Historical Aspects of Calcaneus InjuryCHAPTER 1

Throughout history man has broken his limbs; the humble “bone setter” was accorded recognition by man over the ages, and this is documented in most of our civilization's history. These were usually self trained persons, or people who had apprenticed to other bone setters. The modern profession of treating bone fractures was given the name “Orthopedics” by Andre; Jones expanded the specialty to include fractures and the treatment of adults.² Countless other medical men and surgeons developed manipulative and surgical procedures to increase the knowledge base in this field from the last 150 years, to achieve what we now know as modern day fracture care. However, even today one of the most controversial bones to break is the calcaneus (Dhillon et al 2011);³ in the whole of the last century, there have been diametrically opposed opinions with regard to the optimal management of this particular group of fractures.

The calcaneus is a unique bone, with a unique mechanism of fracture; even though isolated calcaneal fractures are not life-threatening, the associated disability is often significant and cases have been often crippled due to badly deformed heels. Even in the famous Edwin Smith Surgical Papyrus, sketchy references to fractures of the clavicle, the humerus, and the cervical spine are noted, but none to the calcaneus.⁴ From archeological excavations found in the Nubian Desert, several specimens of forearm fractures were found which are now in the museum of the Royal College of Surgeons in London.¹ This fracture was common perhaps due to the fact that the forearm was often used to protect a person from blows. Calcaneal fractures were less commonly seen, as falls from great heights were few, and often people did not survive these falls. Road accidents in the previous eras were usually low velocity injuries, in contrast to the modern era, and so heel fractures and injuries have been less commonly documented over the passage of time.

Hippocrates has spoken of many treatments for fractures;⁵ he described a method for reducing fractures of the spine. “The patient was bound to a ladder, which was then raised perpendicularly with ropes and pulleys and let down suddenly, so that the jolting might reduce the deformity”. He has also described the appearance of a heel of a patient who had fallen from a height; however, he did not probably recognize a “calcaneal fracture”, making this case perhaps the first documented missed calcaneal fractures in history.¹

It is pertinent to note that Theodoricus, in I546, and others following him, denied that the calcaneus was ever fractured: “Calcaneus non fragitur, quiaos durum est et protectum ligamentis.” “Nullopactocalcisaccidit fractura”.⁶ Malgaigne distinguished two separate mechanisms for calcaneus fracture by avulsion due to muscular action and by crushing force (Fig. 1.1).⁷

Understanding the pathomechanics and optimal treatment for calcaneal fractures during the 20th century has been as controversial as was the realization of existence of these fractures in the century before that (1800s). Possibly, the first documented description of the treatment of calcaneal fracture was in 1720 by Petit and DeSault.⁸ They advocated rest and limb elevation which remained the principle treatment till the end of 19th century. Paszkowski was the first to recommend immobilization in a cast as a treatment for calcaneal fractures in 1880.⁸ Although with better understanding of these fractures, more focused treatment methods have evolved, cast immobilization still remained as a viable method of treatment till recently. This was emphasized by proponents of this method principally because of inability to obtain uniformly acceptable results and relatively poor outcomes using other methods.

The advent of roentgenograms, in 1895, kindled the desire of restoring the distorted anatomy of this bone. This resulted in development of methods of closed reduction, and several methods were described in first half of last century. Cotton and Wilson⁹ first described such a method in 1908, and were the first to recognize the importance of reducing the lateral wall of the calcaneus, which we now know is vital for restoring the width of the heel.

In 1931, Bohler described his modification of closed reduction¹⁰ where traction was provided by a pin in the calcaneal tuberosity, along with a pin in the tibia for counter-traction (perhaps the fore runner of the modern distractor?) (Fig. 1.6); lateral compression was provided by a specially designed clamp applied over the skin for this purpose (Fig. 1.7). He also emphasized the importance of restoring the tuberosity joint angle (the Bohler angle).

Alongside the popular attempts at refining methods of closed reduction, operative techniques were also being used increasingly by some physicians in the early 20th century. Operative procedures used during this period were either open reduction or primary arthrodesis. First such recorded instance dates back to 1902 where Morestin recommended the direct lateral approach to elevate the depressed fragment of the posterior fragment.⁸ This was followed by recommendation of primary arthrodesis by Van Stockum in 1912.⁸ Both these operative methods were evolving simultaneously, and various authors reported early good results with either method, without any definitive randomized comparative study. Although primary arthrodesis gained some support (mostly during the 1950s and 60s) with several reports of favorable outcomes, continued development of better surgical techniques and superior devices for internal fixation, lead to open reduction with internal fixation becoming the preferred treatment for 4significantly displaced fractures of the calcaneus. Presently, subtalar arthrodesis is primarily reserved as a salvage procedure for disabling pain after initial treatment with other methods, with the recommended time for this procedure being at least 2 years after failed primary treatment.

Palmer in 1948,¹⁴ disappointed with results of primary subtalar arthrodesis as a treatment option, reported on results of his open reduction technique which formed the principle basis of modern open reduction techniques. During early days, there were several proponents of medial, lateral or combined approach to the fractures and all three approaches were used without clear evidence of superiority one over another. McReynolds (1958)⁸ was one such staunch supporter of the medial approach, and emphasized the importance of medial displacement and medial rotation of the superomedial fragment. This concept was challenged by Stephenson in 1983,¹⁵ who used CT scans to ascertain that the superomedial fragment essentially remained in its position, while the rest of the posterior facet was displaced inferiorly and rotated. The use of computed tomography has perhaps had the most dramatic effect on the understanding and management of the calcaneus fractures and has become an indispensable tool in the diagnosis and treatment planning of these fractures. Based on coronal CT images, Saunders¹⁶ developed a classification system which forms the pillar for fracture understanding and treatment planning in the modern era.

With growing popularity of open reduction, the need for better fixation devices was an obvious consequence. In the initial phases, multiple wires or stout steinman pins were employed to hold the displaced tuberosity; the three dimensional reconstruction was a concept that was understood only in the last-half of the 20th century. Subsequent developments lead to the use of screws to hold the displaced facet after elevation, semitubular or reconstruction plates to span the fracture, and ultimately the development of specialized plates manufactured solely for use in calcaneal fracture. The 1990s saw the development of the low profile, multi-limbed titanium plates, which could hold various parts of the fracture, allowed fixed angle locked or compression screws and have a low enough profile to avoid impingement on the lateral soft tissues.

Rehabilitation after the calcaneus fracture has had fewer controversies than other aspects of treatment of these fractures.^17–19 A new approach of early mobilization began with the report by Day in 1950¹⁷and many subsequent authors including Essex-Lopresti strongly supported the concept. Lindsay and Dewar in 1958¹⁸ and later Lance et al in 1963¹⁹ reported favorable results after early mobilization of calcaneal fractures, even when treated conservatively. This approach was widely used during 1960s when many believed that attempts at reduction (closed or open) did not offer any clear advantage, while inviting potential of complications which would seem unnecessary in the scenario. Although this approach of early mobilization without any attempt at reduction has since been challenged, early mobilization after calcaneal fractures has remained the cornerstone of current treatment strategies.

One fact in our evolution of knowledge about calcaneal fractures is pertinent. Perhaps more has been written in the past quarter century about this fracture which was unknown in middle ages, than all the combined published literature prior to that.^3,20 Our knowledge and understanding of these fractures has changed immensely in past few decades, but such is the nature and complexity of this fracture that all is not yet known about it. Our continued endeavor will perhaps keep shedding light on all facets of this fracture which shall aid our treatment strategies in future. Future generations may still say that the surgeons of 2011 had limited knowledge about this fracture. But such is the nature of history.