Calcaneal Fracture

　　A calcaneal fracture is the most common type of talus fracture, accounting for about 60% of all talus fractures. It is usually caused by a fall from a height, with the foot landing and the heel suffering a vertical impact. The following is an introduction to the common causes of calcaneal fractures.

　　1. Longitudinal Fracture of the Calcaneal Tuberosity

　　It usually occurs when the heel is in an inverted position and the bottom of the tuberosity lands on the ground from a height, causing the medial eminence of the tuberosity to be subjected to shearing external force. There is usually little displacement, and it generally does not require treatment.

　　2. Horizontal (Beak-shaped) Fracture of the Calcaneal Tuberosity

　　It is a type of Achilles tendon avulsion fracture. If the avulsed bone fragment is small, it will not affect the function of the Achilles tendon. If the fracture fragment is more than 1/3 of the tuberosity, and there is rotation and severe obliquity, or severe upward traction, it can be surgically reduced and fixed with screws.

　　3. Fracture of the Calcaneal Tuberosity

　　It is caused by the navicular tuberosity being impacted from below by the talus below the navicular bone when the foot is in an inverted position, which is rare. Generally, there is little displacement, and if there is displacement, it can be pushed back to the original position with the thumb, and short leg casting can be fixed for 4-6 weeks.

　　4. Fracture at the Front End of the Calcaneus

　　It is less common. The injury mechanism is the strong adduction of the forefoot plus plantar flexion. An oblique X-ray film should be taken to exclude the avulsion fracture of the anterior superior process of the calcaneus, and short leg casting can be fixed for 4-6 weeks.

　　5. Fracture Close to the Talocalcaneal Joint

　　It is a fracture of the calcaneal body. The injury mechanism is also a fall from a height where the calcaneus hits the ground, or the heel is subjected to an upward impact force from below. The fracture line is oblique. The fracture line appears obliquely from the posterior to the anterior on the frontal X-ray, but does not pass through the talocalcaneal joint surface. Because the calcaneus is cancellous bone, in the axial view, the sides of the calcaneal body are widened; in the lateral view, the posterior half of the calcaneal body and the calcaneal tuberosity move upward and backward, causing the calcaneal abdomen to bulge towards the sole in a rocking chair shape.

　　There are many complications of calcaneal fractures, the most common being: swelling, tension blisters, fascial compartment syndrome, nerve and vascular injury, wound dehiscence and infection, heel pad pain, calcaneal spurs, malunion of fractures, arthritis, etc. Other complications include limping, Achilles tendinosis, lateral impact syndrome, and tibial nerve neuritis, etc.

　　Fractures of the calcaneus often occur with severe soft tissue swelling and tension blisters. Blisters usually occur after fractures, including: continuous severe pain in the injured foot, severe swelling, weakness of toe flexion, pain in toe extension, decreased sensation in the sole, the appearance of tension blisters or ecchymosis, and severe tensional swelling of the heel, which are characteristic manifestations of this syndrome. Pressure monitoring should be applied to the deep, superficial, and intermediate fascial compartments of the calcaneus, and if the pressure reaches 30 mmHg (1 mmHg = 0.133 kPa) or reaches 10-30 mmHg during diastole, it should be considered as an indication for surgical incision. In addition, there are also other complications such as:

　　1. Calcaneal Deformity or Bony Protuberance

　　It is the most common sequelae. When the pressure in the localized area of the calcaneus increases, it is easy to form calluses and pain. Due to the irregularity of the plantar cortex stimulating the plantar fascia, plantar fasciitis occurs and causes pain.

　　2. Traumatic Arthritis of the Subtalar Joint

　　Patients often complain of pain at the talor fossa, and joint fusion surgery can be performed for confirmed diagnoses.

　　3. Peroneal Tendon Entrapment Syndrome

　　Manifested as limited or widespread tenderness below the lateral malleolus and pain during movement, which is often misdiagnosed as traumatic arthritis of the talocalcaneal joint and talocalcaneal arthrodesis, thus failing to relieve pain. Wide excision of the calcaneus part where hyperplasia causes impingement and release of the tendons can alleviate the symptoms.

　　4. Adhesion of the flexor tendons of the toes, leading to claw toe deformity

　　Seen in the flexor tendons of the toes and metatarsals, and can be treated with tenotomy or tenodesis.

　　5. Weakness of the Achilles tendon

　　Due to the reduction of the angle of the tubercle joint, the calcaneal tubercle moves upward, causing the Achilles tendon to become relatively relaxed, resulting in weakness during walking and a calcaneal gait. Calcaneal osteotomy can be performed for correction.

　　6. Posterior calcaneal pad pain

　　Destruction of the calcaneal pad structure, malnutrition of adipose tissue, and decreased pain threshold.

　　7. Nerve entrapment

　　Due to compression of the medial and lateral branches of the posterior tibial nerve or peroneal nerve.

　　8. Foot varus deformity

　　After the fracture of the calcaneal body, the lateral bone block moves outward, causing a valgus flatfoot. Subtalar joint fusion correction or calcaneal osteotomy can be performed.

　　9. Calcaneal infection

　　Commonly caused by manipulation reduction or open reduction, severe cases can lead to calcaneal osteomyelitis.

　　Calcaneal fractures, as the name implies, refer to fractures of the posterior heel, which often occur in adults and are usually accompanied by other types of fractures. It is easy to ignore during diagnosis. The following are common symptoms of calcaneal fractures, and attention should be paid to diagnosis.

　　1. Pain in the heel, difficulty in standing and walking after trauma.

　　2. Local swelling, tenderness, deformity, or palpable crepitus.

　　Calcaneal fractures are caused by external trauma, such as falling from a height, traffic accidents, etc. Human violent behavior can also lead to calcaneal fractures. Therefore, for the prevention of this disease, attention should be paid mainly to daily production safety and life safety, without other special preventive measures.

　　Calcaneal fractures can generally be diagnosed by X-ray films (including anteroposterior, lateral, and calcaneal axis films). For those with difficult diagnosis, CT scanning or MRI examination can be performed, especially CT scanning plays a significant role in the diagnosis and prognosis of this fracture. The main auxiliary examination method for this disease is imaging examination, which is mainly manifested as:

　　1. Anterior process fracture of the calcaneus.

　　2. Vertical fracture of the calcaneal tubercle.

　　3. Talocalcaneal fracture.

　　4. Comminuted calcaneal fracture.

　　5. Crushed calcaneal fracture.

　　Fractures not only rely on external medication but also need to be supplemented with necessary nutrition through food therapy. Therefore, fracture patients should pay particular attention to dietary coordination. So, what are the dietary therapies for fractures?

　　1 to 2 weeks after the fracture

　　At this stage, the fractured area is bruised and swollen, the meridians and collaterals are blocked, and the Qi and blood are stagnant. Attention should be paid to promoting blood circulation and removing blood stasis, and dispersing Qi. The patient experiences pain at the fractured area, and there is a decrease in appetite and gastrointestinal function. Therefore, the diet should mainly consist of light, appetizing, easy-to-digest, and easy-to-absorb foods, such as vegetables, eggs, soy products, fruits, fish soup, lean meat, etc. The preparation should mainly be steamed or simmered, and it is best to avoid acid, spicy, dry, and greasy foods that are fried, sautéed, or braised. As for soybean and bone soup, it belongs to the category of fatty and nourishing foods, containing a lot of fat that is not easy to digest and absorb, and may cause constipation. It is best not to eat it at this stage.

　　Dietary recipe: 10 grams of Panax notoginseng, 10 grams of Angelica sinensis, 1 pigeon, stewed until tender, and the soup and meat are consumed together. Take once a day, and continue for 7 to 10 days.

　　2. 2 to 4 weeks after the fracture

　　At this time, the patient has adapted physically and mentally to the condition after the fracture, and the pain caused by the fracture has also been relieved, and most of the ecchymosis and swelling have disappeared. Appetite and gastrointestinal function have also been restored. The diet should change from light to moderate high-nutrition to meet the needs of bone callus growth. Bone soup, Cordyceps chicken stew, fish, eggs, and animal liver can be added to the initial diet to provide more vitamin A, D, calcium, and protein. Eat more vegetables rich in vitamin C such as green peppers, tomatoes, amaranth, green vegetables, cabbage, and radishes to promote bone callus growth and wound healing.

　　Dietary recipe: 10 grams of Angelica sinensis, 15 grams of Fructus seu Semen Myristicae, 10 grams of Dipsacus asper, 250 grams of fresh pork ribs or beef ribs, stewed for more than 1 hour, and the soup and meat are consumed together. Use continuously for two weeks.

　　3. More than 5 weeks after the fracture

　　The ecchymosis at the fracture site has basically absorbed, and there is already bone callus growth, and it is transforming from the bone callus to the bone tissue. The patient's appetite is open, and there are no dietary taboos, and any high-nutrient food and food rich in calcium, phosphorus, iron, and other minerals can be eaten. Traditional Chinese medicine has extensive research on this, and it is believed that the diet during this period can be matched with old hen chicken soup, pork bone soup, sheep bone soup, deer tendons soup, stewed water fish, etc. Those who can drink can appropriately drink Du Zhong bone broken补 wine, chicken blood vine wine, tiger bone papaya wine, etc.

　　Dietary recipe: 10 grams of Chinese wolfberry, 15 grams of Fructus seu Semen Myristicae, 10 grams of Dipsacus asper, 50 grams of Job's tears. First decoct Fructus seu Semen Myristicae and Dipsacus asper to remove the dregs, then add the remaining two ingredients to cook porridge for consumption. Take once a day, and 7 days constitute one course of treatment. There should be an interval of 3 to 5 days between each course, and 3 to 4 courses can be used.

　　Practical evidence shows that for patients with fractures, nourishing according to the above-mentioned sequence of dietary therapy can significantly shorten the recovery period.

　　Fractures of the calcaneus are frequently encountered in daily life, mostly caused by carelessness. The treatment is mainly surgical, and the following is an introduction to the surgical treatment methods for calcaneal fractures.

　　1. Fractures of the calcaneal lingula, transverse fractures of the calcaneal body involving the joint with displacement can be reduced under anesthesia using a Kirschner wire, and then fixed with a lower leg cast in a mild plantar flexion position for 4 to 6 weeks.

　　2. Fractures of the calcaneus with displacement, such as transverse fractures, lingual fractures, and posterior calcaneal tuberosity fractures, should be treated with open reduction and compression screw internal fixation. The cast is fixed in the functional position for 4 to 6 weeks postoperatively.

　　3. Fractures of the calcaneus in young and middle-aged individuals, including comminuted fractures, are recommended to be treated with early open reduction and bone grafting to restore the general shape of the calcaneus and the longitudinal arch of the foot. Internal fixation may or may not be used depending on the situation. The lower leg cast is used for fixation for 6 to 8 weeks postoperatively.

　　4. Severe comminuted calcaneal fracture, some people advocate early arthrodesis, including talocalcaneal and talocalcaneal joints. However, most people advocate for initial functional therapy to promote edema subsidence and prevent tendinous and joint adhesions. When complications occur later, arthrodesis of the three joints of the foot is performed.

　　5. Surgical Methods

　　①Osteotome Reduction and Fixation The operation is performed under a pneumatic tourniquet after anesthesia. A small incision is made with a sharp knife on the lateral side of the Achilles tendon at the posterior tubercle of the calcaneus, and a thick K-wire is inserted through it to the near fracture block. Then, the knee is flexed to relax the gastrocnemius muscle. The operator holds the K-wire and presses it downwards towards the plantar surface of the foot to reduce the fracture block. Finally, the K-wire is struck into the distal fracture block to fix it.

　　②Open Reduction and Compression Screw Internal Fixation Starting from 2 to 3 cm below the posterior lower part of the external malleolus, an arched incision is made forward to the navicular bone. After incising the deep fascia, the fibular muscle tendon is pulled backward, and the calcaneal body transverse fracture and the talocalcaneal joint are exposed. Under direct vision, a periosteal剥离器 is used to reduce the displaced fracture, and a compression screw is fixed from the outer surface of the posterior fracture block to the anterior and superior side. The tongue-shaped fracture or posterior tubercle fracture is fixed from above to below with a screw.

　　③Open Reduction and Bone Grafting The incision and exposure of soft tissue are the same as above, exposing the subarticular surface of the talus and the compressed凹陷 calcaneal fracture and its articular surface. A periosteal剥离器 is inserted below the凹陷 fracture of the calcaneus, and the compressed fracture block is levered into reduction. The residual gaps are filled with bone blocks with three-sided cortical bone taken from the iliac bone. The postoperative fixation is with a cast for 6 to 8 weeks in a functional position.

　　④Arthrodesis This section introduces two methods, both of which are indicated by the occurrence of post-traumatic arthritis later.

　　⑤Calcaneal Osteotomy Due to transverse compression fracture of the calcaneus, early reduction was not performed, the Bhler angle and the longitudinal arch of the foot disappeared, but the traumatic arthritis of the subtalar joint was not obvious or mild, this operation can be performed. A lateral micro-arc incision is made, the deep fascia is incised, and the fibular muscle is pulled forward and upward. The calcaneus is stripped off subperiosteally from the superior, lateral, and plantar sides. The calcaneus is osteotomized in the shape of a wedge, and after removing the triangular bone block, a compression screw is used to fix it from the plantar side upwards. The postoperative fixation is the same as before.