Staging of fractures
The purpose of staging is to select the treatment plan and determine the prognosis. The first typing system accepted by most scholars was proposed, which was based on the change of the lateral Bhler and Gissane angles and the “double density shadow” in the heel bone, and was divided into type I: fractures not involving the talocalcaneal joint, including fractures of the calcaneal tuberosity and fractures involving the heel dice joint; type II: fractures involving the talocalcaneal joint Type II: fractures involving the subtalar joint, classified as lingual fractures and joint collapse fractures according to the course of the secondary fracture line (relying on the retrograde segment when violence is applied).
After the introduction of CT, new typing systems were proposed, among which the Sanders typing [3] was accepted by most scholars. It was classified by the number of fracture segments and the fracture line alignment of the posterior articular surface in coronal and axial CT films: the posterior articular surface was divided into three equal zones, namely the medial, central and lateral columns, on the axial surface with two lines A and B parallel to the longitudinal axis of the heel bone, and the third fracture line C was aligned with the medial border behind and separated from the carrier talus, resulting in four potential fracture segments. The fracture lines are marked with A, B, and C from the outside to the inside.
Type I: all undisplaced intra-articular fractures.
Type II: 2 fragment fractures of the posterior articular surface, classified into three subtypes IIA, IIB, and IIC according to the localization of the fracture line.
type III: posterior 3-fragment fractures with central fragment injury, classified as IIIAB, IIIAC, and IIIBC according to the location of the two fracture lines
Type IV: four-fragment fractures behind, or more than four-fragment fractures.
Treatment.
1.Non-surgical treatment
(1) Non-displaced heel fractures, including those with fracture lines leading to the joint, are braked with a calf cast for 4-6 weeks, and the cast is removed after clinical healing, and wrapped with an elastic bandage to promote the swelling to subside. At the same time, do functional exercise. However, it is not advisable to walk on the ground too early, usually after 12 weeks after the injury.
(2) Displaced fractures such as longitudinal fractures of the heel, avulsion fractures of the heel tuberosity and talar fractures of the heel. The fracture can be repositioned manually under anesthesia and then fixed in the functional position with a calf cast for 4-6 weeks, and the posterior tuberosity fracture should be fixed in the plantar flexion position.
(3) Functional therapy is used for severe compression fractures in elderly people over 60 years old. In other words, after 3-5 days of rest, the fracture is wrapped with an elastic bandage and then functional exercise is performed, supplemented by physical therapy and massage.
2.Surgical treatment
(1) Tongue fracture of heel bone, transverse fracture of heel bone and displaced heel bone can be repositioned under anesthesia by prying with bone round pin, and then fixed in mild plantar flexion position with calf cast for 4-6 weeks.
(2) Displaced transverse heel fractures, lingual fractures, and posterior heel tuberosity fractures should be repositioned by incision and internal fixation with compression screws. The postoperative cast should be fixed in the functional position for 4-6 weeks.
(3) Compression fractures or even comminuted fractures of the heel in young adults are advocated for early incision and bone grafting to restore the general shape of the heel and the longitudinal arch of the foot. Depending on the situation, internal fixation is used or not, and the calf is fixed in plaster for 6-8 weeks after surgery.
(4) Severe comminuted fractures of the heel are advocated for early arthrodesis, including the heel spur and heel dice joints. However, most people advocate functional therapy first to promote edema subsidence and prevent tendon and joint adhesions. When complications arise at a later stage, triple fusion of the foot is then performed.
(5) Surgical methods
(1) Bone round pin prying repositioning and fixation.
(ii) Internal fixation with incisional repositioning and compression screwing.
(iii) incisional repositioning and bone grafting.
(iv) joint fusion.
(5) Achilles osteotomy.
3.Rehab treatment
Regardless of surgery or not, active activities of quadriceps and toes should be performed during cast fixation. If the fracture has healed or the joint has fused after the cast is removed, active exercise of the ankle joint and foot function should be performed, including the application of equipment.