1、Preop lateral demonstrating joint depression type of fracturewith displacement of a tuberosity and extension into the calcaneal cuboid joint.,The 30 degree semi-coronal and axial CAT scans of the fracture.,TALUS,DISPLACED POSTERIOR FACET,INTACTPOSTERIOR FACET,SECONDARY FRACTURE LINE,TUBEROSITY,ANTER
2、OLATERALFRAGMENT,THALAMIC (SUSTENTACULAR) FRAGMENT,DISPLACEDPOSTERIOR FACET,The patient is positioned carefully in the lateral decubitusposition with pads under the axilla and downside peronealnerve. The down leg is placed forward against and parallelwith the anterior edge of the bed.,Pillows are pl
3、aced between the legs and enough sheetsbehind the down leg such that the operative leg lies parallel with the ground and at the level of the patients hip.,The wrinkle test, as described by Sanders, involves dorsiflexingthe foot from a plantar-fixed position and looking for normal skin turgor, as evi
4、denced by wrinkling of the skin along the area of the lateral part of the foot.,ANTERIORACHILLESBORDER,INCISION,PERONEALTENDONS,FIFTHMETATARSAL,The 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
5、the sole of the foot and then curving slightly up anteriorly at its distal extent.,FIBULA,With the tourniquet inflated, the corner of the incision is brought directly down to bone.,ABDUCTORFASCIA,Toward the distal extent of the incision the fascia of the abductor should be identified and dissection
6、should be performed superficially to this so as not to devascularize the muscle layer.,In 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 awayfrom the foot with a
7、sharp retractor held deep in the flap.,TENSION,The tension as developed allows for easy dissection in asubperiosteal manner, with a knife that is held essentiallyparallel with the bone. Many #15 blades will be necessaryin order to dissect out the entire calcaneus.,PERONEALTENDONS,After the flap is c
8、ompletely elevated, the peroneal tendons arevisible at the distal extent of the flap. Care must be taken notto damage these tendons as the dissection progresses distally.,LATERAL PROCESSOF TALUS,Closeup view demonstrating that with flap elevation the lateral process and posterior facet of the talus
9、is identified. A K-wire is placed into the talar body from the lateral process and used to retract the flap.,PIN IN FIBULA,PIN INTALUS,DISPLACEDPOSTERIORFACET,The lateral wall and displaced portion of the posterior facet of the calcaneus us removed.,TUBEROSITY,INTACT POSTERIORFACET OF CALCANEUS,POST
10、ERIORFACET TALUS,DISPLACEDPOSTERIORFACET,A 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.,TUBEROSITY,INTACT POSTERIORFACET OF CALCANEUS,POSTERIORFACET TALUS,DISPLACEDPOST
11、ERIORFACET,In this figure, the posterior facet of the talus is visible with theintact medial portion of the posterior facet of the calcaneus remaining in its reduced position. The fractured lateral portionof the facet is visible as it is being removed.,K-WIRE,FREERELEVATOR,After cleaning the fragmen
12、t, the posterior facet is reducedanatomically with the aid of a Freer elevator in palpatingthe reduction, which is sometimes very difficult to see.This is held in place with a K - wire,K-WIRE,FREERELEVATOR,Once the reduction is confirmed under direct vision and fluoroscopy, it is fixed with cortical
13、 lag screws (next image). The fracture is anatomically reduced and visible with forceful inversion of the heel.,POSTERIORFACET TALUS,POSTERIOR FACETREDUCTION,A head lamp can direct light against the posterior facet of thecalcaneus by reflecting it off the posterior facet of the talus.,The lateral x-
14、ray demonstrating K-wire holding the tuberosity inposition. Also note a K-wire in the area of the angle of Gissane,holding the anterolateral fragment reduced.,Reduction of the anterolateralfragment is usually obtainedby forceful manipulation witheither a ball spike or periostealelevator. A K-wire ca
15、n thenbe placed in the anterolateralfragment into the intact medial sustentacular fragment (arrow).,ANGLE OFGISSANE,The lateral wall fragments are pieced back as well aspossible, given that they are sometimes comminuted.,Lateral radiograph and clinical picture after the anterolateral and anterior po
16、rtion of calcaneus have been fixed with lag screws, demonstrating reduction of the facet, the anterior calcaneus and the tuberosity.,After the bone is repositioned and held in place with K-wires,it is plated. In this example, two mini-fragment platesare used. However, many options are available for
17、the platefixation.,Lateral radiograph after initial plate fixation.,The closure is exceedingly important and must be done inseveral layers. The deep fascia must be repaired to theperiosteum of the flap with interrupted sutures.,DRAIN,The 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.,Intraoperative plain radiographs in the lateral and APplane demonstrate reduced calcaneus.,
