Fig. 4-6).

Figure 1

The patient T., age of 28. Diagnosis: “Brain contusion, multiple pelvic fractures (a), closed intraarticular fracture of right calcaneal bone (b) with displaced fragments, open intraarticular fracture of left calcaneal bone with displaced fragments (c)

  

Figure 2

The patient T., age of 28. The surgery was performed: pelvis osteosynthesis with external fixation device (a), osteosynthesis of calcaneal bones with external fixation device (b, c)

  

Figure 3

The appearance of the patient T., age of 28, after performed surgical treatment: a - personal appearance, b – left calcaneal bone, c – right calcaneal bone

  

Figure 4

The patient D., age of 38. Diagnosis: “Brain contusion, closed intraarticular fracture of right calcaneal bone (b) with displaced fragments”: a - lateral X-ray of right calcaneal bone, b – axial X-ray

 

Figure 5

The patient D., age of 38, after surgical treatment of right calcaneal bone with cannulated screws: a – lateral X-ray of right calcaneal bone, b – axial X-ray  

  

Figure 6

The patient D., age of 40, after removal of cannulated screws 2 years after trauma: a – lateral X-ray of right calcaneal bone, b – axial X-ray, c – the patient’s appearance 2 years after trauma

  

Frequency of use of treatment methods in dependence on a type of heel bone fracture is given in the table 2. The table 2 shows that plaster immobilization was used predominantly for non-displaced fractures, but skeletal traction and different techniques of osteosynthesis – for displacement. Surgical methods of treatment were more often used for patients with PT.

Table 2

Methods of treatment of calcaneal bone fractures in examined patients

For evaluation of efficiency of used methods of treatment of heel bone fractures the number of early (deep venous thrombosis, purulence, soft tissue necrosis) and late (up to a year) complications (malunions, fixator migration, persistent contracture, osteomyelitis) were studied.

 The long term (1-3 years after trauma) outcomes were examined in 154 (29.1 %) of the patients with 173 heel bone fractures. AO FAS was used [8]. Interviewing and clinical examination with foot radiography in standard plains were performed. Pain syndrome intensity, foot function and adaptation of its part to surface were evaluated. The point evaluation system was used. The best result corresponded to the maximal amount of points (40 points for pain syndrome  assessment, 50 points for functional assessment, 10 points for evaluation of adaptation of the foot to surface).       

During data description the median (Me) and interquartile range (25^th and 75^th percentiles) were defined. For evaluation of statistical significance of differences the calculation of χ2 with Yates' correction and Bonferroni method with multiple comparisons were used. During testing null hypothesis the critical level of significance was < 0.05 [9].

The study was reviewed and approved by the ethical committee. The written informed consent was received from all patients or their close relatives (protocol #15 from 23.12.2010, local ethic committee, Altay State Medical University, Barnaul, Papanintsev St., 126).

 

RESULTS AND DISCUSSION

There were no lethal outcomes among the patients with heel bone fractures. The table 3 shows local complications in the patients with heel bone fractures. The table 3 demonstrates that two types of complications were noted during use of plaster immobilization: malunions and persistent contractures of adjacent joints – 2 cases for each type.

Table 3
Local complications of calcaneal bone fractures after different methods of treatment

Note: calculation of χ2 was used,		differences are statistically significant compared to the results of cannulated screws
** - p < 0.01; *** - p < 0.001.

In case of skeletal traction, deep venous thrombosis was noted in 7 cases, malunions of heel bones – 5, purulence and soft tissue necrosis – 3, persistent contractures in adjacent joints – 3. With ANF persistent contractures of adjacent joints were developed in 6 cases, deep venous thrombosis – 3, purulence and soft tissue necrosis – 3, subsequent osteomyelitis – 2.

With using plates and screws deep venous thrombosis, persistent contracture of adjacent joints and soft tissue purulence with subsequent development of osteomyelitis (1 case for each) were noted. In the last case the infectious complications were noted in patient M., age of 32 (brain contusion, closed non-penetrating compression fracture of the body of the first lumbar vertebra with compression of degree 3, closed intraarticular fracture of left heel bone with displaced fragments), with concomitant hepatitis C (Fig. 7). In case of standard screw use the complications in view of malunions (3 cases) and fixator migration were noted (4 cases).

Figure 7

Appearance of left foot of the patient M., age of 32, with infectious complications after internal osteosynthesis of left calcaneal bone with plate  

During osteosynthesis with cannulated screws 6 cases of deep venous thrombosis in an injured extremity were registered, including 1 case with fixator displacement which was removed after fracture consolidation.

Therefore, during treatment of heel bone fractures the complications were most commonly associated with use of standard plates and screws, ANF, skeletal traction, with statistically significant differences in frequency.

Use of heel plates was accompanied by high risk of purulence and soft tissue necrosis, mostly, because of unsatisfactory state of skin and late surgical intervention in PT, like in situations with deep venous thrombosis, which often was a consequence of polysegmentary fractures in patients with PT.

Development of malunions and fixator migration in use of standard screws were conditioned by impossibility of achievement of sufficient compression of bone fragments in rigid fixation.

Formation of persistent contractures in ANF was associated with long term fixation of soft tissue formations to a bone with transosseous elements, absence of full load and movements in adjacent joints resulting in venous hemodynamics disorders and higher frequency of thrombosis and infection complications.

Malunions of heel bone fractures during skeletal traction were conditioned by impossibility of achieving sufficient accurate anatomic reposition and firm fixation of bone fragments in some cases. High risk of thrombosis development was favored by long term (1.5-2 months) bed rest.

We observed the lowest amount of complications in treatment of heel bone fractures with using plaster immobilization and cannulated screws.

During comparison of frequency of local complications for surgical techniques of treatment of heel bone fractures it was noted that the lowest risk of their development was observed with cannulated screws. With skeletal traction the complication rate was 1.6 higher compared to cannulated screws, 3.4 times higher compared to external fixation device (p < 0.01), and 10.4 higher compared to screws and plates (p < 0.001).

The assessment of long term results of treatment of heel bone fractures was performed with AO FAS (Table 4). As one can see in the table 4, evident pain syndrome was observed in the patients of the group 3 (14.5 ± 4.1 points), i.e. with skeletal traction. It corresponds to “bad” mark according to AO FAS.

Table 4
Results of treatment of calcaneal bone fractures according to AO FAS in points (Ì ± δ)

Note: calculation of χ2 was

used, differences are statistically significant compared to the group 1 - * - p < 0.05; ** - p < 0.01; *** - p < 0.001.

The patients of the groups 1 and 2 had non-constant and non-significant pains, when cannulated screws and plaster immobilization were used (37.1 ± 2.2 points and 35.6 ± 2.1 points correspondingly).

There were more significant disorders in foot function in the patients of the group 3 (skeletal traction). Satisfactory provision of foot function preservation was noted in the patients of the groups 4 and 5 (ANF, plates and screws). The best indices of foot function were noted in the patients of the groups 1 and 2 and were associated with cannulated screws and plaster immobilization.

Unsatisfactory adaptation of the foot to surface was observed in the patients of the groups 3 and 4 (skeletal traction, ANF), satisfactory one – in the patients of the group 5 (plates and screws). The best adaptation of the foot to surface was achieved with cannulated screws and plaster immobilization (groups 1 and 2).

Therefore, the best outcomes of treatment (93.4 ± 2.6 points) were received in the patients of the group 1 with cannulated screws that is “good” result. The patients of the group 2 had lower results – 87.3 ± 1.7 points. “Satisfactory” results were in the patients of the groups 4 and 5 with ANF, plates and screws – 55.8 ± 2.5 and 56.4 ± 1.7 points correspondingly. “Unsatisfactory” results were achieved in the group 3 with skeletal traction (35.3 ± 3.2 points).

Administration of plaster immobilization allowed achieving quite good results of treatment (on average 87.3 points) that indicated its appropriateness for intraarticular and extraarticular fractures of heel bone without displacement. Considering the surgical techniques, the best outcomes were received with cannulated screws (93.4 ± 2.6 points), and it is more statistically significant compared to other methods of treatment (p < 0.001). Even in case of severe heel bone fractures with PT and impossibility of surgical treatment in acute period, use of cannulated screws in late period after trauma allows achieving good results.

 

CONCLUSION:

1. Isolated fractures of heel bone are 2.2 times lower than as a part of polytrauma.

2. Among heel bone fractures in polytrauma the greatest proportion includes severe opened, intraarticular fractures with displaced fragments.

3. For treatment of heel bone fractures without displacement of bone fragments it is appropriate to use plaster immobilization.

4. In case of intraarticular fractures of heel bone with displacement of bone fragments the most effective way is use of percutaneous osteosynthesis with cannulated screws.