Republication of "A Novel Casting Technique for Tongue-Type Calcaneus Fractures With Soft Tissue Compromise"

Abstract

Displaced calcaneal fractures encompass a spectrum of fracture patterns, many of which are associated with soft tissue complications. Displaced tongue-type calcaneal fractures often cause pressure on the posterior heel skin, particularly when treatment is delayed. Resultant partial- or full-thickness skin necrosis presents significant challenges to the treating surgeon. In this article, the authors report on a case of full-thickness skin necrosis associated with a displaced tongue-type calcaneus fracture. The authors describe the use of a specialized heel window casting technique, which eliminates posterior heel pressure and greatly facilitates soft tissue surveillance and local wound care. The article also reviews the literature on soft tissue complications associated with displaced calcaneus fractures.

Keywords: calcaneal tuberosity fracture; calcaneus fracture; casting; heel wound; skin break down; tongue-type.

Figure 1.

(A) Lateral radiograph of the patient’s left foot on the date of injury, demonstrating a displaced tongue-type calcaneus fracture. (B) Immediate postoperative radiograph showing anatomic reduction and fixation with 2 fully threaded 4.5-mm cortical screws with washers.

Figure 2.

(A) Clinical photograph and (B) lateral radiograph of the patient’s left heel 10 days after index fixation. The patient admitted to having fallen at home on the day of discharge. (C) Immediate postoperative lateral radiograph after revision percutaneous reduction and internal fixation with 2 partially threaded 6.5-mm cannulated screws.

Figure 3.

Technique for applying the modified short-leg splint/cast with posterior heel window and strut (A-C, splinting; D-I, casting). (A) A towel is used to create a potential space over the posterior heel that allows application of a plaster posterior slab splint with the heel free. (B) A window in Jones cotton and Webril padding is made to keep the heel uncovered. (C) The towel is removed once the plaster hardens, leaving a strut to protect the posterior heel. (D) Stockinette is placed proximally and distally and wrapped with cast padding. (E) A large stack of 4″ × 4″ gauze is positioned over the posterior heel wound and wrapped with additional cast padding. (F) The desired position of the ankle is maintained while fiberglass cast material is applied, along with the addition of a foot plate. (G) Once the fiberglass has hardened, a posterior cast window is cut at the margins of the gauze bulge. (H) After the gauze is removed and tape is used to cover the cut fiberglass edges, 2-inch-wide aluminum splinting material is contoured to provide a supporting strut posterior to the heel. (I) The aluminum is overwrapped with fiberglass casting material and then secured to the cast proximally and distally with additional fiberglass.

Figure 4.

Clinical photograph of the patient’s left heel after application of a modified short leg cast with a posterior heel window and fiberglass-wrapped aluminum strut, which entirely eliminates heel pressure.

Figure 5.

(A-C) Clinical photographs demonstrating progressive healing of the posterior soft tissue injury at 5, 8, and 12 weeks following revision percutaneous reduction and internal fixation. (D) Lateral radiograph at the 12-week mark demonstrating stable fixation and progressive fracture healing.

Figure 6.

(A, B) Clinical photographs demonstrating the patient’s left ankle range of motion in maximum active dorsiflexion and plantarflexion. (C, D) Clinical photograph and radiograph of the patient’s left heel 7 months after revision fixation demonstrating complete soft tissue and bony healing.