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1、(Rammelt and Zwipp, 2004). Until the end of the 19th century the prevention of life-threatening infections by partial or total calcanectomy was the primary goal of fracture treatment. In 1938, Goff described more than 40 different operative treatment methods for calcaneal fractures, most of them per
2、cutaneous. Above all, the French surgeons of the 1920s pioneered in open reduction and internal fixation of displaced intra-articular calcaneus frac- tures with staples or screws and even defect filling with autologous bone grafts (Leriche,1922; Lenormant et al., 1928). In 1934, the German surgeon W
3、esthues used percutaneous pin leverage for reduction of the main tuberosity fragment andTrauma 2006; 8: 197212 2006 SAGE Publications10.1177/1460408606073367Calcaneus fracturesStefan Rammelt and Hans ZwippAssessment and treatment of calcaneal fractures have made substantial progress over the last tw
4、o decades. Open reduction and stable internal fixation without joint transfixation has been established as standard therapy for most displaced intra-articular fractures with good to excellent results in more than two-thirds of patients in larger clinical series. The use of bone grafting or bone subs
5、titutes appears unnecessary in most cases. Important prognostic factors are anatomical reduction of subtalar joint congruity and the overall shape of the calcaneus. Therefore, quality of joint reduction should be reliably proved intra-operatively either with open subtalar arthroscopy or high-resolut
6、ion (3D) fluoroscopy. Treatment results are adversely affected by open fractures, delayed reduction after more than 14 days, a high body mass index and smoking. The extended lateral approach respects the neurovascular supply to the heel and allows a good exposition of the fractured lateral wall, the
7、 subtalar and calcaneocuboid joints in complex fractures. In simple fracture patterns percutaneous screw fixation, supplemented by arthroscopic control if necessary, is a good alternative. Open fractures, compartment syndrome and fractures with severe soft tissue compromise are treated as emergency
8、cases. Early, stable soft tissue coverage exploiting the full armamentarium of pedicled and free tissue transfer appears promising in improving the functional results and infection rates after open fractures. Calcaneal malunions after conservative therapy of displaced fractures are disabling conditi
9、ons that can be treated successfully with a staged protocol according to the type of deformity. Treatment options include lateral wall decompression, in situor correctional subtalar arthrodesis and calcaneal osteotomies.Key words: calcaneal fracture; calcaneal malunion; open reduction; percu- taneou
10、s reduction; subtalar arthroscopyIntroductionFew injuries of the human body have generated so many controversies and seen so many changes of treatment concepts like fractures of the calcaneusDepartment of Trauma Tornetta, 2000; Rammelt et al., 2004a). However, unacceptably high infection rates and i
11、nadequate fixation devices have led to a decline of calcaneus surgery in the mid-20th century with many surgeons advocating primary or secondary subtalar arthrodesis (Gallie, 1943; McLaughlin, 1963). The unsatisfying clinical results after conser- vative treatment of displaced intra and articular ca
12、lcaneus fractures (James and Hunter, 1983) and the routine availability of CT scanning for diagnosis resulted in a reappraisal of the surgical approach in the 1980s (Sanders et al., 1992; Bzes et al., 1993; Benirschke and Sangeorzan, 1993; Zwipp et al., 1993). Today open reduction and internal fixat
13、ion is favoured by most surgeons although the strategy is still a matter of debate (Sanders, 2000; Rammelt and Zwipp, 2004). Furthermore, widely differing criteria for fracture classification and outcome assessment still make comparison between different studies and general conclusions on the topic
14、difficult. Because a high proportion of calcaneal fractures occur in young male industrial workers, the sequelae of these injuries have a considerable socio-economic impact (Sanders, 2000).Anatomy and biomechanicsThe calcaneus is the largest and most irregularly shaped bone of the foot. It makes up
15、the whole posterior part of the longitudinal foot arch and the lateral foot column. Through the action of the Achilles tendon, the plantar fascia and intrinsic foot muscles it acts as a strong lever arm during walking, standing and crouching. The calcaneus has a cortical shell of varying thickness a
16、nd a vaultlike trabecular pattern of the cancellous bone that reflects the forces transmitted through it to the calcaneal tuberosity and the fore- foot (Figure 1). This leaves a neutral triangle with sparse trabeculae that is prone to impaction of the posterior facet in calcaneus fractures. Conversely, the cancellous bone is dense beneath the posterior facet of the subtalar joint forming the thalamic portion of the calcaneus. The cortical bone is espe- cially thin at the lateral calcanea
