Abstract
Intra-articular fractures of calcaneum are known to be difficult to manage and lead to multiple complications including subtalar arthritis and malunion. However, non-union of calcaneum is rarely encountered. Only a total of six studies reporting on 12 patients could be found on reviewing the available literature (English language only). One such case of non-union of calcaneal fracture and its successful management is being reported in this case report. In addition, extremely limited literature available on calcaneal non-union is also briefly reviewed. Role of subtalar arthrodesis with internal fixation of fracture and bone grafting for successful management of this rare complication is highlighted along with the possibility of under-reporting of this relatively unknown complication.
Keywords: Calcaneal fracture non-union, Subtalar arthrodesis, Internal fixation
1. Introduction
Intra-articular fractures of calcaneum are known to be difficult to manage and lead to multiple and frequent complications including subtalar arthritis and malunion.1 However, non-union of calcaneum is rarely encountered and most studies on management of complications of calcaneal fractures do not include non-unions.1,2 Only a total of six studies reporting on 12 patients could be found on reviewing the available literature (English language only).3–8 One such case of non-union of calcaneal fracture and its successful management is being reported in this case report. In addition, extremely limited literature available on calcaneal non-union is also briefly reviewed.
2. Case report
A 29 year old obese female sustained a closed calcaneal fracture following a fall from height. She was managed conservatively with cast immobilization for eight weeks followed by protected weight bearing for another 8 weeks at another hospital. She was referred to our hospital with persistent pain and swelling of her heel. Clinical and radiological assessment, including CT scan of the foot, revealed evidence of calcaneal non-union with subtalar arthritis (Figs. 1 and 2). She was also detected to have Diabetes mellitus during pre-operative assessment. The patient was managed by subtalar arthrodesis and open reduction internal fixation of calcaneal non-union using two 6.5 mm cancellous screws and autogenous bone grafting. In the immediate post-operative phase, patient developed wound dehiscence with superficial surgical site infection which was managed successfully by wound dressings and antibiotics. The patient has been followed up for one year. At last follow up, the subtalar joint was completely arthrodesed and there was complete union at calcaneal non-union site (Fig. 3). She is ambulant without support and is completely pain free.
Fig. 1.
Radiograph (Lateral view of both heels) showing non-union of calcaneal fracture-right at time of presentation (6 months from injury).
Fig. 2.
CT scan (Axial section) of both heels confirmatory of right calcaneal non-union at time of presentation (6 months from injury).
Fig. 3.
Post-operative follow-up radiograph (Lateral view of right heel) at one year after surgery which is confirmatory of union of calcaneum and subtalar fusion.
3. Discussion and review of literature
The available literature (in English language only) consists of only case reports and is summarized in Table 1.
Table 1.
Summary of available literature on calcaneal non-union.
| Case report (As per year of publication) | Age | Gender | Initial treatment | Associated risk factors | Definitive treatment | Follow-up (Months) |
|---|---|---|---|---|---|---|
| Thomas & Wilson (1993)3 | 36 | Female | Conservative | Osteotomy, plate, bone graft | 3 | |
| Thermann et al (1999)4 | 49 (mean) | Male-2 Female-2 |
Conservative | Subtalar arthrodesis | 62 | |
| Gehr et al (2000)5 | 42 | Male | ORIF | Osteotomy, screws, bone graft | 2 | |
| Karakurt et al (2004)6 | 61 | Male | Conservative | Smoking | Bone graft | 8 |
| Zwipp & Rammeltt (2006)7 | 61, 45 | Female (2 patients) | Conservative-1 Percutaneous fixation-1 |
Subtalar arthrodesis | – | |
| Tim S & Peter P (2008)8 | 47 (Mean) | Female-1 Male-2 |
Percutaneous fixation-1 Conservative-2 |
Subtalar arthrodesis | 14, 3, 6 | |
| Present case | 29 | Female | Conservative | Diabetes mellitus | Subtalar arthrodesis, ORIF with screws, bone graft | 12 |
The first reported case was published as recent as 1993 and only a total of 12 patients have been reported in six studies published till date.3–8 There is no difference in incidence between male or female gender even in the small number of cases reported. No similarities exist between various available case reports/series. However, there is a trend towards non-union mostly after conservative treatment. Thermann et al described an unusually high incidence of 10% non-union (n = 4/40) in their series after conservative treatment.4
Smoking has been described as a probable risk factor.9,10 Diabetes mellitus may possibly be a risk factor in this case report. Internal fixation with bone grafting has been the mainstay of treatment combined with subtalar arthrodesis in most of the cases in all published reports, as was done in our case.
Non-union of calcaneum has been rarely described in literature. Subtalar arthrodesis with ORIF and bone grafting offers a reasonable and successful treatment in this rare complication of calcaneal fractures. Though non-union of calcaneal fractures has been rarely reported, one needs to be alert to this complication for its successful management. Also, its incidence may be underestimated because of underreporting.
Conflicts of interest
The author has none to declare.
References
- 1.Howard J.L., Buckley R., McCormack R. Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. J Orthop Trauma. 2003;17:241–249. doi: 10.1097/00005131-200304000-00001. [DOI] [PubMed] [Google Scholar]
- 2.Lim E.V.A., Leung J.P.E. Complications of intraarticular calcaneal fractures. Clin Orthop. 2001;391:7–16. doi: 10.1097/00003086-200110000-00003. [DOI] [PubMed] [Google Scholar]
- 3.Thomas P., Wilson L.F. Non-union of an os calcis fracture. Injury. 1993;24:630–632. doi: 10.1016/0020-1383(93)90132-p. [DOI] [PubMed] [Google Scholar]
- 4.Thermann H., Hufner T., Schratt H.E., Held C., Tscherne H. Subtalar fusion after conservative or surgical treatment of calcaneus fracture. A comparison of long-term results. Unfallchirurg. 1999;102:13–22. doi: 10.1007/s001130050367. [DOI] [PubMed] [Google Scholar]
- 5.Gehr J., Schmidt A., Friedl W. Calcaneus pseudarthrosis: a clinical rarity. Unfallchirurg. 2000;103:499–503. doi: 10.1007/s001130050572. [DOI] [PubMed] [Google Scholar]
- 6.Karakurt L., Yilmaz E., Incesu M., Serin E. Pseudarthrosis of a calcaneus fracture; a case report. Acta Orthop Traumatol Turc. 2004;38:288–290. [PubMed] [Google Scholar]
- 7.Zwipp H., Rammelt S. Subtalar arthrodesis with calcaneus osteotomy. Orthopade. 2006;35:387–404. doi: 10.1007/s00132-005-0923-5. [DOI] [PubMed] [Google Scholar]
- 8.Schepers Tim, Patka Peter. Calcaneal nonunion: three cases and a review of the literature. Arch Orthop Trauma Surg. 2008;128:735–738. doi: 10.1007/s00402-007-0516-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Assous M., Bhamra M.S. Should Os calcis fractures in smokers be fixed? A review of 40 patients. Injury. 2001;32:631–632. doi: 10.1016/s0020-1383(00)00130-3. [DOI] [PubMed] [Google Scholar]
- 10.Easley M.E., Trnka H.J., Schon L.C., Myerson M.S. Isolated subtalar arthrodesis. J Bone Joint Surg Am. 2000;82:613–624. doi: 10.2106/00004623-200005000-00002. [DOI] [PubMed] [Google Scholar]