R
e v ie w
A
r t ic l e
MILITARY MEDICINE, 179, 11:1228, 2014
H ig h S e a s to H igh E xplosives: T h e E vo lu tio n o f C a lc a n e u s F ra c tu re M a n a g e m e n t in th e M ilita ry LCDR George C. Balazs, MC USN; CPT Elizabeth M. Polfer, MC USA; CPT Alaina M. Brelin, MC USA; Lt Col Wade T. Gordon, USAF MC
ABSTRACT Calcaneus fractures typically occur as a consequence of axial load. In the civilian population, this is most often because of motor vehicle accidents or falls from height. Early management of these injuries in the military population largely mirrored that of civilian surgeons. However, calcaneus fractures secondary to underfoot blasts became a significant source of morbidity and mortality in World War II. First described in the aftermath of large-scale naval battles between metal-deck ships, this “deck-slap” phenomenon is associated with high rates of concomitant injuries, infection, and amputation. We review the historical and contemporary management of calcaneus fractures by military orthopedic surgeons, as well as detailing the unique challenges faced in managing the soft-tissue component and associated injuries commonly observed in this population. Combat-related calcaneus fractures are associated with very high rates of concom itant injuries and extensive soft-tissue wounds. Despite significant research and technological advances, functional outcomes following these devastating injuries have remained unsatisfying.
INTRODUCTION The calcaneus is composed of a relatively thin shell of cortical bone encasing an irregular core of cancellous bone. The cortex is thickest adjacent to the posterior tuberosity, superiorly along the angle of Gissane, and the lateral surface below the poste rior facet. The cancellous core is arranged in trabecular arrays running anteroposterior in the long axis and parallel to the posterior border within the posterior tuberosity, with a paucity of mineralization seen in the “neutral triangle” anteroinferiorly. This pattern roughly corresponds to the stresses of weight bearing, where the hindfoot may experience forces 300 to 400% of body weight. As a consequence of this adap tive mineralization, calcaneus fractures during normal activity are uncommon, and typically require high-energy axial load to occur in structurally competent bone.12 Most calcaneus fractures in the civilian population occur during falls from height or motor vehicle accidents.3 Mili tary surgeons, however, have long recognized that rapid deceleration of the human body is not the only mechanism that produces axial force on weight-bearing bones. Rapid acceleration beneath the feet produces similar forces, and therefore similar patterns of injury. This “underfoot” mecha nism (high velocity, low amplitude force directed superiorly along the longitudinal axis of the axial skeleton) occurs only
Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. doi: 10.7205/MILMED-D-14-00156
1228
in very specific environments, most commonly combat. Termed “deck-slap injuries,” these injuries have played a prominent role in military lower-extremity trauma since World War I. The purpose of this article is to review the evolution of the mechanism and management of combat-related calcaneus fractures. We will review the injury patterns specific to armed combat, as well as describe historical and current treatment techniques and outcomes. HISTORICAL PERSPECTIVE Fractures of the calcaneus are a signature injury of the indus trial era. Until mankind began routinely working at (and therefore falling from) great heights, the injury was uncom mon.4 The first modem discussions of the fracture came from French and German surgeons in the early 1700s. They advo cated a strict policy of benign neglect, observation, and rest until fracture fragments had consolidated.5'6 A century later, emphasis shifted to immobilization, utilizing various dress ings of lint, egg albumin, and cottage cheese until fracture consolidation occurred.7 Around this same time, the first ten tative forays into surgical intervention occurred, with Pott (and later Norris) advocating excision of bone ends in cases of open fracture to prevent tetanus. Results were generally poor and deaths frequent.5 The injury became more prominent in the medical literature with industrialization. By the late 19th century, a plethora of case series and proposed treatments appeared in the medical
MILITARY MEDICINE, Vol. 179, November 2014
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
literature. The themes of minimal intervention and observation continued to predominate. Following the passage of workmen’s compensation laws in Europe and the United States, surgeons began to take more of an interest in this often disabling injury ,s The first radiographic study of calcaneus fractures occurred in 1895, and many surgeons began to attempt closed reduc tion of the fracture in order to promote consolidation. The first significant innovation in treatment came from Cotton and Wilson, who argued that the severity of calcaneus frac tures was underappreciated by most surgeons, and that the majority of such injuries were actually highly comminuted crush injuries.9 “The general assumption in these cases was that there was a breaking across the os calcis. It was known that complicated crushing of the os calcis might, in fact, occur, and this was shown in museum specimens, but that such was the condition in the average case never to have been assumed... it is our belief that the lesions in all these cases are nearly alike, varying mainly in the extent and direction of the displacement of the con fused fragments.” In treating all calcaneus fractures as crush injuries, Cotton redirected surgical thought on the subject. His method, fre quently emulated and modified in the three decades following his original publication, involved disimpacting the fracture fragments with mallet strikes, followed by soft-tissue traction with a wire inserted behind the Achilles tendon. Manual manip ulation was then employed to recreate a more natural contour and approximate the preinjury width of the heel. Numerous authors subsequently proposed reduction methods.10-12 By 1938, Goff was able to cite 84 different published techniques for managing calcaneus fractures.11 Most methods reported good-to-excellent results of treatment in majority of patients. No clear consensus on appropriate treatment emerged, with various authors arguing for some combination of open reduc
tion, traction, closed manipulation, early weight bearing, prolonged immobilization, early subtalar arthrodesis, and benign neglect. WORLD WAR II
The burgeoning interest in calcaneus fractures from the late 19th century into the first half of the 20th century focused almost exclusively on civilian construction workers, and no mention is made of battlefield casualties in any of the case studies available from this period. The American Civil War, the Napoleonic Wars, and World War I advanced medical understanding of traumatic wounds by leaps and bounds, but their influence on calcaneus fracture management is essen tially nonexistent. This is all the more fascinating in that World War I aviators sparked modem interest in talar frac tures (the so-called “aviator’s astralgus”) 1' with scant men tion of calcaneus fractures. Lorenz Bohler, presenting at the 1930 annual meeting of the American Academy of Orthopedic Surgeons, describes establishing a 200-bed field hospital 20 miles behind the front in Italy devoted exclusively to the treatment of fractures. However, he says that it was not until after the war in Vienna, when he met with workmen’s compensation insurance adjus tors, that he turned his attention to the problem of calcaneus fractures.14 His method of treatment, essentially a modifica tion of the original description by Cotton, began with mallet blows to the medial and lateral heel to break up fracture fragments. Traction was then applied to the tuberosity with an ice clamp, followed by heel molding and casting as seen in Figure 1. The goal of this treatment was not, as with earlier methods, to recreate normal width to the heel. Rather, it was designed to restore a normal tuber angle (Bohler’s angle), and therefore a normal relationship between the talus and poste rior facet of the calcaneus. This was the first recognition of the vital importance of reconstructing the weight-bearing posterior facet, presaging present-day classification systems
FIGURE 1. Bohler’s method of manual molding (A) followed by traction and immobilization (B) of calcaneus fractures. (Images used with permission from Bohler L, J Bone Joint Surg Am, 1931 JanOl; 13(1): 75-89, © Journal of Bone and Joint Surgery.)
MILITARY MEDICINE, Vol. 179, November 2014
1229
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
and operative techniques. Bohler’s methodology would prove highly influential over the coming decades.15'16 Military surgeons first began writing about calcaneus fractures during World War II. Several features of the con flict brought calcaneus injuries to the forefront. First, the use of high-explosive mines increased dramatically in both ground combat and at sea. Second, for the first time in history, multiple combatant nations possessed large fleets of steel ships and submarines. Third, technological advances facili tated the rapid treatment and transport of injured soldiers. In earlier conflicts, it is likely these injured combatants would either have perished from their wounds or had their injured limb amputated. A British surgeon, Brigadier General Rowley Bristow, was the first to note the increase in calcaneus fractures seen during World War II.17 His description is a scant 2 paragraphs in a much larger work comparing patterns of injury and medical treatment between World War I and World War II. Nonetheless, it is both succinct and enduring, and could easily apply to any conflict as: “Fractures of the os calcis are more common than in peacetime. They are produced by land mines, by a bomb which goes off between decks, and have occurred also in men who slide down the side of a sinking ship and hit their heels against the projecting bilge on the hull. Many of these fractures are hopelessly comminuted, but then generally become painlessly ankylosed, but if not, the joint is arthrodesed.” Realizing that prolonged immobilization produces a “stiff useless foot,” he advocated reduction with a traction pin, 4 weeks of immobilization, range of motion activities, and nonweight bearing until 4 months after injury. Later works from this period focused on calcaneus frac tures occurring at sea. Termed “solid blast injuries,” or more commonly “deck-slap injuries,” these fractures occurred as a result of below-deck explosions, causing force transmission across rigid steel decks into the lower extremities of sailors above. Bailey says that these injuries were first noted in 1939 when smaller ships, such as minesweepers or trawlers, struck mines.18 Injured personnel with any ankle or knee dislocations were reduced under traction and placed in reinforced long leg casts for the duration of their healing. Harris added under vehicle mines as another cause of wartime calcaneus fractures, but stated that long transit times to hospitals rarely allowed for any specific treatment to be performed. Despite this, out comes were not necessarily poor, which probably contributed to the persistence of “benign-neglect” as the treatment modal ity of choice. “Most war fractures of the os calcis have ended with fusion of the fragments into a greatly distorted mass. It must be stated, however, that the degree of permanent disablement, though severe, often is not as great as might be expected from the distortion of the bone.”8
1230
The culmination of the World War II experience was a large case series published by Barr, Draeger, and Sager.19 They personally interviewed 50 injured service members in four different Naval Hospitals who had sustained calcaneus fractures at sea. All occurred in young, otherwise healthy men and all resulted from high-explosive ordinance (mines, torpe does, bombs). Most men had concurrent injuries such as fractures of the ankle and tibia, vertebral fractures, and head injuries. The most revealing detail in their study was that at least 20% of injured personnel were not actually thrown into the air, but instead “crumpled” when hit by the blast from below. Several others were thrown into the air and “hung up” on various structures in the ship. This is strong evidence that the fractures seen in these individuals were sustained at the time of the initial blast, and were not secondary to a fall from height. The ideal treatment regimen, as described by Barr, et al, recognized both the need for early intervention, as well as the reality of limited resources and skill sets in a theatre of operations. Soft-tissue injuries were debrided— unless older than 12 hours—and delayed primary closure undertaken within 1 week. When feasible, heavy traction under anesthesia was performed, followed by manual molding of fracture frag ments and cast placement. They stated that open reduction was rarely, if ever, indicated. No summarized outcome data are published with their case series, but the 20% amputation rate they cite suggests that treatment was frequently unsatisfactory. World War II was the first to look at calcaneus fractures sustained in a battlefield. Although there is a paucity of liter ature from this period, nonoperative measures were the treat ment of choice from this era, employing varying techniques of traction and immobilization. In the coming decades, these seemingly simple principles of management would be chal lenged, as the complexity of calcaneus fractures became better understood. POST-WORLD WAR II AND THE VIETNAM ERA Following World War II, both civilian and military manage ment of calcaneus fractures remained in a state of flux with out any clear consensus on preferred management. Various authors recommended no treatment and usually early mobili zation,20 22 whereas others performed variations of Cotton’s original method,23-2:1 primary subtalar arthrodesis,26’27 or open reduction and fixation.28-30 The lack of agreement in fracture management seems to have arisen from the need for a unifying classification system. The earliest classification scheme still commonly used today (Essex-Lopresti) recog nized the significant difference between intra-articular and extra-articular fracture patterns, but was (and is) of little use beyond its ability to simply communicate fracture mecha nism. Later classification schemes attempted to delineate the prognostic significance between various types of intra-articular fractures, but these did not come into common usage until the late 1980s and early 1990s. It is no surprise then, that the literature from this period is largely descriptive.
MILITARY MEDICINE, Vol. 179, November 2014
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
Brav conducted an Army-wide survey of patients who had sustained calcaneus fractures, correlating patient-reported satisfaction with available medical records.11 He found similar results between operative versus nonoperative treatment, with the exception of mildly comminuted fractures with sig nificant articular surface depression. These seemed to fare better when treated with open reduction. He also found no relationship between the loss of a normal Bohler angle and ultimate outcome, suggesting that articular surface involve ment is not the only factor predicting long-term results. Brav summarized his findings by recommending manual molding of the heel in comminuted fractures, followed by early range of motion and weight bearing. He recommended open reduc tion and bone grafting only in rare cases with significant articular surface depression but minimal comminution. Ten years after Brav, calcaneus fractures remained on the radar of military surgeons, as evidenced by Reich’s editorial in Military Medicine.16 The unreferenced article is fascinating in that it largely relied on the work of Bohler, with no mention of intervening classification systems or treatment regimens. Like Brav, Reich argued for manual manipulation of fracture fragments in nearly all cases except isolated, minimally com minuted fractures of the posterior facet, for which fixation was recommended. Unlike Brav, however, Reich recom mended periods of prolonged immobilization and nonweight bearing up to 14 weeks. No rationale for this postoperative course was offered. This may have signaled a renewed under standing that surgical management of complex calcaneus frac tures carries significant risks of perioperative complications, and offers only questionable long-term functional benefit. The post-World War II period was marked by the first serious forays into operative treatment of calcaneus fractures. Recognition of the poor functional outcomes after surgical fixation and high postoperative complication rates tempered enthusiasm for the adoption of surgical management of battle field calcaneus fractures. In the years to come military litera ture would take on a different tone, as military surgeons considered the liability of newer limb salvage techniques. THE MODERN ERA Modem management of calcaneal injuries in military hos pitals has undergone substantial changes during our recent conflicts in the Middle East. As alluded to in the above discussion, calcaneus fractures in military troops were not particularly different from those seen in civilian populations, at least those that were amenable to surgical capabilities at the time. However, the wars in Iraq and Afghanistan (and to a lesser extent, conflicts in the Balkans and near east nations) have produced greater numbers of calcaneus fractures that are substantially more comminuted with significant soft-tissue injury in patients with multiple extremity injuries (Fig. 2). The use of concealed explosive devices against both vehi cles and dismounted troops has expanded substantially in modem conflicts. These munitions produce injury both from a primary blast wave of high-velocity pressurized air as
MILITARY MEDICINE, Vol. 179, November 2014
FIGURE 2. Afghan teenager who inadvertently sustained a complex open hindfoot injury while placing an improvised explosive device.
well as a secondary wave of environmental debris that act as high-speed projectiles.'12 ’1 Penetrating wounds produced by explosives are highly contaminated, as dirt and debris are pulled into the body. Concealed explosive devices (including landmines, improvised explosive devices, and booby traps) have been responsible for up to 51 % of injuries seen in field hospitals, with a disproportionate number of lower-extremity injuries.34 In Owens analysis of the casualty data from the first half of the Iraqi and Afghan wars, 26% of all casualties sustained lower-extremity wounds, 12% had fractures of the foot, and of those 76% were open fractures.13 Ramasamy described 104 battle casualties treated at a British field hospital during Operation TELIC in 2006, and found an even higher rate of lower-extremity injuries at 38%, with open wounds and fractures present in 73.8% of survivors.36 In other con flicts, numbers are similar or even higher. Bilukha’s study of Nepalese landmine casualties between 2006 and 2010 found 43% of surviving victims with lower-extremity wounds.37 A UN field hospital during the conflict in the former Yugoslavia treated 41 patients with musculoskeletal blast injuries, with an overall lower-extremity amputation rate of 17%.38 Ramasamy has also pointed out how the expanded use of vehicle armoring has resulted in a resurgence of “deck-slap” injuries not described in military conflicts since World War II.39 McKay’s cadaveric modeling of these injuries shows that the calcaneus tends to fracture first with an underfoot compressive load.40 Despite being nonpenetrating injuries, Ramasamy’s series of 40 calcaneal fractures had 13 open injuries, and 11 of those ultimately became infected. As Bluman points out, the characteristics described above essentially invert the characteristics observed in civilian pop ulations.41 Calcaneus fractures occurring in modern combat are more likely to be open, comminuted fractures with sub stantial soft-tissue loss and bony defects. Whereas the debate over open reduction internal fixation (ORIF) versus primary fusion versus nonoperative management continues without resolution among civilian surgeons, military surgeons are
1231
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
today much more concerned with meticulous debridement and management of soft tissues. Bluman, Tintle, and others describe the need for meticulous soft-tissue debridement and coverage.41-44 Bony fragments are initially stabilized only to the degree necessary to facilitate later reconstruction or fusion. Free flaps are employed liberally, and delayed bony reconstruction is undertaken only when surgeons feel con vinced that infection is cleared and soft-tissue coverage is adequate. External fixation methods, including Ilizarov tech niques of distraction-osteogenesis, are used both for initial stabilization and frequently definitive management. The com plex nature of the bony injury usually dictates the treatment method employed, be it primary subtalar fusion, percuta neous pinning, external fixation techniques, internal fixa tion, or hybrid techniques (Figs. 3 and 4). Even within the civilian world, where these injuries are far more likely to be closed without associated limb-threatening injuries, results of various treatments have essentially been equal and offer minimal assistance in decision making (Table I). Despite what feels like significant technological advance ments in the management of these injuries, results published to date are generally disappointing. Ramasamy’s series of 40 deck-slap injuries had a 45% amputation rate, with 10%
undergoing delayed amputation because of chronic pain long after the resolution of their acute injuries.39 Another series of 63 British soldiers with lower-extremity blast injuries showed a 29% amputation rate with hindfoot injury strongly predictive of eventual amputation.45 Within this series, 74% of patients experienced persistent symptoms at long-term follow-up, and only 14% were able to return to duty. In a large retrospective cohort of American servicemembers sustaining lowerextremity injuries, the METALS cohort found better quality of life scores, lower rates of post-traumatic stress disorder (PTSD), and higher likelihood of engaging in sporting activities among amputees versus those who underwent limb salvage.49 In the largest published series of combat-related calcaneus fractures, Dickens et al found lower visual analog pain scale (VAS) scores and higher Tenger activity scores among amputees versus limb salvage patients.47 This may have been related to the very high rates of infection (46%), and ipsilateral talus (47%) and tibia (43%) fractures. Simi lar to the British experience, the patients in the Dickens cohort had a 15% delayed amputation rate because of late infection and chronic pain. Bevevino et al gathered data on all combat-related open calcaneus fractures sustained by American servicemembers from 2003 to 2012, and iden-
FIGURE 3. (A) Lateral radiograph of the left foot demonstrating an open displaced comminuted calcaneus fracture after a blast injury in Afghanistan. The patient initially underwent irrigation and debridement with external fixator and smooth wire placement to reduce the joint (B) The clinical photograph demonstrates a severe soft-tissue deficit (C) Provisional pinning before ORIF to maintain calcaneal height. The patient ultimately underwent transtibial amputation because of osteomyelitis and failure to achieve soft-tissue coverage.
1232
MILITARY MEDICINE, Vol. 179, November 2014
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
FIGURE 4. (A) Lateral radiograph of the foot following dismounted blast injury in Afghanistan. (B) Axial CT scan of the same foot demonstrates extensive intra-articular comminution and displacement. (C) The patient ultimately underwent subtalar fusion.
tified increasing American Society of Anesthesiologists (ASA) classification, absent plantar sensation, Gustillo-Anderson grade, Sander’s classification, vascular injury, male gender, and dismounted blast mechanism as significant predictors of need for eventual amputation.48 Some smaller studies have been more optimistic. Demiralp reported on 42 landmine victims with complex hindfoot inju ries who underwent either limb salvage or amputation, and found higher functional scores among their limb salvage patients.49 However, these patients tended to have less severe initial injuries. Gur looked at 18 severely comminuted calca neus fractures with bony defects treated with distraction oste ogenesis following soft-tissue coverage, and rated 15 patients with good-to-excellent outcomes.50 The overall impression one gains from the modem litera ture is that combat-related calcaneus fractures have become substantially more complex, requiring close attention to soft-tissue coverage and prevention/treatment of infection. The nature of the injury largely dictates the treatment methods employed. In spite of our best efforts, we are often unable to return our warrior back to duty. The overall modest functional outcomes seen after surgical treatment of calca neus fractures have spurred the development of a significant innovation in orthotics and rehabilitation protocols for young servicemembers who sustain severe lower-extremity trauma. Although not exclusive to calcaneus fractures, the Intrepid
MILITARY MEDICINE, Vol. 179, November 2014
Dynamic Exoskeletal Orthosis (IDEO) brace has allowed significantly increased activity levels, including return to duty, in patients who previously would have been severely limited. Hsu et al compared the rates of return to duty in lower-extremity trauma patients who underwent rehabilita tion with IDEO brace and specific therapy protocol versus IDEO brace alone.51 They found a significantly higher pro portion of servicemembers returning to duty after dual modality therapy (51.3% vs. 12.9%) than just bracing alone. Of note, the majority of these patients sustained injuries via explosive mechanisms or gunshot wounds, which were identi fied as negative risk factors for return to duty. As mentioned previously, calcaneus fractures are frequently associated with blast injuries, thus making it difficult to extrapolate improved outcomes in return to duty in this specific population with the IDEO brace. With advancements in orthotic design, limb salvage is a more desirable option for patients to return to prior high levels of functioning. Bedigrew et al (2014) evaluated pain and functional outcomes following an orthotic and rehabilita tion program with promising results.52 Patient-reported out comes, pain scores, and performance levels were markedly improved after 8 weeks of treatment. Most notably within this cohort, 50 patients initially considered an amputation but at the conclusion of the 8-week program 41 had transitioned to favoring limb salvage. Again, although not specific to patients
1233
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
TABLE I.
Summary Results o f Civilian Management of Calcaneus Fractures
with calcaneus fractures, this data will likely prove to be influential in future treatment options for this population.
1234
CONCLUSION Calcaneus fractures sustained in combat largely mirrored civilian injuries up until modem conflicts. The combination of advanced limb salvage techniques and widespread use of concealed explosive devices has resulted in substantially more complex injuries. Meticulous soft-tissue management including the use of free flaps, close attention to infectious complications, and a wide variety of options for definitive bony treatment have allowed us to save many limbs that would have been unsalvageable in earlier wars. Nonethe less, outcomes remain suboptimal, and these injuries remain difficult to manage, with no clear answer on the best way to prevent amputation and maximize functional outcomes. REFERENCES 1. Fernandez CFJ, Morante MP, Rodriguez TR, Cortes GA, Gomez PL: Densitometric analysis of the human calcaneus. J Anat 1996; 189(Pt 1): 205-9. 2. Sabry FF, Ebraheim NA, Mehalik JN, Rezcallah AT: Internal archi tecture of the calcaneus: implications for calcaneus fractures. Foot Ankle Int 2000; 21(2): 114-8. 3. Dhillon MS, Bali K, Prabhakar S: Controversies in calcaneus fracture management: a systematic review of the literature. Musculoskelet Surg 2011; 95(3): 171-81. 4. Wells C: Fractures of the heel bones in early and prehistoric times. Practitioner 1976; 217: 294-8. 5. Goff CW: Fresh fracture of the os calcis. Arch Surg 1938: 36(5): 74465. 6. Schepers T. Patka P: Treatment of displaced intra-articular calcaneal fractures by ligamentotaxis: current concepts’ review. Arch Orthop Trauma Surg 2009; 129(12): 1677-83. 7. Cooper S: The First Lines of the Practice of Surgery. Philadelphia, Grigg & Elliot, 1835. 8. Harris RI: Fractures of the os calcis: their treatment by tri-radiate trac tion and subastragalar fusion. Ann Surg 1946; 124(6): 1082-99. 9. Cotton FJW, Louis T: Fractures of the os calcis. Boston Med Surg J 1908; 159: 559-65. 10. Magnuson PB. Coulter JS: Fracture of both os calci. Internat Clin 1920; 2: 224. 11. Mumford EB: Fractures of the calcaneum. J Indiana M A 1920; 13: 200. 12. Bendixen PA: Fractures of the os calcis. J Iowa M Soc 1917; 7: 140. 13. Coltart WD: Aviator’s astragalus. J Bone Joint Surg Br 1952; 34-B(4): 545-66. 14. Bohler L: Diagnosis, pathology, and treatment of fractures of the os calcis. J Bone Joint Surg Am 1931; 13(1): 75-89. 15. MacAusland WR: Treatment of fractures of the os calcis by pin trac tion. Surg Gynec Obst 1936; 63: 782. 16. Reich RS: Editorial: Fractures of the calcaneus. Mil Med 1975; 140 (7): 491-2. 17. Bristow WR: Some surgical lessons of the war. J Bone Joint Surg 1943; 25(3): 524-34. 18. Bailey H: Surgery of Modern Warfare. Baltimore. Williams & Wilkins, 1941. 19. Barr JS, Draeger RH, Sager WW: Solid blast personnel injury: a clinical study. Mil Surg 1946; 98(1): 1-12. 20. Bertelsen A, Hasner E: Primary results of treatment of fracture of the os calcis by “foot-free walking bandage” and early movement. Acta Orthop Scand 1951; 21(2): 140-54.
MILITARY MEDICINE, Vol. 179, November 2014
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management 21. Carothers RG, Lyons JF: Early mobilization in treatment of os calcis fractures. Am J Surg 1952; 83(3); 279-80. 22. Barnard L, Odegard JK: Conservative approach in the treatment of frac tures of the calcaneus. J Bone Joint Surg Am 1955; 37-A(6): 1231-6. 23. Amesen A: Fracture of the os calcis and its treatment. II. A contribution to the discussion on the treatment of calcaneus fracture based on an analysis of a ten-year material treated by closed reduction and traction, from Sentralsykehuset i Trondheim. Acta Chir Scand Suppl 1958; 15(Supp 234): 1-51. 24. Fantato S, Bajardi AA: The treatment of fractures of the calcaneus with sunken talus. Panminerva Med 1962; 4: 225-8. 25. Gissane W: Fractures of the os calcis. J Bone Joint Surg 1947; 29: 254-5. 26. Conn HR: The treatment of fractures of the os calcis. J Bone Joint Surg 1935; 27(2): 392-405. 27. Gallie WE: Subastragalar arthrodesis in fractures of the os calcis. J Bone Joint Surg Am 1943; 25(4): 731-6. 28. Whittaker AH: Fractures of the os calcis: preliminary report. Am J Surg 1947; 74(3): 378. 29. Leonard MH: Treatment of fractures of the os calcis. AMA Arch Surg 1957; 75(6): 990-7. 30. Maxfield JE: Os calcis fractures. Treatment by open reduction. Clin Orthop Relat Res 1963; 30: 91-9. 31. Brav EA: End results of treatment of fractures of the os calcis. An Army-wide study. Mil Med 1965: 130: 23-36. 32. Mellor SG: The pathogenesis of blast injury and its management. Br J Hosp Med 1988; 39(6): 536-9. 33. Wightman JM, Gladish SL: Explosions and blast injuries. Ann Emerg Med 2001; 37(6): 664-78. 34. Ramasamy A, Harrisson S, Lasrado I, Stewart MP: A review of casualties during the Iraqi insurgency 2006—a British field hospital experience. Injury 2009; 40(5): 493-97. 35. Owens BD, Kragh JF Jr., Macaitis J, Svoboda SJ, Wenke JC: Charac terization of extremity wounds in Operation Iraqi Freedom and Opera tion Enduring Freedom. J Orthop Trauma 2007; 21(4): 254-57. 36. Ramasamy A, Hill AM, Clasper JC: Improvised explosive devices: pathophysiology, injury profiles and current medical management. J R Army Med Corps 2009; 155(4): 265-272. 37. Bilukha OO, Laurenge H. Danee L, Subedi KP, Becknell K: Injuries and deaths due to victim-activated improvised explosive devices, landmines and other explosive remnants of war in Nepal. Inj Prev 2011; 17(5): 326-31. 38. Covey DC, Lurate RB, Hatton CT: Field hospital treatment of blast wounds of the musculoskeletal system during the Yugoslav civil war. J Orthop Trauma 2000; 14(4): 278-86; discussion 277.
MILITARY MEDICINE, Vol. 179, N ovem ber 2014
39. Ramasamy A, Hill AM, Phillip R, Gibb I, Bull AM, Clasper JC; The modem “deck-slap” injury—calcaneal blast fractures from vehicle explosions. J Trauma 2011; 71(6): 1694-8. 40. McKay BJ, Bir CA: Lower extremity injury criteria for evaluating military vehicle occupant injury in underbelly blast events. Stapp Car Crash J 2009; 53: 229-49. 41. Bluman EM, Ficke JR, Covey DC: War wounds of the foot and ankle: causes, characteristics, and initial management. Foot Ankle Clin 2010; 15(1): 1-21. 42. Tintle SM, Keeling JJ, Shawen SB: Combat foot and ankle trauma. J Surg Orthop Adv 2010; 19(1): 70-6. 43. Shawen SB, Keeling JJ, Branstetter J, Kirk KL, Ficke JR: The mangled foot and leg: salvage versus amputation. Foot Ankle Clin 2010; 15(1): 63-75. 44. Keeling JJ, Hsu JR, Shawen SB, Andersen RC: Strategies for managing massive defects of the foot in high-energy combat injuries of the lower extremity. Foot Ankle Clin 2010; 15(1): 139-49. 45. Ramasamy A, Hill AM, Masouros S, et al: Outcomes of IED foot and ankle blast injuries. J Bone Joint Surg Am 2013; 95(5): e25. 46. Doukas WC, Hayda RA, Frisch HM, et al: The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of ampu tation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am 2013; 95(2): 138-45. 47. Dickens JF, Kilcoyne KG, Kluk MW, Gordon WT, Shawen SB, Potter BK: Risk factors for infection and amputation following open, combat-related calcaneal fractures. J Bone Joint Surg Am 2013; 95(5): e24. 48. Bevevino AJ, Dickens JF, Potter BK, Dworak T, Gordon W, Forsberg JA: A model to predict limb salvage in severe combat-related open calcaneus fractures. Clin Orthop Relat Res 2013 Nov 19. 49. Demiralp B, Ege T. Kose O, Yurttas Y, Basbozkurt M: Amputation versus functional reconstruction in the management of complex hind foot injuries caused by land-mine explosions: a long-term retrospective comparison. Eur J Orthop Surg Traumatol 2014; 24(4): 621-6. 50. Gur E, Atesalp S, Basbozkurt M, Aydogan N, Erler K: Treatment of complex calcaneal fractures with bony defects from land mine blast injuries with a circular external fixator. Foot Ankle Int 1999; 20(1): 37-41. 51. Blair JA, Patzkowski JC, Blanck RV, Owens JG, Hsu JR: Return to duty after integrated orthotic and rehabilitation initiative. J Orthop Trauma 2014; 28(4): e70-4. 52. Bedigrew KM, Patzkowski JC, Wilken JM, et al: Can an integrated orthotic and rehabilitation program decrease pain and improve function after lower extremity trauma? Clin Orthop Relat Res 2014 Apr 18.
1235
Copyright of Military Medicine is the property of AMSUS and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
e v ie w
A
r t ic l e
MILITARY MEDICINE, 179, 11:1228, 2014
H ig h S e a s to H igh E xplosives: T h e E vo lu tio n o f C a lc a n e u s F ra c tu re M a n a g e m e n t in th e M ilita ry LCDR George C. Balazs, MC USN; CPT Elizabeth M. Polfer, MC USA; CPT Alaina M. Brelin, MC USA; Lt Col Wade T. Gordon, USAF MC
ABSTRACT Calcaneus fractures typically occur as a consequence of axial load. In the civilian population, this is most often because of motor vehicle accidents or falls from height. Early management of these injuries in the military population largely mirrored that of civilian surgeons. However, calcaneus fractures secondary to underfoot blasts became a significant source of morbidity and mortality in World War II. First described in the aftermath of large-scale naval battles between metal-deck ships, this “deck-slap” phenomenon is associated with high rates of concomitant injuries, infection, and amputation. We review the historical and contemporary management of calcaneus fractures by military orthopedic surgeons, as well as detailing the unique challenges faced in managing the soft-tissue component and associated injuries commonly observed in this population. Combat-related calcaneus fractures are associated with very high rates of concom itant injuries and extensive soft-tissue wounds. Despite significant research and technological advances, functional outcomes following these devastating injuries have remained unsatisfying.
INTRODUCTION The calcaneus is composed of a relatively thin shell of cortical bone encasing an irregular core of cancellous bone. The cortex is thickest adjacent to the posterior tuberosity, superiorly along the angle of Gissane, and the lateral surface below the poste rior facet. The cancellous core is arranged in trabecular arrays running anteroposterior in the long axis and parallel to the posterior border within the posterior tuberosity, with a paucity of mineralization seen in the “neutral triangle” anteroinferiorly. This pattern roughly corresponds to the stresses of weight bearing, where the hindfoot may experience forces 300 to 400% of body weight. As a consequence of this adap tive mineralization, calcaneus fractures during normal activity are uncommon, and typically require high-energy axial load to occur in structurally competent bone.12 Most calcaneus fractures in the civilian population occur during falls from height or motor vehicle accidents.3 Mili tary surgeons, however, have long recognized that rapid deceleration of the human body is not the only mechanism that produces axial force on weight-bearing bones. Rapid acceleration beneath the feet produces similar forces, and therefore similar patterns of injury. This “underfoot” mecha nism (high velocity, low amplitude force directed superiorly along the longitudinal axis of the axial skeleton) occurs only
Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. doi: 10.7205/MILMED-D-14-00156
1228
in very specific environments, most commonly combat. Termed “deck-slap injuries,” these injuries have played a prominent role in military lower-extremity trauma since World War I. The purpose of this article is to review the evolution of the mechanism and management of combat-related calcaneus fractures. We will review the injury patterns specific to armed combat, as well as describe historical and current treatment techniques and outcomes. HISTORICAL PERSPECTIVE Fractures of the calcaneus are a signature injury of the indus trial era. Until mankind began routinely working at (and therefore falling from) great heights, the injury was uncom mon.4 The first modem discussions of the fracture came from French and German surgeons in the early 1700s. They advo cated a strict policy of benign neglect, observation, and rest until fracture fragments had consolidated.5'6 A century later, emphasis shifted to immobilization, utilizing various dress ings of lint, egg albumin, and cottage cheese until fracture consolidation occurred.7 Around this same time, the first ten tative forays into surgical intervention occurred, with Pott (and later Norris) advocating excision of bone ends in cases of open fracture to prevent tetanus. Results were generally poor and deaths frequent.5 The injury became more prominent in the medical literature with industrialization. By the late 19th century, a plethora of case series and proposed treatments appeared in the medical
MILITARY MEDICINE, Vol. 179, November 2014
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
literature. The themes of minimal intervention and observation continued to predominate. Following the passage of workmen’s compensation laws in Europe and the United States, surgeons began to take more of an interest in this often disabling injury ,s The first radiographic study of calcaneus fractures occurred in 1895, and many surgeons began to attempt closed reduc tion of the fracture in order to promote consolidation. The first significant innovation in treatment came from Cotton and Wilson, who argued that the severity of calcaneus frac tures was underappreciated by most surgeons, and that the majority of such injuries were actually highly comminuted crush injuries.9 “The general assumption in these cases was that there was a breaking across the os calcis. It was known that complicated crushing of the os calcis might, in fact, occur, and this was shown in museum specimens, but that such was the condition in the average case never to have been assumed... it is our belief that the lesions in all these cases are nearly alike, varying mainly in the extent and direction of the displacement of the con fused fragments.” In treating all calcaneus fractures as crush injuries, Cotton redirected surgical thought on the subject. His method, fre quently emulated and modified in the three decades following his original publication, involved disimpacting the fracture fragments with mallet strikes, followed by soft-tissue traction with a wire inserted behind the Achilles tendon. Manual manip ulation was then employed to recreate a more natural contour and approximate the preinjury width of the heel. Numerous authors subsequently proposed reduction methods.10-12 By 1938, Goff was able to cite 84 different published techniques for managing calcaneus fractures.11 Most methods reported good-to-excellent results of treatment in majority of patients. No clear consensus on appropriate treatment emerged, with various authors arguing for some combination of open reduc
tion, traction, closed manipulation, early weight bearing, prolonged immobilization, early subtalar arthrodesis, and benign neglect. WORLD WAR II
The burgeoning interest in calcaneus fractures from the late 19th century into the first half of the 20th century focused almost exclusively on civilian construction workers, and no mention is made of battlefield casualties in any of the case studies available from this period. The American Civil War, the Napoleonic Wars, and World War I advanced medical understanding of traumatic wounds by leaps and bounds, but their influence on calcaneus fracture management is essen tially nonexistent. This is all the more fascinating in that World War I aviators sparked modem interest in talar frac tures (the so-called “aviator’s astralgus”) 1' with scant men tion of calcaneus fractures. Lorenz Bohler, presenting at the 1930 annual meeting of the American Academy of Orthopedic Surgeons, describes establishing a 200-bed field hospital 20 miles behind the front in Italy devoted exclusively to the treatment of fractures. However, he says that it was not until after the war in Vienna, when he met with workmen’s compensation insurance adjus tors, that he turned his attention to the problem of calcaneus fractures.14 His method of treatment, essentially a modifica tion of the original description by Cotton, began with mallet blows to the medial and lateral heel to break up fracture fragments. Traction was then applied to the tuberosity with an ice clamp, followed by heel molding and casting as seen in Figure 1. The goal of this treatment was not, as with earlier methods, to recreate normal width to the heel. Rather, it was designed to restore a normal tuber angle (Bohler’s angle), and therefore a normal relationship between the talus and poste rior facet of the calcaneus. This was the first recognition of the vital importance of reconstructing the weight-bearing posterior facet, presaging present-day classification systems
FIGURE 1. Bohler’s method of manual molding (A) followed by traction and immobilization (B) of calcaneus fractures. (Images used with permission from Bohler L, J Bone Joint Surg Am, 1931 JanOl; 13(1): 75-89, © Journal of Bone and Joint Surgery.)
MILITARY MEDICINE, Vol. 179, November 2014
1229
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
and operative techniques. Bohler’s methodology would prove highly influential over the coming decades.15'16 Military surgeons first began writing about calcaneus fractures during World War II. Several features of the con flict brought calcaneus injuries to the forefront. First, the use of high-explosive mines increased dramatically in both ground combat and at sea. Second, for the first time in history, multiple combatant nations possessed large fleets of steel ships and submarines. Third, technological advances facili tated the rapid treatment and transport of injured soldiers. In earlier conflicts, it is likely these injured combatants would either have perished from their wounds or had their injured limb amputated. A British surgeon, Brigadier General Rowley Bristow, was the first to note the increase in calcaneus fractures seen during World War II.17 His description is a scant 2 paragraphs in a much larger work comparing patterns of injury and medical treatment between World War I and World War II. Nonetheless, it is both succinct and enduring, and could easily apply to any conflict as: “Fractures of the os calcis are more common than in peacetime. They are produced by land mines, by a bomb which goes off between decks, and have occurred also in men who slide down the side of a sinking ship and hit their heels against the projecting bilge on the hull. Many of these fractures are hopelessly comminuted, but then generally become painlessly ankylosed, but if not, the joint is arthrodesed.” Realizing that prolonged immobilization produces a “stiff useless foot,” he advocated reduction with a traction pin, 4 weeks of immobilization, range of motion activities, and nonweight bearing until 4 months after injury. Later works from this period focused on calcaneus frac tures occurring at sea. Termed “solid blast injuries,” or more commonly “deck-slap injuries,” these fractures occurred as a result of below-deck explosions, causing force transmission across rigid steel decks into the lower extremities of sailors above. Bailey says that these injuries were first noted in 1939 when smaller ships, such as minesweepers or trawlers, struck mines.18 Injured personnel with any ankle or knee dislocations were reduced under traction and placed in reinforced long leg casts for the duration of their healing. Harris added under vehicle mines as another cause of wartime calcaneus fractures, but stated that long transit times to hospitals rarely allowed for any specific treatment to be performed. Despite this, out comes were not necessarily poor, which probably contributed to the persistence of “benign-neglect” as the treatment modal ity of choice. “Most war fractures of the os calcis have ended with fusion of the fragments into a greatly distorted mass. It must be stated, however, that the degree of permanent disablement, though severe, often is not as great as might be expected from the distortion of the bone.”8
1230
The culmination of the World War II experience was a large case series published by Barr, Draeger, and Sager.19 They personally interviewed 50 injured service members in four different Naval Hospitals who had sustained calcaneus fractures at sea. All occurred in young, otherwise healthy men and all resulted from high-explosive ordinance (mines, torpe does, bombs). Most men had concurrent injuries such as fractures of the ankle and tibia, vertebral fractures, and head injuries. The most revealing detail in their study was that at least 20% of injured personnel were not actually thrown into the air, but instead “crumpled” when hit by the blast from below. Several others were thrown into the air and “hung up” on various structures in the ship. This is strong evidence that the fractures seen in these individuals were sustained at the time of the initial blast, and were not secondary to a fall from height. The ideal treatment regimen, as described by Barr, et al, recognized both the need for early intervention, as well as the reality of limited resources and skill sets in a theatre of operations. Soft-tissue injuries were debrided— unless older than 12 hours—and delayed primary closure undertaken within 1 week. When feasible, heavy traction under anesthesia was performed, followed by manual molding of fracture frag ments and cast placement. They stated that open reduction was rarely, if ever, indicated. No summarized outcome data are published with their case series, but the 20% amputation rate they cite suggests that treatment was frequently unsatisfactory. World War II was the first to look at calcaneus fractures sustained in a battlefield. Although there is a paucity of liter ature from this period, nonoperative measures were the treat ment of choice from this era, employing varying techniques of traction and immobilization. In the coming decades, these seemingly simple principles of management would be chal lenged, as the complexity of calcaneus fractures became better understood. POST-WORLD WAR II AND THE VIETNAM ERA Following World War II, both civilian and military manage ment of calcaneus fractures remained in a state of flux with out any clear consensus on preferred management. Various authors recommended no treatment and usually early mobili zation,20 22 whereas others performed variations of Cotton’s original method,23-2:1 primary subtalar arthrodesis,26’27 or open reduction and fixation.28-30 The lack of agreement in fracture management seems to have arisen from the need for a unifying classification system. The earliest classification scheme still commonly used today (Essex-Lopresti) recog nized the significant difference between intra-articular and extra-articular fracture patterns, but was (and is) of little use beyond its ability to simply communicate fracture mecha nism. Later classification schemes attempted to delineate the prognostic significance between various types of intra-articular fractures, but these did not come into common usage until the late 1980s and early 1990s. It is no surprise then, that the literature from this period is largely descriptive.
MILITARY MEDICINE, Vol. 179, November 2014
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
Brav conducted an Army-wide survey of patients who had sustained calcaneus fractures, correlating patient-reported satisfaction with available medical records.11 He found similar results between operative versus nonoperative treatment, with the exception of mildly comminuted fractures with sig nificant articular surface depression. These seemed to fare better when treated with open reduction. He also found no relationship between the loss of a normal Bohler angle and ultimate outcome, suggesting that articular surface involve ment is not the only factor predicting long-term results. Brav summarized his findings by recommending manual molding of the heel in comminuted fractures, followed by early range of motion and weight bearing. He recommended open reduc tion and bone grafting only in rare cases with significant articular surface depression but minimal comminution. Ten years after Brav, calcaneus fractures remained on the radar of military surgeons, as evidenced by Reich’s editorial in Military Medicine.16 The unreferenced article is fascinating in that it largely relied on the work of Bohler, with no mention of intervening classification systems or treatment regimens. Like Brav, Reich argued for manual manipulation of fracture fragments in nearly all cases except isolated, minimally com minuted fractures of the posterior facet, for which fixation was recommended. Unlike Brav, however, Reich recom mended periods of prolonged immobilization and nonweight bearing up to 14 weeks. No rationale for this postoperative course was offered. This may have signaled a renewed under standing that surgical management of complex calcaneus frac tures carries significant risks of perioperative complications, and offers only questionable long-term functional benefit. The post-World War II period was marked by the first serious forays into operative treatment of calcaneus fractures. Recognition of the poor functional outcomes after surgical fixation and high postoperative complication rates tempered enthusiasm for the adoption of surgical management of battle field calcaneus fractures. In the years to come military litera ture would take on a different tone, as military surgeons considered the liability of newer limb salvage techniques. THE MODERN ERA Modem management of calcaneal injuries in military hos pitals has undergone substantial changes during our recent conflicts in the Middle East. As alluded to in the above discussion, calcaneus fractures in military troops were not particularly different from those seen in civilian populations, at least those that were amenable to surgical capabilities at the time. However, the wars in Iraq and Afghanistan (and to a lesser extent, conflicts in the Balkans and near east nations) have produced greater numbers of calcaneus fractures that are substantially more comminuted with significant soft-tissue injury in patients with multiple extremity injuries (Fig. 2). The use of concealed explosive devices against both vehi cles and dismounted troops has expanded substantially in modem conflicts. These munitions produce injury both from a primary blast wave of high-velocity pressurized air as
MILITARY MEDICINE, Vol. 179, November 2014
FIGURE 2. Afghan teenager who inadvertently sustained a complex open hindfoot injury while placing an improvised explosive device.
well as a secondary wave of environmental debris that act as high-speed projectiles.'12 ’1 Penetrating wounds produced by explosives are highly contaminated, as dirt and debris are pulled into the body. Concealed explosive devices (including landmines, improvised explosive devices, and booby traps) have been responsible for up to 51 % of injuries seen in field hospitals, with a disproportionate number of lower-extremity injuries.34 In Owens analysis of the casualty data from the first half of the Iraqi and Afghan wars, 26% of all casualties sustained lower-extremity wounds, 12% had fractures of the foot, and of those 76% were open fractures.13 Ramasamy described 104 battle casualties treated at a British field hospital during Operation TELIC in 2006, and found an even higher rate of lower-extremity injuries at 38%, with open wounds and fractures present in 73.8% of survivors.36 In other con flicts, numbers are similar or even higher. Bilukha’s study of Nepalese landmine casualties between 2006 and 2010 found 43% of surviving victims with lower-extremity wounds.37 A UN field hospital during the conflict in the former Yugoslavia treated 41 patients with musculoskeletal blast injuries, with an overall lower-extremity amputation rate of 17%.38 Ramasamy has also pointed out how the expanded use of vehicle armoring has resulted in a resurgence of “deck-slap” injuries not described in military conflicts since World War II.39 McKay’s cadaveric modeling of these injuries shows that the calcaneus tends to fracture first with an underfoot compressive load.40 Despite being nonpenetrating injuries, Ramasamy’s series of 40 calcaneal fractures had 13 open injuries, and 11 of those ultimately became infected. As Bluman points out, the characteristics described above essentially invert the characteristics observed in civilian pop ulations.41 Calcaneus fractures occurring in modern combat are more likely to be open, comminuted fractures with sub stantial soft-tissue loss and bony defects. Whereas the debate over open reduction internal fixation (ORIF) versus primary fusion versus nonoperative management continues without resolution among civilian surgeons, military surgeons are
1231
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
today much more concerned with meticulous debridement and management of soft tissues. Bluman, Tintle, and others describe the need for meticulous soft-tissue debridement and coverage.41-44 Bony fragments are initially stabilized only to the degree necessary to facilitate later reconstruction or fusion. Free flaps are employed liberally, and delayed bony reconstruction is undertaken only when surgeons feel con vinced that infection is cleared and soft-tissue coverage is adequate. External fixation methods, including Ilizarov tech niques of distraction-osteogenesis, are used both for initial stabilization and frequently definitive management. The com plex nature of the bony injury usually dictates the treatment method employed, be it primary subtalar fusion, percuta neous pinning, external fixation techniques, internal fixa tion, or hybrid techniques (Figs. 3 and 4). Even within the civilian world, where these injuries are far more likely to be closed without associated limb-threatening injuries, results of various treatments have essentially been equal and offer minimal assistance in decision making (Table I). Despite what feels like significant technological advance ments in the management of these injuries, results published to date are generally disappointing. Ramasamy’s series of 40 deck-slap injuries had a 45% amputation rate, with 10%
undergoing delayed amputation because of chronic pain long after the resolution of their acute injuries.39 Another series of 63 British soldiers with lower-extremity blast injuries showed a 29% amputation rate with hindfoot injury strongly predictive of eventual amputation.45 Within this series, 74% of patients experienced persistent symptoms at long-term follow-up, and only 14% were able to return to duty. In a large retrospective cohort of American servicemembers sustaining lowerextremity injuries, the METALS cohort found better quality of life scores, lower rates of post-traumatic stress disorder (PTSD), and higher likelihood of engaging in sporting activities among amputees versus those who underwent limb salvage.49 In the largest published series of combat-related calcaneus fractures, Dickens et al found lower visual analog pain scale (VAS) scores and higher Tenger activity scores among amputees versus limb salvage patients.47 This may have been related to the very high rates of infection (46%), and ipsilateral talus (47%) and tibia (43%) fractures. Simi lar to the British experience, the patients in the Dickens cohort had a 15% delayed amputation rate because of late infection and chronic pain. Bevevino et al gathered data on all combat-related open calcaneus fractures sustained by American servicemembers from 2003 to 2012, and iden-
FIGURE 3. (A) Lateral radiograph of the left foot demonstrating an open displaced comminuted calcaneus fracture after a blast injury in Afghanistan. The patient initially underwent irrigation and debridement with external fixator and smooth wire placement to reduce the joint (B) The clinical photograph demonstrates a severe soft-tissue deficit (C) Provisional pinning before ORIF to maintain calcaneal height. The patient ultimately underwent transtibial amputation because of osteomyelitis and failure to achieve soft-tissue coverage.
1232
MILITARY MEDICINE, Vol. 179, November 2014
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
FIGURE 4. (A) Lateral radiograph of the foot following dismounted blast injury in Afghanistan. (B) Axial CT scan of the same foot demonstrates extensive intra-articular comminution and displacement. (C) The patient ultimately underwent subtalar fusion.
tified increasing American Society of Anesthesiologists (ASA) classification, absent plantar sensation, Gustillo-Anderson grade, Sander’s classification, vascular injury, male gender, and dismounted blast mechanism as significant predictors of need for eventual amputation.48 Some smaller studies have been more optimistic. Demiralp reported on 42 landmine victims with complex hindfoot inju ries who underwent either limb salvage or amputation, and found higher functional scores among their limb salvage patients.49 However, these patients tended to have less severe initial injuries. Gur looked at 18 severely comminuted calca neus fractures with bony defects treated with distraction oste ogenesis following soft-tissue coverage, and rated 15 patients with good-to-excellent outcomes.50 The overall impression one gains from the modem litera ture is that combat-related calcaneus fractures have become substantially more complex, requiring close attention to soft-tissue coverage and prevention/treatment of infection. The nature of the injury largely dictates the treatment methods employed. In spite of our best efforts, we are often unable to return our warrior back to duty. The overall modest functional outcomes seen after surgical treatment of calca neus fractures have spurred the development of a significant innovation in orthotics and rehabilitation protocols for young servicemembers who sustain severe lower-extremity trauma. Although not exclusive to calcaneus fractures, the Intrepid
MILITARY MEDICINE, Vol. 179, November 2014
Dynamic Exoskeletal Orthosis (IDEO) brace has allowed significantly increased activity levels, including return to duty, in patients who previously would have been severely limited. Hsu et al compared the rates of return to duty in lower-extremity trauma patients who underwent rehabilita tion with IDEO brace and specific therapy protocol versus IDEO brace alone.51 They found a significantly higher pro portion of servicemembers returning to duty after dual modality therapy (51.3% vs. 12.9%) than just bracing alone. Of note, the majority of these patients sustained injuries via explosive mechanisms or gunshot wounds, which were identi fied as negative risk factors for return to duty. As mentioned previously, calcaneus fractures are frequently associated with blast injuries, thus making it difficult to extrapolate improved outcomes in return to duty in this specific population with the IDEO brace. With advancements in orthotic design, limb salvage is a more desirable option for patients to return to prior high levels of functioning. Bedigrew et al (2014) evaluated pain and functional outcomes following an orthotic and rehabilita tion program with promising results.52 Patient-reported out comes, pain scores, and performance levels were markedly improved after 8 weeks of treatment. Most notably within this cohort, 50 patients initially considered an amputation but at the conclusion of the 8-week program 41 had transitioned to favoring limb salvage. Again, although not specific to patients
1233
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management
TABLE I.
Summary Results o f Civilian Management of Calcaneus Fractures
with calcaneus fractures, this data will likely prove to be influential in future treatment options for this population.
1234
CONCLUSION Calcaneus fractures sustained in combat largely mirrored civilian injuries up until modem conflicts. The combination of advanced limb salvage techniques and widespread use of concealed explosive devices has resulted in substantially more complex injuries. Meticulous soft-tissue management including the use of free flaps, close attention to infectious complications, and a wide variety of options for definitive bony treatment have allowed us to save many limbs that would have been unsalvageable in earlier wars. Nonethe less, outcomes remain suboptimal, and these injuries remain difficult to manage, with no clear answer on the best way to prevent amputation and maximize functional outcomes. REFERENCES 1. Fernandez CFJ, Morante MP, Rodriguez TR, Cortes GA, Gomez PL: Densitometric analysis of the human calcaneus. J Anat 1996; 189(Pt 1): 205-9. 2. Sabry FF, Ebraheim NA, Mehalik JN, Rezcallah AT: Internal archi tecture of the calcaneus: implications for calcaneus fractures. Foot Ankle Int 2000; 21(2): 114-8. 3. Dhillon MS, Bali K, Prabhakar S: Controversies in calcaneus fracture management: a systematic review of the literature. Musculoskelet Surg 2011; 95(3): 171-81. 4. Wells C: Fractures of the heel bones in early and prehistoric times. Practitioner 1976; 217: 294-8. 5. Goff CW: Fresh fracture of the os calcis. Arch Surg 1938: 36(5): 74465. 6. Schepers T. Patka P: Treatment of displaced intra-articular calcaneal fractures by ligamentotaxis: current concepts’ review. Arch Orthop Trauma Surg 2009; 129(12): 1677-83. 7. Cooper S: The First Lines of the Practice of Surgery. Philadelphia, Grigg & Elliot, 1835. 8. Harris RI: Fractures of the os calcis: their treatment by tri-radiate trac tion and subastragalar fusion. Ann Surg 1946; 124(6): 1082-99. 9. Cotton FJW, Louis T: Fractures of the os calcis. Boston Med Surg J 1908; 159: 559-65. 10. Magnuson PB. Coulter JS: Fracture of both os calci. Internat Clin 1920; 2: 224. 11. Mumford EB: Fractures of the calcaneum. J Indiana M A 1920; 13: 200. 12. Bendixen PA: Fractures of the os calcis. J Iowa M Soc 1917; 7: 140. 13. Coltart WD: Aviator’s astragalus. J Bone Joint Surg Br 1952; 34-B(4): 545-66. 14. Bohler L: Diagnosis, pathology, and treatment of fractures of the os calcis. J Bone Joint Surg Am 1931; 13(1): 75-89. 15. MacAusland WR: Treatment of fractures of the os calcis by pin trac tion. Surg Gynec Obst 1936; 63: 782. 16. Reich RS: Editorial: Fractures of the calcaneus. Mil Med 1975; 140 (7): 491-2. 17. Bristow WR: Some surgical lessons of the war. J Bone Joint Surg 1943; 25(3): 524-34. 18. Bailey H: Surgery of Modern Warfare. Baltimore. Williams & Wilkins, 1941. 19. Barr JS, Draeger RH, Sager WW: Solid blast personnel injury: a clinical study. Mil Surg 1946; 98(1): 1-12. 20. Bertelsen A, Hasner E: Primary results of treatment of fracture of the os calcis by “foot-free walking bandage” and early movement. Acta Orthop Scand 1951; 21(2): 140-54.
MILITARY MEDICINE, Vol. 179, November 2014
High Seas to High Explosives: The Evolution of Calcaneus Fracture Management 21. Carothers RG, Lyons JF: Early mobilization in treatment of os calcis fractures. Am J Surg 1952; 83(3); 279-80. 22. Barnard L, Odegard JK: Conservative approach in the treatment of frac tures of the calcaneus. J Bone Joint Surg Am 1955; 37-A(6): 1231-6. 23. Amesen A: Fracture of the os calcis and its treatment. II. A contribution to the discussion on the treatment of calcaneus fracture based on an analysis of a ten-year material treated by closed reduction and traction, from Sentralsykehuset i Trondheim. Acta Chir Scand Suppl 1958; 15(Supp 234): 1-51. 24. Fantato S, Bajardi AA: The treatment of fractures of the calcaneus with sunken talus. Panminerva Med 1962; 4: 225-8. 25. Gissane W: Fractures of the os calcis. J Bone Joint Surg 1947; 29: 254-5. 26. Conn HR: The treatment of fractures of the os calcis. J Bone Joint Surg 1935; 27(2): 392-405. 27. Gallie WE: Subastragalar arthrodesis in fractures of the os calcis. J Bone Joint Surg Am 1943; 25(4): 731-6. 28. Whittaker AH: Fractures of the os calcis: preliminary report. Am J Surg 1947; 74(3): 378. 29. Leonard MH: Treatment of fractures of the os calcis. AMA Arch Surg 1957; 75(6): 990-7. 30. Maxfield JE: Os calcis fractures. Treatment by open reduction. Clin Orthop Relat Res 1963; 30: 91-9. 31. Brav EA: End results of treatment of fractures of the os calcis. An Army-wide study. Mil Med 1965: 130: 23-36. 32. Mellor SG: The pathogenesis of blast injury and its management. Br J Hosp Med 1988; 39(6): 536-9. 33. Wightman JM, Gladish SL: Explosions and blast injuries. Ann Emerg Med 2001; 37(6): 664-78. 34. Ramasamy A, Harrisson S, Lasrado I, Stewart MP: A review of casualties during the Iraqi insurgency 2006—a British field hospital experience. Injury 2009; 40(5): 493-97. 35. Owens BD, Kragh JF Jr., Macaitis J, Svoboda SJ, Wenke JC: Charac terization of extremity wounds in Operation Iraqi Freedom and Opera tion Enduring Freedom. J Orthop Trauma 2007; 21(4): 254-57. 36. Ramasamy A, Hill AM, Clasper JC: Improvised explosive devices: pathophysiology, injury profiles and current medical management. J R Army Med Corps 2009; 155(4): 265-272. 37. Bilukha OO, Laurenge H. Danee L, Subedi KP, Becknell K: Injuries and deaths due to victim-activated improvised explosive devices, landmines and other explosive remnants of war in Nepal. Inj Prev 2011; 17(5): 326-31. 38. Covey DC, Lurate RB, Hatton CT: Field hospital treatment of blast wounds of the musculoskeletal system during the Yugoslav civil war. J Orthop Trauma 2000; 14(4): 278-86; discussion 277.
MILITARY MEDICINE, Vol. 179, N ovem ber 2014
39. Ramasamy A, Hill AM, Phillip R, Gibb I, Bull AM, Clasper JC; The modem “deck-slap” injury—calcaneal blast fractures from vehicle explosions. J Trauma 2011; 71(6): 1694-8. 40. McKay BJ, Bir CA: Lower extremity injury criteria for evaluating military vehicle occupant injury in underbelly blast events. Stapp Car Crash J 2009; 53: 229-49. 41. Bluman EM, Ficke JR, Covey DC: War wounds of the foot and ankle: causes, characteristics, and initial management. Foot Ankle Clin 2010; 15(1): 1-21. 42. Tintle SM, Keeling JJ, Shawen SB: Combat foot and ankle trauma. J Surg Orthop Adv 2010; 19(1): 70-6. 43. Shawen SB, Keeling JJ, Branstetter J, Kirk KL, Ficke JR: The mangled foot and leg: salvage versus amputation. Foot Ankle Clin 2010; 15(1): 63-75. 44. Keeling JJ, Hsu JR, Shawen SB, Andersen RC: Strategies for managing massive defects of the foot in high-energy combat injuries of the lower extremity. Foot Ankle Clin 2010; 15(1): 139-49. 45. Ramasamy A, Hill AM, Masouros S, et al: Outcomes of IED foot and ankle blast injuries. J Bone Joint Surg Am 2013; 95(5): e25. 46. Doukas WC, Hayda RA, Frisch HM, et al: The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of ampu tation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am 2013; 95(2): 138-45. 47. Dickens JF, Kilcoyne KG, Kluk MW, Gordon WT, Shawen SB, Potter BK: Risk factors for infection and amputation following open, combat-related calcaneal fractures. J Bone Joint Surg Am 2013; 95(5): e24. 48. Bevevino AJ, Dickens JF, Potter BK, Dworak T, Gordon W, Forsberg JA: A model to predict limb salvage in severe combat-related open calcaneus fractures. Clin Orthop Relat Res 2013 Nov 19. 49. Demiralp B, Ege T. Kose O, Yurttas Y, Basbozkurt M: Amputation versus functional reconstruction in the management of complex hind foot injuries caused by land-mine explosions: a long-term retrospective comparison. Eur J Orthop Surg Traumatol 2014; 24(4): 621-6. 50. Gur E, Atesalp S, Basbozkurt M, Aydogan N, Erler K: Treatment of complex calcaneal fractures with bony defects from land mine blast injuries with a circular external fixator. Foot Ankle Int 1999; 20(1): 37-41. 51. Blair JA, Patzkowski JC, Blanck RV, Owens JG, Hsu JR: Return to duty after integrated orthotic and rehabilitation initiative. J Orthop Trauma 2014; 28(4): e70-4. 52. Bedigrew KM, Patzkowski JC, Wilken JM, et al: Can an integrated orthotic and rehabilitation program decrease pain and improve function after lower extremity trauma? Clin Orthop Relat Res 2014 Apr 18.
1235
Copyright of Military Medicine is the property of AMSUS and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
