Preop lateral demonstrating joint depression type of fracture

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Preop lateral demonstrating joint depression type
of fracture with displacement of a tuberosity and
extension into the calcaneal cuboid joint.
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SECONDARY FRACTURE LINE
ANTEROLATERAL FRAGMENT
TALUS
DISPLACED POSTERIOR FACET
INTACT POSTERIOR FACET
TUBEROSITY
DISPLACED POSTERIOR FACET
THALAMIC (SUSTENTACULAR) FRAGMENT
The 30 degree semi-coronal and axial CAT scans of
the fracture.
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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.
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Pillows 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 patients hip.
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The 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.
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FIBULA
ANTERIOR ACHILLES BORDER
PERONEAL TENDONS
FIFTH METATARSAL
INCISION
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 the sole of the foot and then
curving slightly up anteriorly at its distal
extent.
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With the tourniquet inflated, the corner of the
incision is brought directly down to bone.
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ABDUCTOR FASCIA
Toward 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.
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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 sharp retractor held
deep in the flap.
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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.
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PERONEAL TENDONS
After 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.
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LATERAL PROCESS OF TALUS
Closeup 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.
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PIN IN FIBULA
PIN IN TALUS
DISPLACED POSTERIOR FACET
The lateral wall and displaced portion of the
posterior facet of the calcaneus us removed.
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POSTERIOR FACET TALUS
DISPLACED POSTERIOR FACET
TUBEROSITY
INTACT POSTERIOR FACET OF CALCANEUS
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.
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POSTERIOR FACET TALUS
DISPLACED POSTERIOR FACET
TUBEROSITY
INTACT POSTERIOR FACET OF CALCANEUS
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.
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K-WIRE
FREER ELEVATOR
After 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 - wire
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K-WIRE
FREER ELEVATOR
Once 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.
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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.
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The 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.
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ANGLE OF GISSANE
Reduction 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).
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The lateral wall fragments are pieced back as
well as possible, given that they are sometimes
comminuted.
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Lateral 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.
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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.
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Lateral radiograph after initial plate fixation.
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The 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.
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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.
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Intraoperative plain radiographs in the lateral
and AP plane demonstrate reduced calcaneus.