Calcaneal Fracture Fixation: Plate and Screw Considerations

Questions related to internal fixation surgery for calcaneal intra-articular fractures using plates?

Hello Dr.
Lee, I would like to ask you some questions regarding the use of plates for fixation in the treatment of calcaneal fractures.
First, as far as I know, there are traditional Y-shaped plates and the self-funded Aplus anatomical plates for calcaneal fixation.
I would like to know if there is a difference in the types of screws used for fixation between these two plates.
Does the screw hole of the Y-shaped plate have threads?
Secondly, what should be considered when inserting the screws? What criteria do physicians use to determine the number of screws needed? How long should the screws be? Do they need to penetrate through the calcaneus, or is it sufficient for them to adequately engage the cancellous bone and reach the opposite cortical bone?
Thirdly, during calcaneal internal fixation surgery, at what amount of displacement (in mm) within the fracture would it lead to fixation failure? I apologize for the complexity of these questions, and I greatly appreciate and look forward to your response.

Xiao Zeng, 20~29 year old female. Ask Date: 2019/09/08

Dr. Li Yongheng reply Orthopedics

1.
The traditional Y-shaped plate has screw holes that are not threaded.
The self-funded A Plus anatomical plate allows for fewer bone screws to be used in fixation compared to the traditional Y-shaped plate, and the types of bone screws used for both plates are different.

2.
The principles of fixation are accurate reduction and stable internal fixation.
The number of bone screws is based on achieving stable fixation.
The length of the screws depends on the thickness of the bone; sometimes they need to penetrate the opposite bone, while other times it is sufficient to pass through the cancellous bone to reach the opposite cortical bone.
3.
An acceptable displacement is generally 2-3 mm.

Reply Date: 2019/09/08

More Info

Understanding calcaneal fractures and their fixation is crucial for optimal recovery and function. Calcaneal fractures, commonly known as heel bone fractures, can significantly impact mobility and quality of life. The fixation methods, particularly the choice of plates and screws, play a vital role in the healing process.

Types of Plates and Screws
1. Plate Types: The traditional Y-shaped plate and the newer Aplus anatomical plate are both used for calcaneal fracture fixation. The Y-shaped plate is designed to provide stability across the fracture site and is often used in more complex fractures. The Aplus anatomical plate, on the other hand, is contoured to fit the calcaneus more closely, which can provide better stability and potentially improve outcomes.

2. Screw Considerations: The screws used with these plates can differ in design and function. The Y-shaped plate typically utilizes screws with threads that engage the bone more effectively, providing a secure fixation. The Aplus plate may also use similar screws, but the design may allow for different screw lengths and angles to optimize fixation based on the fracture pattern.

Screw Insertion Guidelines
When inserting screws during fixation, several factors must be considered:
- Screw Length: The length of the screws should be sufficient to penetrate the cancellous bone and engage the opposite cortex. This ensures that the screws provide adequate stability. Generally, screws should be long enough to achieve bicortical fixation, meaning they should pass through the cancellous bone and engage the far cortex.

- Placement Technique: Proper technique is crucial. The screws should be inserted at the correct angle to avoid damaging surrounding structures and to ensure they provide the necessary support. The surgeon must also consider the fracture pattern and the amount of displacement when determining screw placement.

- Number of Screws: The number of screws used is determined by the fracture's complexity and stability. In general, more screws may be required for unstable fractures or those with significant displacement. Surgeons often follow guidelines based on the fracture type and their clinical experience.

Displacement and Fixation Failure
Displacement is a critical factor in the success of fracture fixation. If the fracture fragments are displaced beyond a certain threshold, it can lead to fixation failure.
- Critical Displacement Threshold: While there is no universally accepted measurement, a displacement of more than 2-3 mm is often considered significant and may compromise the stability of the fixation. If the fracture fragments are not adequately aligned and stabilized, it can lead to malunion or nonunion, necessitating further surgical intervention.

Conclusion
In summary, the choice of fixation method for calcaneal fractures involves careful consideration of the type of plate and screws used, the technique of screw insertion, and the management of displacement. The goal is to achieve stable fixation that allows for proper healing and restoration of function. If you have further questions or concerns about your specific situation, it is essential to discuss them with your orthopedic surgeon, who can provide personalized advice based on your condition and treatment plan.

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