1、Preop lateral demonstrating joint depression type of fracture with 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 INTACT POSTERIOR FACET SECONDARY FRACTURE LINE TUBEROSITY ANTER
2、OLATERAL FRAGMENT THALAMIC (SUSTENTACULAR)FRAGMENT DISPLACED POSTERIOR FACET The 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.Pillows are
3、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 patients hip.The wrinkle test,as described by Sanders,involves dorsiflexing the 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.ANTERIOR ACHILLES BORDER INCISION PERONEAL TENDONS FIFTH METATARSAL 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.ABDUCTOR FASCIA Toward the distal extent of the incision the fascia of the abductor should be identified and dissection sh
6、ould 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 away from the foot with a sha
7、rp retractor held deep in the flap.TENSION The 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.PERONEAL TENDONS After the flap is compl
8、etely 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.LATERAL PROCESS OF TALUS Closeup view demonstrating that with flap elevation the lateral process and posterior facet of the talus is i
9、dentified.A K-wire is placed into the talar body from the lateral process and used to retract the flap.PIN IN FIBULA PIN IN TALUS DISPLACED POSTERIOR FACET The lateral wall and displaced portion of the posterior facet of the calcaneus us removed.TUBEROSITY INTACT POSTERIOR FACET OF CALCANEUS POSTERI
10、OR FACET TALUS DISPLACED POSTERIOR FACET 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 POSTERIOR FACET OF CALCANEUS POSTERIOR FACET TALUS DISPLACED POS
11、TERIOR FACET In 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.K-WIRE FREER ELEVATOR After cleaning the fragm
12、ent,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-wire K-WIRE FREER ELEVATOR 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.POSTERIOR FACET TALUS POSTERIOR FACET REDUCTION A head lamp can direct light against the posterior facet of the calcaneus by reflecting it off the posterior facet of the talus.The lateral x-r
14、ay 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.Reduction of the anterolateral fragment is usually obtained by forceful manipulation with either a ball spike or periosteal elevator.A K-wire c
15、an then be placed in the anterolateral fragment into the intact medial sustentacular fragment(arrow).ANGLE OF GISSANE The lateral wall fragments are pieced back as well as possible,given that they are sometimes comminuted.Lateral radiograph and clinical picture after the anterolateral and anterior p
16、ortion 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 plates are used.However,many options are available for the plate fixation.Lateral radiograph after initial plate fixation.The closure is exceedingly important and must be done in several layers.The deep fascia must be repaired to the periosteum of the flap wit