跟骨骨折手术方法PPT课件.ppt

,1,Preoplateraldemonstratingjointdepressiontypeoffracturewithdisplacementofatuberosityandextensionintothecalcanealcuboidjoint.,2,The30degreesemi-coronalandaxialCATscansofthefracture.,TALUS,DISPLACEDPOSTERIORFACET,INTACTPOSTERIORFACET,SECONDARYFRACTURELINE,TUBEROSITY,ANTEROLATERALFRAGMENT,THALAMIC(SUSTENTACULAR)FRAGMENT,DISPLACEDPOSTERIORFACET,3,Thepatientispositionedcarefullyinthelateraldecubituspositionwithpadsundertheaxillaanddownsideperonealnerve.Thedownlegisplacedforwardagainstandparallelwiththeanterioredgeofthebed.,4,Pillowsareplacedbetweenthelegsandenoughsheetsbehindthedownlegsuchthattheoperativelegliesparallelwiththegroundandatthelevelofthepatientship.,5,Thewrinkletest,asdescribedbySanders,involvesdorsiflexingthefootfromaplantar-fixedpositionandlookingfornormalskinturgor,asevidencedbywrinklingoftheskinalongtheareaofthelateralpartofthefoot.,6,ANTERIORACHILLESBORDER,INCISION,PERONEALTENDONS,FIFTHMETATARSAL,TheincisionisslightlycurvedandL-shaped,beginningjustanteriortotheAchilles,curvingattheleveloftheskincolorchange,runningparallelwiththesoleofthefootandthencurvingslightlyupanteriorlyatitsdistalextent.,FIBULA,7,Withthetourniquetinflated,thecorneroftheincisionisbroughtdirectlydowntobone.,8,ABDUCTORFASCIA,Towardthedistalextentoftheincisionthefasciaoftheabductorshouldbeidentifiedanddissectionshouldbeperformedsuperficiallytothissoasnottodevascularizethemusclelayer.,9,Inordertodissectdirectlyonthecalcaneusinasubperiostealmanner,significanttensionshouldbedevelopedbyholdingtheheelinvertedwiththethumbandpullingdirectlylaterallyawayfromthefootwithasharpretractorhelddeepintheflap.,10,TENSION,Thetensionasdevelopedallowsforeasydissectioninasubperiostealmanner,withaknifethatisheldessentiallyparallelwiththebone.Many#15bladeswillbenecessaryinordertodissectouttheentirecalcaneus.,11,PERONEALTENDONS,Aftertheflapiscompletelyelevated,theperonealtendonsarevisibleatthedistalextentoftheflap.Caremustbetakennottodamagethesetendonsasthedissectionprogressesdistally.,12,LATERALPROCESSOFTALUS,Closeupviewdemonstratingthatwithflapelevationthelateralprocessandposteriorfacetofthetalusisidentified.AK-wireisplacedintothetalarbodyfromthelateralprocessandusedtoretracttheflap.,13,PININFIBULA,PININTALUS,DISPLACEDPOSTERIORFACET,Thelateralwallanddisplacedportionoftheposteriorfacetofthecalcaneususremoved.,14,TUBEROSITY,INTACTPOSTERIORFACETOFCALCANEUS,POSTERIORFACETTALUS,DISPLACEDPOSTERIORFACET,Abonehookcanbeusedtopullthetuberositydowntoitsnormalposition;thisreductionisnecessarytoallowforreductionoftheposteriorfacetwithoutstericinterference.,15,TUBEROSITY,INTACTPOSTERIORFACETOFCALCANEUS,POSTERIORFACETTALUS,DISPLACEDPOSTERIORFACET,Inthisfigure,theposteriorfacetofthetalusisvisiblewiththeintactmedialportionoftheposteriorfacetofthecalcaneusremaininginitsreducedposition.Thefracturedlateralportionofthefacetisvisibleasitisbeingremoved.,16,K-WIRE,FREERELEVATOR,Aftercleaningthefragment,theposteriorfacetisreducedanatomicallywiththeaidofaFreerelevatorinpalpatingthereduction,whichissometimesverydifficulttosee.ThisisheldinplacewithaK-wire,17,K-WIRE,FREERELEVATOR,Oncethereductionisconfirmedunderdirectvisionandfluoroscopy,itisfixedwithcorticallagscrews(nextimage).Thefractureisanatomicallyreducedandvisiblewithforcefulinversionoftheheel.,18,POSTERIORFACETTALUS,POSTERIORFACETREDUCTION,Aheadlampcandirectlightagainsttheposteriorfacetofthecalcaneusbyreflectingitofftheposteriorfacetofthetalus.,19,Thelateralx-raydemonstratingK-wireholdingthetuberosityinposition.AlsonoteaK-wireintheareaoftheangleofGissane,holdingtheanterolateralfragmentreduced.,20,Reductionoftheanterolateralfragmentisusuallyobtainedbyforcefulmanipulationwitheitheraballspikeorperiostealelevator.AK-wirecanthenbeplacedintheanterolateralfragmentintotheintactmedialsustentacularfragment(arrow).,ANGLEOFGISSANE,21,Thelateralwallfragmentsarepiecedbackaswellaspossible,giventhattheyaresometimescomminuted.,22,Lateralradiographandclinicalpictureaftertheanterolateralandanteriorportionofcalcaneushavebeenfixedwithlagscrews,demonstratingreductionofthefacet,theanteriorcalcaneusandthetuberosity.,23,AftertheboneisrepositionedandheldinplacewithK-wires,itisplated.Inthisexample,twomini-fragmentplatesareused.However,manyoptionsareavailablefortheplatefixation.,24,Lateralradiographafterinitialplatefixation.,25,Theclosureisexceedinglyimportantandmustbedoneinseverallayers.Thedeepfasciamustberepairedtotheperiosteumoftheflapwithinterruptedsutures.,26,DRAIN,Thesuturesshouldallbeplacedandtagged,thenclosedfromthedist