[Overview
The fracture of calcaneus is the most common of all tarsal fractures, accounting for about 60% of all tarsal fractures. Most of them are caused by vertical impact on the heel after falling from a high place and landing on the foot. When a paratrooper lands on his heel and suffers an impact or a mine explodes in naval warfare, or a ship floats from the surface with an impact, the heel of the deck operator is subjected to a counter-impact and a heel fracture can occur. Sometimes the external force is not necessarily large, only jumping from the chair to the ground, may also occur heel compression fracture. Therefore, if the patient has a history of trauma to the ground and heel pain, the possibility of a heel fracture should be suspected.
The heel bone is the common posterior arm of the internal and external arches, and its shape and position have a great influence on the formation of the arch and weight bearing. The Achilles tendon is attached to the posterior tuberosity of the heel bone, and if the tuberosity is displaced upward due to fracture, it can cause relaxation of the gastrocnemius muscle and excessive dorsiflexion of the ankle joint, thus hindering the normal function of the heel and toes. If the heel bone is thickened by scab formation, it can cause pain at the bottom of the heel when standing, heel valgus deformity or even spastic flatfoot; damage to the heel talus joint can also cause serious consequences. Therefore, early treatment of heel fracture is necessary to avoid wasting the disease.
After heel fracture, the heel can be extremely swollen, the posterior ankle sulcus becomes shallow, and the whole hindfoot is swollen and painful, which can be easily misdiagnosed as sprain. x-ray examination, in addition to lateral film, should be taken to determine the type and severity of fracture. In addition, the heel bone is a spongy bone, and there is often no clear fracture line after compression, so it is sometimes not easy to distinguish the fracture.
Treatment Overview
(a) Heel fractures that do not affect the talocrural joint
1. Longitudinal fractures of the heel nodule are usually caused by shearing of the medial elevation of the nodule when the bottom of the nodule lands in the heel valgus position during a fall from a height. It is rarely displaced and generally does not require treatment.
Separation of the metaphysis of the heel tuberosity is caused by the above-mentioned violence before the epiphysis is closed, and the fracture fragment may have obvious upward displacement. The fracture can be repositioned under lumbar anesthesia, with the knee joint flexed and the heel node traction performed with a kyphotic needle and the foot fixed by the assistant, with the direction of backward traction to separate the bone fragments and then downward traction. After the bone piece is reset, the affected foot is fixed in plantarflexion and slight knee flexion position for 4 weeks with a long-leg cast, and if necessary, the Kirschner pin can be sealed in the cast, and after 1 week, the pin is removed and replaced by a short-leg cast, which is fixed for another 4 weeks.
2. Heel node level (beak-shaped) fracture is a kind of Achilles tendon avulsion fracture (Figure 22-117). If the avulsion bone is small, it does not affect the function of the Achilles tendon. If the fracture fragment exceeds 1/3 of the tuberosity, and there is rotation and severe tilt, or serious upward pull, it can be surgically repositioned and fixed with screws. A straight incision on the lateral aspect of the Achilles tendon is feasible during surgery to avoid friction between the surgical scar and the shoe. Postoperatively, the Achilles tendon is fixed in a 30° plantar flexion position with a long-leg cast to keep the Achilles tendon in a relaxed position.
Figure 22-117 Heel tuberosity level fracture
Fracture of the talonavicular process of the heel is caused by the impact of the talonavicular process below the talus when the foot is turned inward, and is rare. If there is displacement, push it back to its original position with the thumb and fix it with a short leg cast for 4 to 6 weeks.
4.Fracture of the front end of the heel bone Rarely. The mechanism of injury is strong pronation of the forefoot plus plantarflexion. Its is a bifurcated heel boat heel dice ligament, which may play a role in avulsion fracture in the injury of the anterior superior process of the heel bone. Therefore, pain located in the heel dice area after a sprain of the tarsal joint of the foot should be radiographically oblique to rule out an avulsion fracture of the anterosuperior process of the heel. These fractures are rarely displaced and can be fixed in a short leg cast for 1 to 6 weeks.
5. Fractures close to the heel talonavicular joint are fractures of the heel body, and the mechanism of injury is also caused by a fall of the heel from a height, or by a counter-impact force on the heel from below. The fracture line is oblique, and on the frontal view of the X-ray, the fracture line is oblique from the inside to the outside, but not through the heel talar joint surface. In the lateral view, the posterior half of the heel body, together with the heel tuberosity, is displaced posteriorly, causing the ventral surface of the heel to protrude toward the center of the foot in the shape of a rocking chair. The upward displacement of the heel tuberosity weakens the tension of the gastrocnemius muscle and directly affects the Achilles tendon, and the joint angle of the heel tuberosity can become smaller, disappear or become a negative angle (Figure 1).
Figure 1 Heel body fracture with the fracture line not entering the heel talonavicular joint
A. Lateral position; B. Heel longitudinal axis position
Treatment: The heel can be rehabilitated under epidural anesthesia by using both hands to snap and squeeze both sides of the heel bone between the palms to correct the widening of the heel body to both sides, and at the same time, in the plantar flexion position, pull downward on the heel tuberosity to restore the tuberosity joint angle. After repositioning, the calf can be fixed in plaster for 4-6 weeks.
If the manual rehabilitation alone is unsatisfactory, traction repositioning is feasible. The affected limb is placed on the Bohler repositioning frame, and the heel node is passed transversely under fluoroscopy through the Searle’s nail, and traction is applied along the longitudinal axis of the heel first, then downward after the fracture line is separated, and after the Bohler’s angle is restored, the heel bone is squeezed on both sides with a heel clip to restore the normal width of the heel. However, many scholars believe that although the Bohler frame traction and width restoration is better, it is just more violent and often leaves heel pain after surgery. Therefore, it is advocated to use manipulation and early functional movement to restore the fracture, although it is worse, but the functional recovery is better than the strong repositioning.
(B) Heel fracture affecting the heel talar joint
1. Collapsed fracture of the lateral heel talocrural joint is mostly caused by a fall from a height and the heel bone landing on the ground (Figure 2). The fracture line slopes from the posterior medial side to the anterior lateral side and enters the subtalar joint. Due to gravitational compression, there is often a lateral dislocation of the broken end with a large portion of the subtalar articular surface. The central bone of the heel is also compressed, predisposing it to severe traumatic arthritis.
Figure 2 Collapsed fracture of the lateral talofibular joint
2. Total heel talar joint collapse fracture is a common fracture of the heel bone (Figure 3). The heel body is completely crushed and sunken by compression, and in severe cases, the heel dice joint may be involved. Traumatic arthritis is inevitable. It is difficult to treat and may leave a degree of residual disease. The treatment of compression fractures of the heel that affect the talocalcaneal joint is divided and can be summarized in four ways.
(1) Non-surgical treatment: also known as sports therapy without revision. The injured foot is wrapped with an elastic bandage and the affected limb is elevated. Encourage the early start of functional movement of the affected limb and rack crutches weight-bearing. Many people believe that this method is faster and more effective than fixed therapy for functional recovery. In general, patients can return to normal activities within six months, and about 3/4 of patients can return to normal work, especially for compression fractures of the heel that do not affect the talocrural joint.
Figure 3 All collapsed fractures of the heel talonavicular joint
(2) Bone traction treatment: treatment under continuous traction of the heel node and according to the principle of early activity can reduce the disuse of the disease.
(3) Open repositioning: for young people with collapsed fractures below the lateral talar joint. The joint angle of the talar tuberosity and the width of the heel body can be corrected first, and then the joint surface can be surgically corrected. A lateral heel incision is made to pry up the collapsed articular surface to a normal position, and then the cavity is filled with osteophyte to maintain the reset. Postoperatively, it was fixed with a tubular cast for 8 weeks. It is believed that internal fixation without external plaster fixation is more satisfactory.
(4) Early arthrodesis: Comminuted fractures involving the joint will definitely cause irreversible damage, so if the surgery is performed within 2-3 weeks after the injury, triple joint or heel spur joint fixation is more effective than late surgery.
(C) Heel fracture sequelae
The main sequelae of heel fracture are deformity healing and walking pain, so many people advocate that the weight-bearing time should be at least 8-12 weeks later, Lindsay and Dewar believe that at least 18 months are needed for the symptoms to stabilize, some patients still have residual symptoms after 4-6 months of resuming the original work, and some patients are still improving gradually after 10 years of follow-up. Therefore, the treatment of residual symptoms should be considered only after the self-perceived symptoms no longer improve.
The residual pain should be analyzed in terms of the type of fracture and whether it affects the heel-talar joint, and the following causes are considered.
1. sub talocrural joint pain Scarring and injurious arthritis can cause limitation of motion of the sub talocrural joint, and it is especially common for those with bone displacement of the articular surface. If the symptoms are severe and the diagnosis is clear, simple heel and talar joint fixation can be treated, but if the heel dice joint is also invaded, triple joint fixation is feasible.
2, peroneus longus tendinitis When the heel fracture is widened, the peroneus can be compressed, the tendon is displaced, if the fracture is not reset, the tendon can continue to suffer from irritation and symptoms, if necessary, the excess bone can be surgically removed to restore the tendon to its original position.
3, bone spurs heel spurs for the third cause of pain, the formation of bone spurs are mostly fracture deformity healing or heel fat pad rupture, the loss of the protective function of the heel, bone direct weight-bearing caused by partial fracture of the bone protrusion in any part of the formation of painful bone scabs, such as the use of insoles to protect no therapeutic effect, but also surgical removal of bone spurs.
4, heel dice arthritis ligament rupture during trauma can cause talus or heel dice joint subluxation, resulting in the formation of traumatic arthritis. Cortisone local seal can relieve the symptoms, such as severe symptoms, feasible triple joint fixation.
5.Nerve entrapment Rarely, the medial or lateral branch of the posterior tibial nerve and the lateral branch of the peroneal nerve can be entrapped by the soft tissue scar of the fracture. If necessary, surgical release should be performed.
(D) Fracture of the heel and talon joint
1. Classification
(1) Essex-Lopresti classification classifies the fracture into lingual fracture and articular compression fracture.
(2), Sanders classification Its typing is based on coronal CT scan. The widest posterior distance from the articular surface of the heel is selected in the coronal plane and divided into three parts A, B, and C from the outside in, representing the location of the fracture line. This results in a possible four-part fracture block, a three-part articular surface fracture block and a two-part carrier talar fracture block (Figure 4).
Type I: all nondisplaced fractures.
Type II: two-part fractures, subdivided into IIA, IIB, and IIC fractures depending on whether the fracture location is in A, B, or C.
Type III: three-part fractures, again subdivided into IIIA, IIIB, and IIIC fractures depending on whether the fracture location is in A, B, or C. typical fractures have a central compression fracture line.
Type IV: fracture containing all fracture lines, IVABC
Figure 4 Sanders CT classification
2. Surgical treatment
(1), Indications
①, posterior displaced fractures of the articular surface, generally considered as 2-part and 3-part displaced fractures of Sanders classification, type B and C of Essex-lopneti classification. The total posterior articular surface fracture displaced by more than 3 mm.
(ii) Those with heel spur angle <10° or completely lost.
③, severe deformity of the heel bone, widening of the heel bone, shortening and inversion deformity of the fracture, posterior articular surface height more than 10% less than normal, or axial film patients with the most width of the heel bone than the normal side of 10% increase is appropriate for surgery.
(4) Severe comminuted fractures.
(2), timing of surgery Incisional repositioning surgery can be performed within 12-24h after the patient’s injury, if the swelling is severe surgery is postponed for 10-14d, when the swelling subsides to the point of skin wrinkling, incisional repositioning will be more difficult after 3 weeks.
(3), purpose The purpose of incision and repositioning internal fixation is to restore the height, length and width of the heel bone, that is, to reconstruct the shape of the posterior talocalcaneal joint surface, to restore the heel talar angle and the width of the heel bone, in order to facilitate the early movement of the joint.
(4) Methods of incision and internal fixation
(1) The lateral approach is suitable for all types of fractures and is more commonly used because it can widely expose the lateral part of the heel, the subtalar joint, the heel dice joint, allow bone grafting and internal fixation, and rectify the lateral wall of the augmentation (Figure 5).
a. Incision and exposure: The incision is made one finger behind the lateral ankle and extends distally. If the heel dice joint is exposed, the incision can be extended to the base of the fifth metatarsal bone, and the skin and subcutaneous skin are sharply cut to reach the lateral wall of the heel bone. Pay attention to the upper and lower supporting bands of the peroneal tendon and the heel attachment point of the heel-fibular ligament and the beginning of the short metatarsal extensor muscle, make a subperiosteal dissection along the lateral wall, lift the peroneal tendon and the whole flap together to the posterior articular surface of the heel, and insert two kerf pins in the talus to block the flap to reduce the pull on the flap and affect the blood flow to avoid skin necrosis of the incision. To reduce incisional complications, Bernischke reported a lateral extension incision along the lateral aspect of the heel between the peroneal artery and the blood supply area of the posterior tibial artery. The incision starts from above the posterior aspect of the lateral ankle to the posterior lateral corner of the heel, and is made transversely between the skin of the plantar aspect of the heel and the lateral skin of the heel, and extends distally.
b. Fracture repositioning: firstly, from the heel tuberosity, the Stenograph pin is penetrated axially into the underside of the posterior articular surface fracture of the heel, and it is tractioned downward, then the Stenograph pin is driven into the distal end of the heel fracture to fix it, correct the heel inversion, outward displacement and restore the heel distance angle and heel height. Then enter through the lateral wall fracture gap and use a small periosteal driver to penetrate to the outer underside of the collapsed fracture fragment of the posterior articular surface, pry up the collapsed fracture and reset the fracture fragment of the medial posterior articular surface and the talonavicular process, the lateral and anterior fracture fragment of the posterior articular surface, and restore the posterior articular surface, which can be temporarily fixed with 2 Kirsch pins from the outer to the inner through the subchondral bone of the posterior articular surface to the talonavicular process and maintain the width of the reset. If the posterior articular surface and the heel talus angle are satisfactorily repositioned, 2 3.5 mm cortical bone screws are used instead of the Kirschner pins for fixation.
After restoration of the posterior articular surface, a large defect of the heel bone is often left below it. Finally, the lateral wall of the fragmented and elevated heel was repaired by manipulation to restore the width of the heel bone and prevent the peroneal tendon from being compressed.
c. Fracture fixation: When the posterior articular surface fracture is not severely crushed and displaced, 2 to 3 screws are used to fix the fracture. Severely crushed and displaced fractures can be fixed again with a splint, and the application of the splint aims to increase the lateral pressure internal fixation force, maintain the fracture repositioning and correct the heel widening, make the fracture stable and early activity. At present, a reconstructive plate, Y-shaped plate, is used to shape the plate to fit the heel bone so that the front end of the plate is below the lateral aspect of the anterior process and the rear end is above the tuberosity. If possible, the plate is screwed into the talar fracture block for maximum stability, with the most anterior screws screwed into the cartilage surface under the supporting heel dice joint and the most posterior screws screwed into the thickened cortex of the heel tuberosity (Figure 6).
d. Postoperative management: postoperative plaster fixation of the short leg, removal of the external fixation at 2 weeks, start of active range of motion exercises of the ankle and subtalar joint, prohibition of weight-bearing for 12 weeks, partial weight-bearing after 12 weeks.
Figure 5 Surgical steps
A. Incision; B. Fracture repositioning; C. Resetting the joint surface; D. Fracture fixation; E. Lateral view of fracture fixation
Achilles fracture fixation
A. Pre-operative; B. Post-operative
②, medial approach: mostly used to carry talar and medial heel fractures, its disadvantages, the lateral exposure of the heel bone is limited, it is difficult to rectify the subtalar joint, the internal fixation operation is limited by the scope of exposure, and bone grafting is difficult. This surgical approach is an 8-10 cm incision made parallel to the sole of the foot between the medial ankle and the plantar aspect of the foot. The sensory nerve passing through the incision is protected by freeing and distracting the neurovascular bundle to reveal the talar fracture fragment and the nodal fracture fragment, which are fixed with U-shaped nails or screws.
(iii) Medial and lateral approach: The medial and lateral approaches can overcome the shortcomings of using only the medial and lateral approaches, improve the correct repositioning of the heel and subtalar joint and improve the efficacy. When using the medial and lateral approaches, the lateral approach is usually done first, followed by the medial approach or the medial approach if necessary.