Contents 1 Pinyin 2 English reference 3 Overview 4 Disease name 5 English name 6 Category 7 ICD number 8 Causes of calcaneal fracture 8.1 Longitudinal fracture of calcaneal tubercle 8.2 Level of calcaneal tubercle (bird's beak shape) ) Fracture 8.3 Calcaneal calcaneal process fracture 8.4 Calcaneal front end fracture 8.5 Fracture close to calcaneal joint 9 Pathogenesis 9.1 Vertical pressure 9.2 Direct impact 9.3 Muscle tension 10 Clinical manifestations of calcaneal fracture 10.1 Articular appearance 10.2 Articular fracture 11 Calcaneus Complications of bone fractures 11.1 Calcaneal deformity or apophysis formation 11.2 Traumatic arthritis of the subtalar joint 11.3 Peroneal tendon entrapment syndrome 11.4 Flexor tendon adhesion Claw toe deformity 11.5 Achilles tendon weakness 11.6 Heel pad pain 11.7 Nerve entrapment 11.8 Valgus foot deformity 11.9 Calcaneal infection 12 Examination 13 Diagnosis of calcaneal fracture 14 Differential diagnosis 15 Treatment of calcaneal fracture 15.1 Non-surgical treatment 15.1.1 Undisplaced calcaneal fracture 15.1.2 Displaced fracture 15.1. 3 Severe compression and comminuted fractures in elderly people over 60 years old 15.2 Surgical treatment 15.2.1 Those with tongue-shaped calcaneal fractures and transverse calcaneal body fractures that affect the joints and are displaced 15.2.2 Displaced transverse and tongue-shaped calcaneal fractures Fractures and posterior calcaneal tubercle fractures 15.2.3 Calcaneal compression fractures or even comminuted fractures in young adults 15.2.4 Severe comminuted calcaneal fractures 15.2.5 Surgical methods 15.2.5.1 Bone pin prying reduction and fixation 15.2.5.2 Open reduction and compression screw internal fixation 15.2.5.3 Open reduction and bone grafting 15.2.5.4 Arthrodesis 15.2.5.5 Calcaneal osteotomy 15.3 Rehabilitation treatment 16 Prognosis 17 References attached: 1 Chinese patent medicines for the treatment of calcaneal fractures 2 Calcaneus fracture in ancient books 3 Prescriptions for treating calcaneus fracture 1 Pinyin
gēn gǔ gǔ zhé 2 English reference
Fracture of calcaneus [Traditional Chinese Medicine Terminology Approval Committee. Traditional Chinese Medicine Terminology (2004)] 3 Overview
Fracture of calcaneus [1] is the name of the disease [2]. It refers to a calcaneal fracture characterized by severe pain in the heel, obvious swelling and ecchymosis, inability to walk with the heel on the ground, and tenderness in the calcaneus [2][1]. It is caused by the interruption of the continuity of the bone or trabecular bone of the calcaneus [2].
Because most calcaneal fractures are caused by falls, and about 50% of calcaneal fractures are combined with thoracic and lumbar fractures, every patient with a calcaneal fracture should be aware of this, pay attention to physical examination, and take care of the thoracolumbar spine. Anteroposterior and lateral radiographs of the spinal column to avoid missed diagnosis. There are more adult patients. The calcaneus is a cancellous bone with a rich blood circulation supply, so nonunion is rare. However, if the fracture line enters the joint surface or is poorly reduced, it is common to suffer from post-traumatic arthritis and pain when the calcaneus is weight-bearing.
4 Disease name
Calcaneal fracture
5 English name
Fracture of calcaneus 6 Classification
Orthopedicsgt; Limb injuriesgt; Ankle Joint and foot injuriesgt; Foot injuries 7 ICD number
S92.0 8 Causes of calcaneal fractures
Calcaneal fractures are the most common tarsal fractures, accounting for approximately 60 with total tarsal fractures. It is usually caused by falling from a height, landing on the foot, and causing a vertical impact on the heel. The height of the fall, the nature of the ground and the weight are all factors in the injury; there is also the impact force acting on the heel from below. 8.1 Longitudinal fracture of the calcaneal tubercle
Longitudinal fractures of the calcaneal tubercle are mostly caused when the heel falls from a height and the bottom of the tubercle touches the ground in the valgus position, and the medial bulge of the tubercle is subjected to shearing force. Caused by. It is rarely displaced and generally does not require treatment. 8.2 Fracture at the level of the calcaneal tubercle (bird’s beak shape)
Fracture at the level of the calcaneal tubercle (bird’s beak shape) is a type of Achilles tendon avulsion fracture. If the avulsion bone fragment is small, it will not affect the function of the Achilles tendon. If the fracture fragment exceeds 1/3 of the nodule, is rotated and severely tilted, or is pulled upwards severely, it can be surgically reduced and fixed with screws. 8.3 Fracture of the calcaneal process
When the calcaneal process fractures in the varus position, it is caused by the impact of the calcaneal process from the medial and inferior sides of the talus, which is extremely rare. Generally, there is not much displacement. If there is any displacement, you can use your thumb to push it back to its original position and fix it with a short leg cast for 4 to 6 weeks. 8.4 Fracture of the front end of the calcaneus
Fractures of the front end of the calcaneus are less common. The mechanism of injury is strong forefoot adduction plus plantar flexion. Oblique X-rays should be taken to rule out tear and fracture of the anterosuperior process of the calcaneus, and the short leg should be immobilized in a cast for 4 to 6 weeks. 8.5 Fractures close to the calcaneotalar joint
Fractures close to the calcaneotalar joint are fractures of the calcaneal body. The injury mechanism is also when the calcaneus lands on the ground after falling from a height, or when the heel is subject to a counter-impact force from below. caused. The fracture line is oblique. Viewed from the front on the X-ray, the fracture line is oblique from medial to posterior to anterior and lateral, but does not pass through the calcaneotalar joint surface. Because the calcaneus is made of spongy bone, in the axial view, both sides of the calcaneal body are widened; in the lateral view, the posterior half of the calcaneal body and the calcaneal tubercle are displaced backward and upward, causing the belly of the calcaneus to bulge toward the center of the foot. In the shape of a rocking chair. 9 Pathogenesis 9.1 Vertical pressure
About 80% of the cases are caused by falling or sliding from a height. Depending on the position of the foot during the fall, the direction of the force is inconsistent and shows different fracture types, but basically compression fractures are the main ones. In addition, the degree of compression changes inconsistently depending on the intensity and duration of the force. 9.2 Direct impact
It is a fracture of the posterior tubercle of the calcaneus, which is mostly caused by a direct impact from an external force. 9.3 Muscle tension
The sudden contraction of the gastrocnemius muscle can cause the Achilles tendon to avulse the calcaneal tubercle. If the varus stress of the foot is too strong, it will cause the anterior calcaneal tubercle to avulse; and the valgus stress will cause the calcaneal tubercle to avulse. Process fracture or longitudinal fracture of the calcaneal tubercle, but the latter is rare. 10 Clinical manifestations of calcaneal fractures
Based on the typical history of trauma, heel pain and tenderness, heel congestion, wide and flat deformity, and the calcaneus tilting outward to appear valgus, and the normal depression under the lateral malleolus disappears etc., it is not difficult to judge the fracture. X-ray films are mainly standard lateral and axial films. When taking axial films, the X-ray tube should be projected at an angle of 40° to the longitudinal axis of the foot. On the lateral films, a line is drawn from the anterior articular process of the calcaneus to the posterior articular surface. , and then draw a line from the posterior articular surface to the calcaneal tubercle. The angle between the two lines is called the calcaneal tubercle angle (B?hler angle), which is normally 20° to 40° (Figure 1).
Generally divided into the following 2 types: 10.1 Extra-articular type
Extra-articular type refers to fractures that do not affect the calcaneotalar joint, including:
(1) Calcaneal Posterior tubercle fracture (Figure 2): It can be divided into longitudinal fracture, transverse fracture and avulsion fracture.
(2) Fracture of the anterior calcaneal tubercle (Figure 3): As shown in the figure, the fracture line passes through the anterior calcaneal tubercle.
(3) Fracture of the calcaneus process (Figure 4): The calcaneal process is fractured, often accompanied by displacement.
(4) Fracture of the calcaneotalar joint in front of the tubercle (Figure 5): In fact, the joint has been affected here, so care should be taken in handling. 10.2 Articular fractures
Depending on their shape and degree of damage, they can be divided into the following 4 types (Figure 6):
(1) Tongue fracture: multi-system Caused by vertical violence.
(2) Compression fracture: also caused by longitudinal vertical external force.
(3) Stump fracture: a longitudinal (oblique) fracture involving the talon-cuboidal and calcaneotalar joints.
(4) Crush fracture: mostly caused by strong compression violence. 11 Complications of calcaneal fracture 11.1 Calcaneal deformity or apophysis formation
Calcaneal deformity or apophysis formation is the most common sequelae. When the pressure on the limited part of the calcaneus increases, calluses, Pain caused by plantar fasciitis due to uneven cortex on the plantar side *** plantar fascia. 11.2 Traumatic arthritis of the subtalar joint
Patients often complain of pain in the tarsal sinus, and arthrodesis may be performed for those diagnosed with the disease. 11.3 Peroneal tendon entrapment syndrome
Peroneal tendon entrapment syndrome manifests as limited or widespread tenderness below the lateral malleolus and pain during movement. It is easily misdiagnosed as traumatic arthritis of the subtalar joint. Fusion surgery failed to relieve the pain. Symptoms can be relieved by widely resecting the part of the calcaneus that is causing compression by hyperplasia and releasing the tendon. 11.4 Claw toe deformity with flexor tendon adhesion
Claw toe deformity with flexor tendon adhesion is seen in the flexor toe and flexor tendon, and tendotomy or release is feasible. 11.5 Achilles tendon weakness
Due to the reduction of the tuberosity joint angle and the upward movement of the calcaneal tubercle, the Achilles tendon is relatively loose, causing weakness during walking and a heel-foot gait, which can be corrected by calcaneal osteotomy. 11.6 Heel pad pain
The heel pad structure is destroyed, the fat tissue is malnourished, and the pain threshold is reduced. 11.7 Nerve entrapment
It is caused by compression of the medial and lateral branches of the posterior tibial nerve or sural nerve. 11.8 Valgus foot deformity
After the calcaneal body is fractured, the lateral bone fragment is displaced outward, resulting in a valgus flat foot. This can be corrected by subtalar joint fusion or calcaneal osteotomy. 11.9 Calcaneal infection
Calcaneal infection is often caused by prying reduction or open reduction. In severe cases, it can cause calcaneal osteomyelitis. 12 Examination
Plain X-ray films (including frontal, lateral and calcaneal axis films) can generally confirm the diagnosis. For those with difficulty in diagnosis, CT scan or MRI can be used, especially CT scan in this fracture. It plays a great role in type diagnosis and prognosis. In X-ray examination, in addition to taking lateral radiographs, axial images of the calcaneus should be taken to determine the type and severity of the fracture. In addition, the calcaneus is a spongy bone. There is often no clear fracture line after compression, and sometimes it is difficult to distinguish. The severity of the fracture must often be analyzed based on changes in the shape of the bone and measurement of the tuberosity joint angle. 13 Diagnosis of calcaneal fractures
The diagnosis of calcaneal fractures is generally not difficult. In addition to the history of trauma and clinical symptoms, the diagnosis is mainly made from plain X-rays (anterior, lateral and axial views). And classify them accordingly. Only individual cases require CT scan or MRI examination. The heel can be extremely swollen, the posterior ankle groove can become shallow, and the entire hindfoot can be swollen and tender, which can easily be misdiagnosed as a sprain. 14 Differential diagnosis
Calcaneal fracture needs to be differentiated from heel sprain.
15 Treatment of calcaneal fractures 15.1 Non-surgical treatment 15.1.1 (1) Undisplaced calcaneal fractures
Undisplaced calcaneal fractures, including those where the fracture line leads to the joint, should be supported by a calf cast. Move for 4 to 6 weeks. After clinical healing, the plaster is removed and wrapped with an elastic bandage to promote the reduction of swelling. Do functional exercises at the same time. However, it is not advisable to walk on the ground too early, usually after 12 weeks after the injury. 15.1.2 (2) Displaced fractures
Such as longitudinal dehiscence of the calcaneus, avulsion fracture of the calcaneal tubercle and fracture of the calcaneal calcaneal process. It can be reduced manually under anesthesia, and then fixed in a functional position with a calf cast for 4 to 6 weeks. Posterior tubercle fractures need to be fixed in the plantar flexion position. 15.1.3 (3) Functional therapy should be used for severe compression and comminuted fractures in people over 60 years old.
That is, after resting for 3 to 5 days, bandage the local area with an elastic bandage, and then perform functional exercises, supplemented by physical therapy***, etc. 15.2 Surgical treatment 15.2.1 (1) Hyoid fractures of the calcaneus and transverse fractures of the calcaneal body affect the joints and are displaced
Hyoid fractures of the calcaneus and transverse fractures of the calcaneal body affect the joints and are displaced The patient can use bone pins to pry and reduce the position under anesthesia, and then use a calf plaster to fix it in a mild plantar flexion position for 4 to 6 weeks. 15.2.2 (2) Displaced transverse calcaneal fracture, tongue fracture and posterior calcaneal tubercle fracture
Displaced transverse calcaneal fracture, tongue fracture and posterior calcaneal tubercle fracture The fracture should undergo open reduction and internal fixation with compression screws. The plaster will be fixed in the functional position for 4 to 6 weeks after surgery. 15.2.3 (3) Compression fractures or even comminuted fractures of the calcaneus in young adults
Some people advocate early open reduction and bone grafting to restore the calcaneus. The general shape and longitudinal arch of the foot. Internal fixation may or may not be used depending on the situation. The calf is immobilized in a cast for 6 to 8 weeks after surgery. 15.2.4 (4) Severe comminuted fracture of the calcaneus
Some people advocate early arthrodesis of the calcaneus and calcaneocuboid joints for severe comminuted fractures of the calcaneus. However, most people advocate functional therapy first to promote the regression of edema and prevent tendon and joint adhesions. When complications occur later, three joint fusions of the feet are performed. 15.2.5 (5) Surgical method 15.2.5.1 ① Reduction and fixation by bone needle prying
The operation is performed under anesthesia and a balloon tourniquet. Make a small opening with a sharp knife on the lateral side of the Achilles tendon at the posterior calcaneal tubercle, and insert a thick round bone needle into the proximal fold (Figure 7). Then bend the knee to relax the gastrocnemius. The surgeon holds the bone pin and presses down on the plantar surface of the foot to reduce the fracture fragment. Finally, the bone pin is driven into the distal fracture fragment for internal fixation (Fig. 8). 15.2.5.2 ② Open reduction and internal fixation with compression screws
Make an arc-shaped incision forward from 2 to 3 cm posterior and inferior to the lateral malleolus, ending at the scaphoid (Figure 9). After incising the deep fascia, the peroneal tendon is pulled posteriorly to expose the transverse fracture of the calcaneal body and the calcaneotalar joint (Figure 10). Under direct vision, use periosteal dissection to reduce the displaced fracture, and fix it with a compression screw from the outside of the posterior fracture fragment to the front and upward (Figure 11). Tongue fractures or posterior tuberosity fractures are fixed with screws from top to bottom (Figure 12). 15.2.5.3 ③Open reduction and bone grafting
The incision and soft tissue exposure are the same as above, exposing the lower articular surface of the talus and the compressed and depressed calcaneal fracture and its articular surface. Use a periosteal stripper to insert to the lower edge of the depressed calcaneal fracture and pry the compressed fracture fragment back into position (Figure 13). The remaining gap was filled with bone fragments from three sides of the ilium with cortical bone (Fig. 14). Postoperatively, the patient is fixed in a functional position with a plaster for 6 to 8 weeks.
If it is a compression comminuted fracture and the B?hler angle disappears, after surgical incision, a periosteal stripper can be inserted through the fracture site and the posterior fracture fragment can be pried backward and downward to restore the B?hler angle. Angles and longitudinal arches. The remaining gap is implanted with bone blocks as above.
15.2.5.4 ④ Arthrodesis
Two methods are introduced here, both of which are indicated by the later occurrence of traumatic arthritis.
Rotating calcaneotalar joint bone grafting and expanded screw internal fixation: Make a transverse incision on the lateral side of the subtalar joint, about 4cm long. After incising the deep fascia, the middle part of the subtalar joint is exposed, and the fibrofatty tissue in the talar sinus is removed. If the subtalar joint space becomes narrow, a 0.5cm wide osteotome can be used to remove the upper and lower cartilage and part of the bone. Then use a trephine saw with an inner diameter of 1.5 to 2.0 cm to open the window from outside to inside across the calcaneotalar joint and remove the bone core. Soak the expansion nail in ice water at 0 to 5°C for about 5 minutes, then clamp it and implant it into the enlarged joint space in the center of the bone core. Rotate the bone core 90° and implant it back into the bone window (Figures 15 and 16). Postoperative cast fixation was the same as before.
The Yiguan Nail is patented by the author of this article. It consists of a horizontal arm and two inclined arms. The horizontal arm can prevent the nail from sliding into the joint cavity, and the distal opening distance of the two oblique arms is 1.5 to 2.0 cm. It is made of nickel-titanium shape memory alloy and then heat treated. Its characteristic is that it becomes soft after being soaked in ice water at O~5℃ for 5 minutes and can be clamped. After rewarming to about 37°C, the two oblique arms expanded on their own (Figure 17). The expansion force during expansion is used to squeeze and fix the bone graft block. Therefore, it has a pressurizing effect on the bone block and can promote the healing of the bone graft. In addition to the application of anterior cervical rotational bone grafting, we also apply it in anterior rotational bone grafting and fusion of lumbar spondylolisthesis, ankle joint fusion and subtalar joint fusion, with good results. Its indication is those without varus or valgus deformity.
Foot arthrodesis: An arc-shaped incision is made on the outside of the foot, equivalent to the calcaneotalar joint plane, starting from 2 to 3 cm posterior and inferior to the lateral malleolus, ending in front of the navicular bone, lateral to the dorsalis pedis artery (Figure 18) . After incising the deep fascia, the extensor digitorum longus tendon is retracted medially and the peroneal tendon is retracted posteriorly. Cut the calcaneal, talonavicular and calcaneocuboid joints to expose the articular surfaces of these three joints, remove the fibrofatty tissue in the talar sinus, and use a 2.5-3.0cm wide osteotome to cut off the cartilage surfaces of these three joints respectively. If there is varus, valgus or plantar flexion deformity, pay attention to correcting it during osteotomy (Figure 19). Then the joint surfaces are brought together and the incisions are sutured layer by layer. Thick cotton pads are used for bandaging, and the calf is fixed with a plaster cast for 2 to 3 weeks. After the sutures are removed, the calf cast is replaced and fixed for 8 to 10 weeks. 15.2.5.5 ⑤ Calcaneal osteotomy
Due to the transverse compression fracture of the calcaneus, which was not reduced in the early stage, the B?hler angle and the longitudinal arch of the foot disappeared, but the traumatic arthritis of the subtalar joint was not obvious or relatively severe. For mild cases, this operation is feasible. A slight arc-shaped incision is made on the lateral side of the calcaneus (Figure 20). After incising the deep fascia, the peroneal muscle is pulled forward and upward. Subperiosteal dissection of the superior posterior, lateral and plantar surfaces of the calcaneus. A wedge-shaped osteotomy is made on the calcaneus, and after the triangular bone fragment is removed, a compression screw is used to fix it from the plantar surface upward (Figure 21). Postoperative fixation is the same as before. 15.3 Rehabilitation treatment
Regardless of surgery or not, active activities of the quadriceps and toes should be performed during cast immobilization. After the cast is removed, if the fracture has healed or the joint has fused, ankle and foot function should be actively exercised, including the use of equipment. 16 Prognosis