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Orthopaedics
Management of Acute Hindfoot Fractures in Diabetics
Built from The Surgical Management of the Diabetic Foot and Ankle
What’s inside
11 sections · 116 slides
Overview
- Scope of this topic
- Aims of hindfoot fracture care
- Soft-tissue vulnerability of the hindfoot
- Consequences of malunion and infection
Recognising the pathologic fracture
- Acute trauma versus pathologic fracture
- Clinical clues suggesting a neuropathic fracture
- Effect of neuropathy on diagnosis and outcome
- Charcot neuroarthropathy: definition and causes
- Contributing factors in Charcot neuroarthropathy
- Anatomical distribution of Charcot lesions
- Frequency of isolated calcaneal involvement
- Acute calcaneal fracture patterns in diabetes
- Pathologic calcaneal and talar fracture patterns
- Reading the fracture pattern images
- Skin breakdown risk in beak fractures
Diabetes as a risk factor
- Published wound and infection risk in diabetes
- Complicated versus uncomplicated diabetes
- Significance of uncomplicated diabetes
- Wound edge necrosis after extensile lateral plate fixation
- Interpreting the wound necrosis photograph
- Fracture and fusion healing in diabetes
- Conditions under which results match non-diabetics
Treatment recommendations
- Overall goals of management
- Treatment stratification by diabetes status
- Standard fixation in well-controlled diabetes
- Restrictions in poorly controlled or complicated diabetes
- Failure of standard fixation in neuropathic fractures
- First-line treatment of neuropathic fractures
- Indications for acute hindfoot fusion
- Rationale for acute fusion over bracing
- Management of ulcerations and bony prominences
Non-operative treatment
- Candidates for non-operative management
- Immobilisation regimen for calcaneal fractures
- Prolonged hindfoot swelling treated non-operatively
- Interpreting the swollen hindfoot images
- Presentations of neuropathic talar fractures
- Weight-bearing protocol after non-operative care
- Acute neuropathic calcaneal and talar head fracture
- Lessons from the offloaded neuropathic fracture
- Team approach and long-term foot care
Standard operative treatment
- Management of open fractures
- Urgent reduction of displaced closed fractures
- Criteria for standard open reduction and internal fixation
- Fixation of displaced talar fractures
- Options for displaced intra-articular calcaneal fractures
- Open reduction of a Sanders type III calcaneal fracture
- Soft-tissue technique in the extensile lateral approach
- Minimally invasive screw fixation of a calcaneal fracture
- Advantages of the sinus tarsi approach
- Postoperative regimen after calcaneal fixation
Late arthrodesis
- Indications and prerequisites for arthrodesis
- Less extensile arthrodesis techniques
- Care of external fixation frames
- Choice of implant for hindfoot fusion
- Preferred approach for malunited calcaneal fractures
- Subtalar bone block fusion through a posterolateral approach
- Salvage of malunited talar fractures
- Follow-up after arthrodesis
Neuropathic (Charcot) fractures
- Goals of treatment in hindfoot Charcot neuroarthropathy
- Features distinguishing Charcot fractures from acute trauma
- Acute fracture as a trigger for Charcot neuroarthropathy
- Charcot neuroarthropathy developing after an ankle fracture
- Sequence shown in the post-fracture Charcot case
- Traditional non-operative management of Charcot neuroarthropathy
- Lifelong requirements after Charcot neuroarthropathy
- Limitations of cast treatment in hindfoot Charcot
- Compliance and implant loading in Charcot patients
- Indications for surgery in Charcot neuroarthropathy
- Sanders and Frykberg classification
- Application of the Sanders and Frykberg classification
Type IV and Type V patterns
- Treatment of Sanders/Frykberg Type IV lesions
- External versus internal fixation in Type IV lesions
- Outcomes of retrograde nailing in Charcot neuroarthropathy
- Complication risk and technical refinements of nailing
- Characteristics of Sanders/Frykberg Type V lesions
- Acute calcaneal fracture with heel ulceration
- Acute neuropathic calcaneal fracture in continuity with a heel ulcer
- Imaging, debridement and total contact cast treatment of the same heel
- Findings that guided the heel ulcer fracture case
- Failure of conventional fixation in Charcot calcaneal fractures
- Non-union and skin necrosis after screw fixation of a neuropathic fracture
- Fixation options when surgery is unavoidable
- Avoiding unnecessary trans-articular fixation
- Excision of the posterior tuberosity fragment
Amputations and salvage
- Infection risk driving amputation
- Internal amputation and astragalectomy
- Staged reconstruction after resection of infected bone
- Direct tibiocalcaneal fusion for malleolar ulceration
- Intraoperative alignment control
- Partial and total calcanectomy
- Chronic osteomyelitis after plate fixation ending in calcanectomy
- Sequence of failure in the calcanectomy case
- Classical amputations at the ankle and hindfoot
- Principle of the Pirogoff amputation
- Technical points of the Pirogoff amputation
Summary
- Core message
- Summary of operative decision making
- Summary of neuropathic fracture management
- Practice points
- References
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- References (continued)
- The Surgical Management of the Diabetic Foot and Ankle