SLR - November 2013 - Jennifer A. Lipman
Reference: Dudda, M., Kruppa, C., Geßmann, J., Seybold, D., Schildhauer, T. (2013) Pediatric and adolescent intra-articular fractures of the calcaneus. Orthop Rev (Pavia), 5 (2), 82-5.
Scientific Literature Review
Reviewed by: Jennifer A. Lipman, DPM
Residency Program: Cambridge Health Alliance
Podiatric Relevance: Calcaneal fractures, particularly intra-articular calcaneal fractures, are relatively rare in the skeletally immature and there is a greater chance of delayed diagnosis than in the adult. Determining the conservative versus surgical outcomes for the pediatric population is very important in choosing the treatment path when the podiatric physician is presented with such a patient. In the past, conservative management was the most common method used. This study aimed to show the outcomes of surgical intervention.
Methods: There were 14 intra-articular calcaneal fractures in 11 children (two girls, nine boys) that were surgically treated. Using the Essex-Lopresti classification system, there were 11 joint depression fractures and three tongue type fractures. One fracture was open and the other 13 fractures were closed. The mean age was 11.5 years. The injuries were all due to high-energy trauma. Average postoperative follow-up was 44 months.
Results: In 11 cases, open reduction and internal fixation with plate, K-wire and screws were performed. A minimally invasive approach with K-wire fixation or screws was used in four cases. Surgery was performed after an average of six days after initial injury. In one case, a fasciotomy was done first because of compartment syndrome and an external fixator was applied. The average preoperative Böhler’s angle was 16 degrees and the average postoperative Böhler’s angle was 30 degrees. All closed fracture cases had good functional and clinical outcomes.
Conclusions: Open reduction and internal fixation of intra-articular pediatric calcaneal fractures is becoming more common in literature and is a good option for anatomic reduction and prevention of degenerative joint disease as the child matures. The authors of this study recommend conservative management if disruption of the three subtalar facets is less than four millimeters and the posterior gap in tongue type fractures is less than one centimeter. With disruptions greater than those described above, surgical intervention is recommended with the goals being reconstruction of joint alignment, width and length of the calcaneus and restoration of the physiological axis and lever arms.