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Claribel Plain Pazos1*, Leonardo Dominguez Plain2, Sergio Morales Pineiro3, Carmen Rosa Carmona Penton1,
Anisbel Perez de Alejo Plain4, Juan Carlos Cedre Gonzalez5 and Daily Calero Ruiz6
1Specialist of I and II Degree in Comprehensive General Medicine, Assistant Professor, Faculty of Medical Sciences of Sagua la Grande, Cuba
23rd year Orthopedic Resident, Provincial General University Hospital “Mártires del 9 de Abril”, Cuba
3Specialist of I and II Degree in Orthopedic, Assistant Professor, Provincial General University Hospital “Mártires del 9 de Abril”, Sagua la Grande, Cuba
43rd Year Student of Medicine, Faculty of Medical Sciences of Sagua la Grande, Cuba
5Specialist of I Degree in Orthopedic, Assistant Professor, Provincial General University Hospital “Martires del 9 de Abril”, Sagua la Grande, Cuba
6Degree in Nursing, Instructor teacher, Provincial General University Hospital “Martires del 9 de Abril”, Sagua la Grande, Cuba
Submission:February 16, 2021; Published: March 26, 2021
*Corresponding author: Claribel Plain Pazos, Specialist of I and II Degree in Comprehensive General Medicine, Faculty of Medical Sciences of Sagua
la Grande, Cuba
How to cite this article: Claribel P P, Leonardo D P, Sergio M P, Carmen R C P, Anisbel P d A P, et al. Calcaneal Fractures: Controversy in Treatment.
Ortho & Rheum Open Access J. 2021; 17(5): 555972. DOI: 10.19080/OROAJ.2021.17.555972
Calcaneal fractures are the most common of the tarsal bones.
It is common for them to occur after traffic accidents or due to
rainfall in the work environment, [1,2] mainly in young people
, and they are considered severe injuries that generate a high
degree of disability [1,2]. They account for approximately 60%
of fractures affecting the tarsus and 1.2% of all fractures [2,3].
In 70% of cases there is joint involvement , around 75% are
intra-articular, compromising the subtalar joint , and even in
the 26% of the subjects can find other associated lesions .
Intra-articular calcaneal fractures are characterized by the
existing controversy regarding their treatment, since for the
same fracture we can find very different solutions and opinions
[4,5], although the literature agrees that the available evidence
is insufficient to affirm that surgical treatment is superior to
conservative . Currently the treatment of choice is open
reduction and internal fixation (ORIF) [2,5]. However, minimally
invasive techniques, through the sinus tarsi approach (AST), have
become in recent years an increasingly popular option among foot
and ankle surgeons [2,4].
A widely used classification for its prognostic value in the
treatment of intra-articular calcaneal fractures is the Sanders
classification, which is based on coronal CT assessment of the
posterior subtalar facet, according to the number of fragments of
this facet displaced more than two millimeters [6,7]. Although its
high intra- and inter-observer variability has been criticized, it is
still the reference classification. In addition, its value in predicting
subtalar arthrodesis has been demonstrated (there is 5.5 times
more probability of ending in subtalar arthrodesis in a Sanders IV
than a Sanders II). Differentiates four main types: [8,9]
i. Type I: without displacement or displaced <2 mm,
subsidiary of orthopedic treatment.
ii. Type II: in two fragments or split fractures (subdivided
into A, B and C, depending on the fracture that sits laterally,
centrally medially in the thalamus). Greater severity, the lesser is
the anteromedial fragment.
iii. Type III: in three fragments or split depression
(subdivided into III AB, AC and BC).
iv. Type IV: in four fragments or comminuted fractures.
The objectives in the treatment of intra-articular calcaneal
fractures are to correct the height, width and length of the heel,
[2,5] to reconstruct the depression of the posterior subtalar joint, to
release the submaleolar impingement and the compression on the
peroneal tendons produced by the fragment of the lateral wall, as
well as correcting the varus or valgus deformity . Open surgical
treatment is associated with a high rate of complications (20-
30%), such as wound dehiscence (10%), deep infection (5-22%)
and even amputation (2-2.5%), lengthening the convalescence
and darkening the prognosis. To avoid postoperative morbidity
associated with open surgical treatment, multiple authors have
sought alternatives through percutaneous techniques and limited
approaches to reduce the risk of soft tissue damage . Among the factors to consider for the surgical approach is the fracture
pattern, which, framing itself in the Sanders classification, is
a. Sanders’s type I, closed treatment.
b. Sanders’s type II and III, open reduction.
c. Sander’s type IV, closed reduction and in hands
experienced primary arthrodesis.
The approach through minimal incisions to resolve a calcaneal
fracture requires knowledge of the anatomy of the calcaneus, as
well as anatomical landmarks and measures to avoid complications
with internal fixation . It is the most experienced specialists
who must undertake this treatment. In several studies carried
out it has been possible to verify that the Sanders classification
is an important prognostic factor of calcaneal fractures, together
with the injury mechanism and the age of the patients [2,4,5].
It depends largely on these three factors future evolution of the
patient. Given the severity and complexity of this type of injury,
associated with the rate of surgical complications and physical
sequelae that they entail, calcaneal fractures continue to be a real
challenge for the orthopedic surgeon . Without a doubt, in the
event of a calcaneal fracture, a good assessment of the case as a
whole and a correct selection of the treatment technique to be
used is a guarantee for the prognosis to be expected. The goal is
not only to treat the fracture, but to ensure that the patient has
the best possible future quality of life. The training and skill of the
surgeon is a decisive factor in the quality of the results.