Kalkaneusfrakturen

Fractures of the calcaneus generally occur in the setting of high-energy trauma, resulting in complex, three-dimensionally oriented fracture patterns. Surgical treatment is typically indicated for displaced intra-articular fractures, permitting restoration of calcaneal height, width and overall morphology, in addition to the posterior facet articular surface where possible, and enabling late in situ arthrodesis as a means of salvage in the event of post-traumatic arthritis. The present article briefly discusses our preferred methods for the management of calcaneal fractures. An English full text version of this article is available at SpringerLink as supplemental.     

Calcaneal fractures: Where are we now?

This review article on the current management for calcaneal fractures discusses the advantages and disadvantages of different treatment options including the problems encountered. Controversies are described and the evidence reviewed. The management of some types of displaced intra-articular calcaneal fractures remains contentious; is there a preferred stabilisation method for each type of calcaneal fracture? How constant is the “constant fragment” in an intra-articular calcaneal fracture and what is the evidence for primary arthrodesis and what is its place in these fractures?     

Management offener Fersenbeinfrakturen

Open calcaneal fractures are one of the most challenging problems in trauma surgery. Infection rates are five- to seven-fold that in the case of closed calcaneal fractures. Because of the unique anatomy of the calcaneus and its soft tissue envelope, grade II or III open fractures with comminution of the bony fragments are among the most serious forms of fracture. The classic treatment consists of thorough emergency debridement, percutaneous reduction and retention of fragments and second- and third-look surgery, with definitive osteosynthesis after soft tissue consolidation. Early and stable soft tissue coverage is of decisive importance in the prevention of infection. In recent years the concept of early definitive soft tissue coverage with free tissue transfer (within 120 hours) has emerged as a promising treatment alternative in complex foot trauma with extensive defects. Complication management in the event of calcaneal osteitis includes radical, serial debridements with plate removal, minimally invasive stabilization, temporary insertion of antibiotic beads and definitive closure of soft tissue and bone defects, for which, again, it may be necessary to transpose free tissue. However, persisting functional impairment is inevitable in these cases. Therefore, surgical treatment of open calcaneus fractures must be directed consistently at preventing infection.     

Die Schwierigkeiten in der Beurteilung von Nachuntersuchungsergebnissen bei plattenosteosynthetisch versorgter Kalkaneusfraktur Gibt es einen praktikablen Score?

A huge amount of publications is existing dealing with topics of operative or nonoperative treatment, results and follow-up of fractures of the os calcis. Comparing the different studies one can see that there are a lot of different scores applicated for follow-up and outcome. Therefore it's difficult or impossible to compare the results of the different publications. The problems are discussed while evaluating own results of operative treated fractures of the os calcis. Between 1993 and 1996 we treated 27 fractures with ORIF (open reduction and internal fixation). 25 of the patients could be followed-up after a mean of 22.1 months. For follow-up three recently published scores, the AOFAS Ankle-Hindfoot Scale (AOFAS), the Calcaneal Fractures Scoring System (CFSS) according to Kerr and the Functional Outcome Assessment-Score (FOA) according to Thordarson were used. The mean AOFAS-Score was 76.52 +/- 14.22, the mean CFSS was 77.40 +/- 15.22 and the mean FOA was 70.08 +/- 18.53 points. The differences between the AOFAS and the FOA-Score were significant (p = 0.017). The differences between the CFSS and the FOA-Score were significant (p = 0.004), too. These different values elucidate the need of uniform structured follow-ups of fractures of the os calcis. To compare different national or international studies uniform scores should be used. In anglo-american literature the AOFAS Ankle-Hindfoot Scale is well established. This scoring-system proved to be quite useful in our own analysis. We suggest that the AOFAS Ankle-Hindfoot Scale also should be taken into account in german literature, especially in follow-up of calcaneal fractures.     

Managing the open calcaneal fracture: A systematic review

IntroductionOpen fractures of the calcaneus are rare. They are mostly caused by high-energy trauma. There are several treatment options for calcaneal fractures. However, treatment of open calcaneal fractures might need a different approach, as open calcaneal fractures are associated with high rates of complications. The purpose of this study was to provide a literature overview on the management of open calcaneal fractures, and deduct a more standardized treatment algorithm.Material and methodsA literature review was conducted in the databases of PubMed, EMBASE and the Cochrane Library for articles describing the management of open calcaneal fractures. Excluded were studies with less than 10 patients, studies describing combat injuries and reviews. Only articles published from 1998 to 2017 were included and there were no language restrictions.ResultsA total of 18 articles were included with 616 open calcaneal fractures in 598 patients. Most wounds were Gustilo grade III and most fractures were Sanders type III. Definitive surgery was performed after a mean of 9.8 days and in most cases in the form of ORIF via ELA. The complication rate was 21% and the mean AOFAS score was 73.7 points.ConclusionThe complication rates of open calcaneal fractures are high and increase with the severity of the wound. A treatment algorithm is suggested. However, to produce a more evidence-based protocol and achieve consensus for treatment, additional research should be done, preferably in the form of a prospective multicenter database.     

跟骨关节内骨折的诊断与治疗

跟骨骨折是跗骨中最常见的骨折,约75%的跟骨骨折为关节内骨折。虽然跟骨骨折的治疗经验日益增多,但对其诊断和处理仍存在争论,包括最合适的分类方法、治疗方法的选择、手术治疗的指征、手术入路及术后处理等。本文对跟骨关节内骨折的诊断和治疗进行综述。对于有移位的跟骨关节内骨折,手术疗效优于保守治疗。     

Treatment of calcaneal fractures: the available evidence

Abstract Calcaneal fracture is the most common of the tarsal fractures and represents 1%–2% of all fractures. The fractures may be divided into extra-articular (not affecting the joint) and intra-articular (involving the talo-calcaneal and calcaneal cuboid joints) types. The management of heel fractures includes nonoperative and operative treatments, but no clear consensus has been reached. The choice of operative treatment is still controversial with many factors influencing the final clinical outcome. Many studies have assessed the outcome of treatment of calcaneal fractures, but there is a general disagreement on their management. The objective of this study was to collect and evaluate the scientific evidence reported in the literature supporting the different treatments for calcaneal fractures.     

Intra-articular calcaneus fracture. Classification in CT as a prerequisite for therapeutic decision and quantitative comparison]

Whether conservative or operative management is selected for intra-articular fractures of the os calcis depends on subjective factors and on the surgeon's experience. There is no classification available that allows ranking of such fractures according to the extent of destruction and the degree of dislocation at the same time. CT scans of 44 calcaneal fractures have been used to elaborate a new classification system for calcaneal surfaces. According to the involvement of joint surfaces, especially of the posterior facet, the degree of dislocation and the number of fragments of the posterior facet, six classes are defined. Within each class of fracture, the formation of "steps" in the posterior facet, widening of the heel, loss of height and deviation of axes are quantified. The new classification provides an instrument for use in the evaluation of joint destruction and dislocation. It helps to provide an objective basis for decisions between functional treatment and open reduction with internal fixation and for prospective analysis of fracture treatment.     

跟骨骨折

跟骨骨折是最常见的跗骨骨折，多因从高处跌下所致。其合适的骨折分型、治疗选择、手术指征、手术入路和术后处理仍存在争议。跟骨骨折分为关节外骨折和关节内骨折。sanders的分型方法对跟骨骨折治疗方法的选择及预后的判断有重要意义。跟骨骨折的治疗具有挑战性，目前尚无理想的治疗方法，有待于进一步深入研究。保守治疗适合于移位小的骨折，对于移位大或粉碎的骨折可应用手术治疗。跟骨骨折的并发症有张力性水疱，筋膜间隙综合征，伤口裂开，伤口感染，疼痛，距跟关节炎等。本文对跟骨骨折的损伤机制、分型、评分、治疗方法及并发症等作一综述。     

跟骨骨折的分型和治疗进展

跟骨骨折是最常见的跗骨骨折,多因从高处跌下所致。其合适的骨折分型、治疗选择、手术指征、手术入路和术后处理仍存在争议。跟骨骨折分为关节外骨折和关节内骨折。Sanders的分型方法对跟骨骨折治疗方法的选择及预后的判断有重要意义。跟骨骨折的治疗具有挑战性,目前尚无理想的治疗方法,有待于进一步深入研究。保守治疗适合于移位小的骨折,对于移位大或粉碎的骨折可应用手术治疗。跟骨骨折的并发症有张力性水泡,筋膜间隙综合征,伤口裂开,伤口感染,疼痛,距跟关节炎等。本文对跟骨骨折的分型、评分、治疗方法、并发症及治疗进展等作一综述。     

保守或简单手术治疗跟骨骨折的临床经验

目的 评价保守治疗或简单手术治疗跟骨骨折的疗效。方法 随访保守治疗或辅以经皮斯氏针撬拨、斯氏针固定、螺钉固定跟骨骨折2年以上的97例患者，管型石膏固定64例(保守组)；经皮斯氏针橇拨固定27例，螺钉固定6例(简单手术组)．结果 随访结果满意，其中优23例、良67例、可5例、差2例，优良率92．7％。2例在伤后1年左右因踝关节痛，行距跟关节融合术。结论 虽然保守治疗或简单手术治疗跟骨骨折疗效满意，但是临床需要有统一分型下的前瞻性对比研究，以进一步证明跟骨骨折是采用切开复位固定还是简单治疗。     

经“八”字切口微创固定治疗跟骨关节内骨折

目的探讨经跟骨外侧"八"字切口、Y型解剖板微创固定治疗跟骨关节内骨折的疗效。方法对46例闭合跟骨关节内骨折采用跟骨外侧"八"字切口、Y型解剖板微创固定治疗。结果 46例均获得随访,时间12~30个月。患者骨折均愈合,无一例发生切口深部感染、皮肤坏死及骨髓炎等严重并发症。按AOFAS评分标准评价:优30足,良14足,可3足,差2足,优良率为89.8%。结论经跟骨外侧"八"字切口、Y型解剖板微创固定治疗跟骨关节内骨折,术中直视下复位跟骨后关节面,固定可靠,可早期活动。     

Fine Wire Circular Fixation for Displaced Intra-Articular Calcaneal Fractures: A Systematic Review

Intra-articular calcaneal fractures represent an ongoing challenge for the orthopedic community, with the benefits of the previous “gold standard” treatment of open reduction and internal fixation having been called into question in several large randomized controlled trials. Fine wire circular fixation may represent a useful alternative treatment for these injuries, combining minimally invasive application with rigid fixation, which allows the possibility of early weight bearing We performed a systematic review of published studies that used circular fixation for calcaneal fractures and recorded functional outcomes at follow-up. In a total of 11 studies with 255 calcaneal fractures for which there was follow-up, our inclusion criteria were met: 8.2% of fractures were bilateral, 11.9% of fractures were open fractures, and 12.6% of patients had multiple orthopedic injuries. Functional outcomes were assessed with the use of a variety of tools across the different studies, but outcomes compared favorably with those seen with open reduction and internal fixation. Although pin site infections were common (22.6%), serious complications, including deep infection (0.8%), wound infection (1.6%), and complex regional pain syndrome (0.8%), were exceedingly rare. The results suggest that this is a viable alternative treatment for calcaneal fractures, but higher-quality randomized controlled trials are required before the technique can enter mainstream use.     

Soft tissue complications following calcaneal fractures

Soft tissue complications following calcaneal fractures can be frustrating to the patient and present reconstructive challenges for the surgeon. Preoperative patient assessment may define a group of patients who are best treated nonoperatively in an effort to avoid disastrous soft tissue complications. Late sequelae will continue to be seen and through the use of differential injections, physical exam, and appropriate intervention, the practitioner can usually decrease symptoms and improve a patient's function. Further studies in the treatment of open calcaneal fractures are necessary to better define treatment algorithms. A working knowledge of these complications and their management is necessary for the surgeon treating calcaneal fractures.     

Wound healing complications in closed and open calcaneal fractures

OBJECTIVES: To determine the rate of serious infection in closed and open calcaneal fractures that were treated with open reduction and internal fixation (ORIF) via an extensile lateral approach. DESIGN: Retrospective review. SETTING: Level 1 trauma center. PATIENTS: Two groups of patients with calcaneal fractures treated with ORIF via an extensile lateral approach by the senior author are included. The first group contained 341 closed fractures in patients injured during the period 1994-2000. The second group included 39 open calcaneal fractures in patients injured during the period 1989-2000. MAIN OUTCOME MEASUREMENTS: The age, sex, pre-existing medical conditions, compliance history, mechanism of injury, soft tissue status, presence of serious infection, and treatment of the infection were recorded for each patient. Data were gathered by review of patient records and by telephone interview when medical records were incomplete. The rate of serious infection in the closed and open samples was determined. A literature review yielded 15 reports that contained sufficient detail to calculate the rate of serious infection. RESULTS: Of patients, 1.8% with closed fractures and 7.7% with open fractures experienced serious infections that required intervention beyond oral antibiotics. All of these feet eventually healed their incisions and fractures. The calculations from data obtained from the literature review indicate rates of serious infection of 0-20% for closed and 19-31% for open calcaneal fractures. CONCLUSIONS: When done correctly in compliant patients, ORIF for calcaneal fractures via the extensile lateral approach (which allows for restoration of calcaneal anatomy after substantial disruption) does not expose the patient to undue risk of serious infection.     

Fractures of the calcaneus

Displaced fractures of the calcaneous are relatively common injuries that remain a treatment enigma. Virtually all aspects of the management of calcaneal fractures are a source of debate. Contemporary imaging, reduction, and fixation techniques attempt to improve the long term results of these injuries. The complex fracture fragments displace in predictable patterns. Meticulous surgical technique, restoration of extra- and intra-articular anatomy, and obtaining rigid fracture fixation are critical to obtaining satisfactory operative results. This article extensively reviews the controversies and summarizes the current opinions in the management of displaced calcaneal fractures.     

Percutaneous treatment of calcaneal fractures

Percutaneous fixation of calcaneal fractures has limited indications. It is most useful for tongue-type fractures in which the displaced portion of posterior facet remains intact to the tuberosity. This allows the tuberosity to be used as a reduction tool for the posterior facet. The technique has been used successfully in 41 patients. In the current study, the indications and technique are reviewed in detail.     

Landing on Your Own Two Feet: A Case Report of Bilateral Calcaneus and Open Pilon Fractures

High energy fractures of the distal tibial plafond and calcaneus have been associated with high functional morbidity and wound complications. Although both of these fractures result from a similar mechanism, they have rarely been reported to occur on an ipsilateral extremity. The combination of these 2 injuries on the same extremity would increase the likelihood of an adverse surgical or functional outcome. We present the case and management strategy of a 43-year-old male with bilateral open pilon fractures and closed calcaneal fractures after falling from a height. A staged protocol was used for the bilateral pilon fractures, with external fixation until operative fixation on day 9. Nonoperative management of the calcaneal fractures resulted in a successful functional outcome at 10 months of follow-up. Treatment of this fracture pattern must incorporate the condition of the soft tissues, an understanding of the fractures, and minimize patient risk factors to optimize the functional and surgical outcomes.     

Management of calcaneal tuberosity fractures

Fractures of the calcaneal tuberosity are relatively uncommon and are seen most frequently in elderly and diabetic patients. These injuries are typically avulsion fractures caused by concentric contraction of the gastrocnemius-soleus muscle complex. Displacement of these fractures can compromise the skin over the posterior aspect of the heel; therefore, early recognition and management are imperative. Surgical management of calcaneal tuberosity fractures requires reduction and stable fixation of the displaced fragment. When the patient has preexisting tightness of the gastrocnemius-soleus complex, successful management must also address this pathology to improve outcome.