In order to dissect directly on the calcaneus in a subperiosteal manner, significant tension should be developed by holding the heel inverted with the thumb and pulling directly laterally away from the foot with a sharp retractor held deep in the flap.
The patient is positioned carefully in the lateral decubitus position with pads under the axilla and downside peroneal nerve. The down leg is placed forward against and pБайду номын сангаасrallel with the anterior edge of the bed.
Preop lateral demonstrating joint depression type of fracture with displacement of a tuberosity and extension into the calcaneal cuboid joint.
ANTEROLATERAL FRAGMENT
The wrinkle test, as described by Sanders, involves dorsiflexing the foot from a plantar-fixed position and looking for normal skin turgor, as evidenced by wrinkling of the skin along the area of the lateral part of the foot.
TENSION
The tension as developed allows for easy dissection in a subperiosteal manner, with a knife that is held essentially parallel with the bone. Many #15 blades will be necessary in order to dissect out the entire calcaneus.
Pillows are placed between the legs and enough sheets behind the down leg such that the operative leg lies parallel with the ground and at the level of the patient’s hip.
LATERAL PROCESS OF TALUS
Closeup view demonstrating that with flap elevation the lateral process and posterior facet of the talus is identified. A K-wire is placed into the talar body from the lateral process and used to retract the flap.
With the tourniquet inflated, the corner of the incision is brought directly down to bone.
ABDUCTOR FASCIA
Toward the distal extent of the incision the fascia of the abductor should be identified and dissection should be performed superficially to this so as not to devascularize the muscle layer.
PERONEAL TENDONS
After the flap is completely elevated, the peroneal tendons are visible at the distal extent of the flap. Care must be taken not to damage these tendons as the dissection progresses distally.
SECONDARY FRACTURE LINE
TALUS
DISPLACED POSTERIOR FACET
INTACT POSTERIOR FACET
DISPLACED POSTERIOR FACET
TUBEROSITY THALAMIC
(SUSTENTACULAR) FRAGMENT
The 30 degree semi-coronal and axial CAT scans of the fracture.
FIBULA
ANTERIOR ACHILLES BORDER
INCISION
PERONEAL TENDONS
FIFTH METATARSAL
The incision is slightly curved and L-shaped, beginning just anterior to the Achilles, curving at the level of the skin color change, running parallel with the sole of the foot and then curving slightly up anteriorly at its distal extent.