Cullen Samuel E, Khan Akib, Park Chang, Allardice Garth
Trauma and Orthopaedics, Northwick Park Hospital, London, GBR.
Cureus. 2021 Oct 6;13(10):e18519. doi: 10.7759/cureus.18519. eCollection 2021 Oct.
Fractures involving the anterior process of the calcaneus (APC) are rare, underdiagnosed, and carry a significant increase in morbidity if not identified acutely. Identifying patients with intra-articular fracture extension is crucial as they may benefit from surgical fixation to reduce the risk of morbidity and post-traumatic osteoarthritis. There are no specific guidelines in the United Kingdom regarding the management of these fractures, and there is little evidence regarding optimal management, mainly limited to case reports and small sample observational trials. Previous reports of surgical intervention have described excision of fragments or fixation using single cancellous screws. A 55-year-old man fell from a height of 2 metres, sustaining an APC fracture extending into the calcaneocuboid joint. This was identified on plain radiographs following a virtual fracture clinic referral from the emergency department and further investigated with computed tomography scanning. He underwent open reduction and internal fixation with a locking T-plate and screws three weeks post-injury to restore congruence of his articular surface. Following a period of non-weight-bearing and progressive physiotherapy, he reported an excellent functional outcome six months post-operatively, measured by the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score of 90%. In the absence of specific guidelines for these fractures, this case provides an example of good initial functional outcomes following surgical fixation using a locking plate and screws, the first such fixation of an APC fracture described in the literature. This case can also be seen as a useful reminder of the need for an index of clinical suspicion for these injuries, given that up to 40% may be missed in the emergency department. While now fairly widespread, not all hospitals will have a virtual fracture clinic system in place, meaning emergency department practitioners must be wary of these injuries before discharging patients with suspicious histories and examination findings with no follow-up. Examination techniques that may help differentiate APC fractures from ankle sprains are discussed to provide clinicians with evidence to support a suspicion of these injuries in the emergency department.
涉及跟骨前突（APC）的骨折较为罕见，易被漏诊，若未及时发现，发病率会显著增加。识别合并关节内骨折延伸的患者至关重要，因为他们可能受益于手术固定，以降低发病风险和创伤后骨关节炎的发生几率。在英国，对于这些骨折的处理尚无具体指南，关于最佳治疗方法的证据也很少，主要局限于病例报告和小样本观察性试验。先前关于手术干预的报道描述了采用切除碎骨片或使用单根松质骨螺钉进行固定。一名55岁男性从2米高处坠落，导致APC骨折并延伸至跟骰关节。经急诊科虚拟骨折门诊转诊后，通过X线平片发现了该骨折，并进一步进行了计算机断层扫描检查。受伤三周后，他接受了切开复位并用锁定T型钢板和螺钉进行内固定，以恢复关节面的一致性。经过一段时间的不负重和逐步的物理治疗，术后六个月，根据美国矫形足踝协会（AOFAS）踝 - 后足评分90%来衡量，他报告功能恢复良好。由于缺乏针对这些骨折的具体指南，该病例提供了一个使用锁定钢板和螺钉进行手术固定后获得良好初始功能结果的例子，这是文献中首次描述的此类APC骨折固定方法。鉴于在急诊科高达40%的此类损伤可能被漏诊，该病例也可被视为一个有用的提醒，即对于这些损伤需要保持临床怀疑指数。虽然现在相当普遍，但并非所有医院都设有虚拟骨折门诊系统，这意味着急诊科医生在对有可疑病史和检查结果且无后续随访的患者进行出院时，必须警惕这些损伤。文中讨论了可能有助于将APC骨折与踝关节扭伤相鉴别的检查技术，为临床医生在急诊科支持对这些损伤的怀疑提供证据。
