CALCANEU跟骨骨折.ppt

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