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Articular Reconstruction of Calcaneal Frx

- Technique:
    - disimpaction of posterior facet:
          - if the posterior facet is impacted down into the cancellous bone, it should be elevated en mass w/ use of an osteotome;
                 - it is important to elevated the posterior facet along w/ a generous amount of cancellous bone so that the articular fragments do not separate;
    - articular reconstruction:
          - medial articular fragments are the most difficult to reduce and the most difficult to visualize;
                  - for this reason, the medial fragment should be reduced first;
                  - for better exposure, excise fat pad behind posterior facet;
                  - finger can then be passed behind and around posterior facet to help directly reduce medial fragment;
                  - medial part of the posterior facet is elevated until it is aligned with the middle facet;
                  - K wires are inserted from posterior to anterior thru tuberosity fragment and into medial sustentaculum fragment;
                  - wires can also be inserted from inferior to superior thru the tuberosity fragment into the sustentacular fragment;
          - if articlar reduction is difficult, consider pressing the articular fragments up against the undersurface of the talus, in order to mold it into reduction;
                  - the articular surface of the talus holds the posterior facet in a reduced position;
                  - articular reduction is maintained w/ K wires;
    - hazards:
          - avoid medial penetration of the posterior facet:
                  - be aware that the posterior facet slopes from lateral-superior to medial-inferion, and therefore screws which are inserted in a horizontal direction at the superior margin of the posterior facet will penetrate the articular surface;
                  - in the report by Jordan C, et al (1999), the authors recommend the following:
                          - at the anterior aspect of the posterior facet, screws need to be angled 5 deg in a plantar direction or need to be placed 1.5 mm below the edge of the articular surface;
                          - at the mid portion, screws need to be angled 20 deg inferiorly or 10 mm below the joint edge;
                          - at the posterior portion, screws need to be angled 32 deg inferiorly or 15 mm below the joint edge

Determining the angle of screw placement for internal fixation of calcaneal fractures.