跟骨骨折

nullnullnullPreop lateral demonstrating joint depression type of fracture with displacement of a tuberosity and extension into the calcaneal cuboid joint.nullThe 30 degree semi-coronal and axial CAT scans of the fracture.TALUSDISPLACED POSTERIOR FACETINTACT POSTERIOR FACETSECONDARY FRACTURE LINETUBEROSITYANTEROLATERAL FRAGMENTTHALAMIC (SUSTENTACULAR) FRAGMENTDISPLACED POSTERIOR FACETnullThe patient is positioned carefully in the lateral decubitus position with pads under the axilla and downside peroneal nerve. The down leg is placed forward against and parallel with the anterior edge of the bed.nullPillows are placed between the legs and enough sheets behind the down leg such that the operative leg lies parallel with the ground and at the level of the patient’s hip.nullThe wrinkle test, as described by Sanders, involves dorsiflexing the foot from a plantar-fixed position and looking for normal skin turgor, as evidenced by wrinkling of the skin along the area of the lateral part of the foot. nullANTERIOR ACHILLES BORDERINCISIONPERONEAL TENDONSFIFTH METATARSALThe incision is slightly curved and L-shaped, beginning just anterior to the Achilles, curving at the level of the skin color change, running parallel with the sole of the foot and then curving slightly up anteriorly at its distal extent.FIBULAnullWith the tourniquet inflated, the corner of the incision is brought directly down to bone.nullABDUCTOR FASCIAToward the distal extent of the incision the fascia of the abductor should be identified and dissection should be performed superficially to this so as not to devascularize the muscle layer.nullIn order to dissect directly on the calcaneus in a subperiosteal manner, significant tension should be developed by holding the heel inverted with the thumb and pulling directly laterally away from the foot with a sharp retractor held deep in the flap.nullTENSIONThe tension as developed allows for easy dissection in a subperiosteal manner, with a knife that is held essentially parallel with the bone. Many #15 blades will be necessary in order to dissect out the entire calcaneus.nullPERONEAL TENDONSAfter the flap is completely elevated, the peroneal tendons are visible at the distal extent of the flap. Care must be taken not to damage these tendons as the dissection progresses distally.nullLATERAL PROCESS OF TALUSCloseup view demonstrating that with flap elevation the lateral process and posterior facet of the talus is identified. A K-wire is placed into the talar body from the lateral process and used to retract the flap.nullPIN IN FIBULAPIN IN TALUSDISPLACED POSTERIOR FACETThe lateral wall and displaced portion of the posterior facet of the calcaneus us removed.nullTUBEROSITYINTACT POSTERIOR FACET OF CALCANEUSPOSTERIOR FACET TALUSDISPLACED POSTERIOR FACETA bone hook can be used to pull the tuberosity down to its normal position; this reduction is necessary to allow for reduction of the posterior facet without steric interference.nullTUBEROSITYINTACT POSTERIOR FACET OF CALCANEUSPOSTERIOR FACET TALUSDISPLACED POSTERIOR FACETIn this figure, the posterior facet of the talus is visible with the intact medial portion of the posterior facet of the calcaneus remaining in its reduced position. The fractured lateral portion of the facet is visible as it is being removed.nullK-WIREFREER ELEVATORAfter cleaning the fragment, the posterior facet is reduced anatomically with the aid of a Freer elevator in palpating the reduction, which is sometimes very difficult to see. This is held in place with a K - wirenullK-WIREFREER ELEVATOROnce the reduction is confirmed under direct vision and fluoroscopy, it is fixed with cortical lag screws (next image). The fracture is anatomically reduced and visible with forceful inversion of the heel. nullPOSTERIOR FACET TALUSPOSTERIOR FACET REDUCTIONA head lamp can direct light against the posterior facet of the calcaneus by reflecting it off the posterior facet of the talus.nullThe lateral x-ray demonstrating K-wire holding the tuberosity in position. Also note a K-wire in the area of the angle of Gissane, holding the anterolateral fragment reduced.nullReduction of the anterolateral fragment is usually obtained by forceful manipulation with either a ball spike or periosteal elevator. A K-wire can then be placed in the anterolateral fragment into the intact medial sustentacular fragment (arrow).ANGLE OF GISSANEnullThe lateral wall fragments are pieced back as well as possible, given that they are sometimes comminuted.nullLateral radiograph and clinical picture after the anterolateral and anterior portion of calcaneus have been fixed with lag screws, demonstrating reduction of the facet, the anterior calcaneus and the tuberosity.nullAfter the bone is repositioned and held in place with K-wires, it is plated. In this example, two mini-fragment plates are used. However, many options are available for the plate fixation.nullLateral radiograph after initial plate fixation.nullThe closure is exceedingly important and must be done in several layers. The deep fascia must be repaired to the periosteum of the flap with interrupted sutures.nullDRAINThe sutures should all be placed and tagged, then closed from the distal extent of the wound towards the apex to continually remove tension from the flap during the closure. The closure should be performed over a Hemovac drain.nullIntraoperative plain radiographs in the lateral and AP plane demonstrate reduced calcaneus.