And progress in the treatment of calcaneal fractures
【Key Words】 calcaneal fractures
Calcaneal fracture is a common clinical fractures, one fracture in the body accounted for 2% of tarsal bone fractures in 60%. Multi-falling from a high place
directly touch the ground when the heel caused by compression, a small number of avulsion fractures caused by traffic accidents in recent years, such fractures also increased. Calcaneus to the complex cortical bone and cancellous bone with a 4 on the
basis of support for the anatomical characteristics of small joints, thereby making subtalar joint and transverse tarsal joints can be a high degree of coupling and precise connections, same time, the calcaneus is constitute the main components of the arch, so
that to ease the shock of foot flexibility. The importance of calcaneal fracture complexity, so that calcaneal fractures has been the people's attention, however, bio-
mechanics study of calcaneal fractures has just started , its variety of clinical types,
treatment methods, especially affected subtalar many joints in arguing. In this paper, and the progress of their treatment are reviewed.
A fracture of the sub-type
The purpose of classification is the choice of treatment and prognosis judgments. In
1952, Essexlopresti  proposed the first one for the majority of scholars accepted classification system, based on X-lateral Bhler angle Gissane angle changes and the
calcaneus in vivo "double-density shadow" as a classification basis, is divided into type
?: did not reach the subtalar joint fracture, including the calcaneal tubercle fractures and fractures involving the joints with the dice; ? type: spread subtalar joint fracture,
according to the secondary fracture line of the Traveling (violent role dependent
retrograde above) is divided into tongue fractures and joint collapse fracture.
CT advent, Johnson, Eastwood, Crosby and Fitzgibbons, Sanders, Zwipp all put forward a new classification system, in which Sanders classification  recognized by
the majority of scholars. The fracture fragments by the number and coronal, axial CT films after the articular surface of the fracture line Traveling classification: In the axial plane parallel to the vertical axis of the calcaneus A, B articular surface after the two
lines will be divided into three and so on major areas, namely, the medial, central and lateral columns, the first three fracture line C and the back of the inside of the boundary line, and with the set from the sudden separation of the resulting four
potential fracture fragments. Fracture line outside to inside with the A, B, C indicated. ? type: all non-displaced intra-articular fractures; ? type: 2 fragments after the
articular surface fracture, according to the positioning of the fracture line is divided
into ? A, ? B, ? C 3 subtype; ? type: associated with the back injury in the central
fragment 3 fragment fracture, the fracture line in accordance with the location of the two sub-? AB, ? AC, ? BC; ? type: fragment fracture of the back four, or more
than four fracture fragments.
As Essexlopresti classification does not accurately reflect the situation of intra-
articular fracture displacement, while the Sanders classification of calcaneal tubercle does not fully reflect the calcaneal cuboid joint body and with the injury situation, so now most of the scholars in the clinical classification of a combination of Essexlopresti and the Sanders classification.
Two treatment methods and research progress
Treatment of calcaneal fractures are divided into surgical and non-surgical
treatment, various methods of 150 years, there has been no indication of a unified standard, present, except for therapeutic purposes to reach consensus, on the handling of many aspects remain controversial. The treatment aims to: restoration of calcaneal height, width, recovery with the distance, with the cuboid articular surface of the anatomical relationship (Bhler angle, Gissane angle and Perie angle), to achieve the re-
fashioning heel and restore joint flexibility.
21 non-surgical treatment
Non-surgical treatment, including manual reduction plus cast immobilization, simple traction, compression bandaging, etc., suitable for non-shift or a small shift did
not reach the subtalar joint fracture, and the existence of local or systemic contraindications surgery patients. Currently approved treatment for the majority of scholars, opinion is: set from the condylar fractures, without displacement of cast immobilization in functional spaces for 4 to 6 weeks, there are displaced through the manual reduction after cast immobilization; calcaneal avulsion fracture of anterior process, leg cast plaster fixation 6 weeks, if not healing, resectable protrusion; calcaneal tubercle longitudinal fractures, without displacement of the pressure bandage, there is lateral displacement of the calcaneus traction pressure reduction after the plaster external fixation ; calcaneal tubercle level of fractures, no displacement of the cast immobilization, there is shift the way the reset plaster fixation; almost from the joint fractures with no displacement of the cast immobilization, there are clear lines displaced calcaneal tubercle traction the entire complex deformity after calcaneus widened cast immobilization. Omoto, and Nakamura  presents a way to repeat extrusion method of reduction plus vertical traction, its indications for 3 d after injury, the peroneal and small bone with ligaments between the structural integrity of the calcaneus fractures. The authors treated 102 cases of calcaneal fracture method has been applied, in which the results of 89 cases of excellent, but a serious tongue-type
fractures and comminuted fracture little effect.
Although non-surgical treatment operation is relatively simple, but most can not be
fully restored inside and outside foot arch height and with distance, with the cuboid articular surface of the anatomical relationships (such as squeezing traction reduction techniques due to lack of strength it is difficult to squeeze compression, broadening of
the calcaneus have been restored), and the resulting subtalar joints and adjacent joints pain, heel varus, heel widened and a series of after-effects.
22 Surgical treatment of
Thordarson and Krieger  1996 for the first time on the spread of subtalar
calcaneal fractures and non-surgical treatment were compared, results showed that:
The mean operative group function score reached 867, rather than the surgical group and only 550 ; from the surgical group under the joint activity of 20 ?, the non-surgical
group was 17, but limits the maximum possible rate with the pain, non-surgical group
was 100%, while only 25% of the surgical group, with the right with the Biomechanics of bone fractures and pathological mechanism of further study, especially now that
such fractures affect subtalar joint fractures surgical treatment more appropriate.
The specific method of surgical treatment are: reduction plus bone poking round pin fixation, external fixation, joint fusion, open reduction and internal fixation (ORIF) and minimally invasive technique. In which open reduction and internal fixation has become the subtalar joint fracture affected the main treatment, its efficacy has been a large multi-center clinical trial has been confirmed .
221 round poking reset pin fixation plus bone
Reset poking round pin fixation plus bone tongue is mainly applied in some joint compression fractures and fracture, this method is simple, easy to master, trauma and
less costly. Tongue fracture of the past, most scholars have adopted poking reset pin plus a single fixed-Gen Gu Yuan, due to a fixed very firmly, after have to use plaster external fixation. Yin Nishikawa et al  was poking reset after four cross-pin fixation
osseous that accordingly the formation of three-dimensional structure of both the
effective fracture fixation of calcaneal tubercle fracture blocks and blocks of tongue, but also against because of Achilles tendon The stretch caused by the upward shift
trend, to restore the normal physiological Achilles tendon tension, effectively prevent secondary caused by plantar fasciitis pain.
222 external fixator
External fixation for severely comminuted calcaneal fractures with severe soft tissue
injury or fracture, and the advantages are: surgery allows early weight-bearing, while
maintaining the subtalar joint separation, will not weight-bearing articular surface of
the subtalar generate pressure to achieve to protect from the articular surface of the
post-break purposes. Early weight-bearing is very important for the recovery of soft
tissue can reduce the heel and adjacent soft tissue pain and mild weight-bearing after-
effects of disuse atrophy. Current applications are more Ilizarov external fixator, and
thus improved hybrid external fixator. Leonard et al  uses a fixed tibia contains two rings and a foot pedal of the external fixator in 23 patients with 25 calcaneal fractures treated with lateral and excellent rate of 92%.
223 with the distance arthrodesis
With the distance arthrodesis for spread of serious subtalar joint fracture, these fractures due to severely damaged after the articular surface, as well as cartilage damage, from the technical and biological terms and were unable to achieve complete
anatomic reduction. Some scholars believe that this line of ORIF after surgery can not only solve the gastrocnemius muscle relaxation or contracture, near the joints of
arthritis or other consequences, but also because of the anatomical part of the reset to
make it easier to implement with the distance fusion; In addition, some scholars think that conservative treatment of early line with the distance arthrodesis is more suitable
for such fractures, reason: with the early formation of bone from the joint stiffness to respond more quickly to restore foot function, while avoiding the pain of two operations. Thermann and Hufner et al  have received right from the arthrodesis
with 40 patients (of which, in ORIF Across the surgery in 23 cases, conservative treatment of 17 cases Across this patients) for up to 10 a follow-up, and used three
different scoring methods study pointed out: In addition to the degree of fracture
surgery group more conservative group of serious things, in the treatment effect, there is no significant difference between the two.
224 Open reduction and internal fixation (ORIF)
As the orthopedic surgeon on the trauma and fracture healing in-depth
understanding, as well as biology, bio-mechanics of the rapid development of open
reduction and internal fixation (ORIF) method has been more and more widely in clinical applications. David et al  pointed out that the severe calcaneus fractures,
due to the complex's proximity to the heel, activities continue to be the impact of the ankle before, there are several key commitments, as well as poking reset after the shoe selection problems and other reasons, suitable for use ORIF treatment. The previous
view that type ORIF for Sanders ?, ? type of fracture and displacement of large
extra-articular fracture, but Zwipp et al  In the latest study, believe that the current ORIF surgical indications are: (1) intra-articular fracture and displacement of
the relevant joint