A talar fracture is serious

Hindfoot fractures

Summary

background

The rear foot plays a central role in the function of the foot, as it is used to introduce the force of the body weight on the one hand and to align the foot in the bipedal gait on the other. Disturbances of the biomechanics in the hindfoot area can therefore have considerable effects on the function of the foot as a supporting and locomotion organ.

Possible consequences of injuries to the rear foot

Even if fractures of the hindfoot are relatively rare injuries, post-traumatic functional restrictions, gait disorders and secondary arthrosis, which can necessitate subsequent reconstructive interventions, are often the consequences of the injury. The professional reintegration of the accident injured is difficult in many cases and a reduction in the ability to work is likely.

Diagnostics and therapy

Injuries to the hindfoot require a well-structured treatment concept that includes primary care and follow-up treatment in addition to diagnostics and in which various hospital disciplines are equally involved. In addition to trauma surgery and orthopedic expertise, the treatment is based on a good knowledge of anatomy and biomechanics.

Goal of the contribution

This article aims to provide an overview of the topic and encourage further reading of this area.

Abstract

Background

The hindfoot plays a central role in the function of the foot. Disorders of the biomechanics in the hindfoot can therefore have a significant impact on the function of the foot as a locomotion organ.

Possible sequelae of injuries of the hindfoot

Although fractures of the hindfoot are rare, these injuries often lead to posttraumatic functional limitations, gait disturbances, and secondary arthritis, which make reconstructive surgery necessary.

Diagnosis and therapy

Injuries of the hindfoot require a well-structured treatment concept that includes the correct diagnosis, primary care and treatment which involves the various disciplines of a trauma center. The basis of the treatment in addition to surgical and orthopedic expertise is good knowledge of the anatomy and biomechanics.

Goal of the article

The goal of the following article is to provide an overview of the topic and to encourage further interest in this area.

history

The treatment of fractures of the hindfoot has long been the domain of conservative therapy. Reasons for this are

  • the complex anatomical shape of the talus (talus) and calcaneus (heel bone),

  • the critical skin-soft tissue coverage and

  • the often difficult intraoperative exposure of the fracture geometry.

In the last century, a number of therapeutic concepts have been proposed, from heel bone modeling with a hammer [3] to primary calcanectomy. It was not until the 1980s that osteosynthesis, which was primarily exercise-stable and not cross-joint, had become established for calcaneal fractures. In recent years, in addition to the classic open reduction method using the extended lateral approach as a standard approach, more and more covered methods have been described for which, in addition to the common osteosynthesis screws, currently inserted angle-stable plate systems and a nail system (heel bone nail) have been brought onto the market.

For the treatment of talus fractures, the use of cannulated screw systems has expanded the range of indications for surgical reconstruction since the 1990s, based on the knowledge that stable osteosynthesis and timely osseous consolidation of the talus fracture are a prerequisite for the revitalization of the osseous structures in this limited tarsal blood supply.

Anatomical aspects

The foot can be anatomically divided into 3 sections:

  • Hindfoot,

  • Metatarsus and

  • Forefoot.

The hindfoot is the skeletal section from the upper ankle joint (talocrural joint) to the Chopart joint line (Articulatio tarsi transversa), it includes the two bones talus (ankle bone) and calcaneus (heel bone). The metatarsus connects distally and the forefoot from the metatarsophalangeal joints.

Talus

It is the switching bone between the lower leg and the foot. It is part of the upper and lower ankle joint and, together with the talonavicular joint (ankle-scaphoid joint), forms the medial section of the Chopart joint. On the one hand, this characterizes its central importance for foot function; on the other hand, the large number of joint surfaces is the reason for the complex morphology and the above-average proportion of cartilage-covered joint surfaces (cartilage proportion of the total surface of almost 60%). This results in a limited nutritive periosteal network of blood vessels from the 3 lower leg arteries as well as slow bone healing and susceptibility of the talus to avascular bone necrosis after trauma [1].

The joints formed by the talus are linked by a kinematic chain [7]. Due to the large forces acting on the ankle joint, the joint structure is relatively simple and geared towards stability. It has an axis of rotation that runs through the tips of the ankles and, when the foot is plantar on the floor, lies approximately horizontally in the frontal plane of the body.

Calcaneus

It is the largest tarsal bone and makes up the majority of the longitudinal arch of the foot and the lateral column of the foot. It consists of the mighty calcaneal tuberosity, on which the Achilles tendon cranially and plantar on 2 forward-facing processes (processus lateralis et medialis) insert the short foot muscles (M. abductor digiti minimi or M. abductor hallucis), which together with the here Also attaching band systems (plantar fascia and lig. plantare longum) intercept the longitudinal arch of the foot.

The upper surface of the calcaneus bears 3 joint facets that articulate with the talus and form the subtalar joint.

The anterior part of the calcaneus forms as the anterior calcaneal process with the articular surface to the cuboid bone (cuboid bone). In the central calcaneus there is a spongiosa zone, the trigonum calcis, from a biomechanical point of view a relatively low-tension area without great compressive forces. The medial joint facet forms the surface of the sustentaculum tali, which is the most stable part of the calcaneus, with strong, cranially directed ligaments to the talus, os cuboideum and tibia. This construction, together with the dynamic tension of the long flexor tendon of the big toe (M. flexor hallucis longus) that passes under the sustentaculum tali, prevents dislocation of the sustentaculum tali fragment in many types of fractures.

The tight interosseous talocalcaneum ligament, an essential stabilizer of the lower ankle joint, to which the talonavicular joint also belongs functionally, runs in the sinus tarsi. Biomechanically, it is a pivot joint that allows rotary movements. The physiological range of motion for the eversion / inversion movement of the rear foot is about 60 °. These movements are important in the gait cycle in the phase of heel strike and serve to adapt the foot to uneven ground and to absorb shock. If disorders of this biomechanics remain after fractures of the rear foot, this can result in significant functional disorders of the foot.

The blood vessel supply is not as critical for the calcaneus as it is for the talus. The bone receives blood from all 3 vessels of the lower leg. Approximately 45% of the calcaneus is supplied from the medial arterial area, so that, as a rule, no nutritional disruption is to be expected even with an extended lateral surgical access.

After an accident injury, the complex morphology together with the limited intraoperative overview / representation makes the anatomical reconstruction of the bony elements of the hindfoot so demanding.

Accident mechanism

Most hindfoot fractures result from traffic (50%) and sports accidents (20%). It is not uncommon for them to be combined injuries to the talus and calcaneus with possible accompanying injuries to the upper ankle joint and the rest of the foot skeleton.

The most common mechanism is an axial compression mechanism which, depending on the position of the hindfoot in relation to the pilon tibiale, leads to fractures of the neck or body of the talus when the joints are blocked (Fig. 1). With these types of fractures, the accompanying damage to the surrounding skin and soft tissue is often problematic due to the considerable force exerted. This injury is obvious and presents little diagnostic difficulty.

Particular attention should be paid to the diagnosis of occult central fractures and v. a. Also offered to the peripheral fractures, which make up about 1/4 of all talus fractures and as a sports injury (e.g. "snowboarders ankle") or often through easy twisting of the ankle.

In calcaneus fractures, the axial compression mechanism leads to primary and secondary fracture lines through penetration of the lateral processus tali into the force-neutral triangle with the rarefied cancellous bone between the posterior joint facet and the anterior process (trigonum calcis). Although the calcaneus fracture is the most common fracture of the tarsus, it only accounts for about 1–2% of all fractures in the human skeleton and, like the talus fracture, is a relatively rare injury.

Classification and diagnostics

classification

For the bony injury to the two hindfoot bones, useful classifications are established that also allow a certain prognostic assessment.

Talus

For the talus fracture, the classification according to Hawkins [5] from the 1970s and in the later modification according to Marti and Weber [8], which are shown schematically in Fig. 2, prevailed. With the Hawkins classification [5], only the talar neck fractures can be recorded. With the Marti and Weber classification [8], all talus fractures can be classified into 4 types, depending on the topography of the main fracture lines.

In the vast majority of cases, the talar neck (50%) or the talus body (25%) are affected; another 25% of the fractures are peripheral fractures, which in a broader sense include the process fractures, the talus head fractures (5–10%) and which include osteochondral shear injuries. Approximately half of the accompanying injuries can be diagnosed in the heel and ankle area, and every 7th injury is an open fracture.

Calcaneus

For calcaneus fractures, the Essex-Lopresti classification from the 1950s [4] is still valid for the orienting description. The pathomorphology is better captured by the modern CT-based (CT: computed tomography) classifications according to Sanders ([14], Fig. 3) and Zwipp et al. [16], which, in addition to a more precise assignment, also allow a prognostic assessment. In the classification according to Zwipp et al. In addition to the fracture geometry, the number of affected joints and, with additional points, the accompanying soft tissue damage, possible debris zones in the main fragments and accompanying injuries are also taken into account [16].

Imaging diagnostics

The exact analysis of the fracture geometry of talus and calcaneus fractures on the basis of the classifications mentioned is decisive for the selection of the best possible therapy concept from the spectrum of conservative or mostly surgical therapy and the subsequent individual design of the individual therapeutic steps. It is therefore essential to have high-resolution imaging to record the complex polyarticular system of the hindfoot, as can only be guaranteed by computer tomography, possibly supplemented by 3D reconstruction (Fig. 4). Consequently, the intraoperative visualization of the fracture reduction and the implant position should also be possible on a comparable level, so that surgical imaging systems with 2D fluorine and integrated 3D scan mode have become increasingly established in recent years.

Conventional projection radiography is used in primary diagnostics for the orientational assessment of the existing pathomorphology after the accident injury and should be carried out in the case of talus and calcaneus fractures with the special X-ray planes specified in Table 1:

Magnetic resonance tomography (MRT) is important in the diagnosis of so-called occult fractures and bone edema ("bone bruise") and the clarification of aseptic talar necrosis after trauma, and then also as a follow-up diagnosis.

therapy

In the case of hindfoot fractures, in the initial phase after the trauma, the assessment and appropriate treatment of the often accompanying soft tissue injury are decisive for the further healing process and the chance of the best possible restoration of foot function. An overlooked manifest foot compartment syndrome will lead to a permanent gait disturbance and reduced stress even after anatomical reconstruction of the bony structures. The aim of the treatment is the best possible restoration of the integrity and function of the rear foot, which is axially aligned, only stable and at the same time mobile in the joints, which enables the physiological movement of humans. It should be noted that the topography of the rear foot includes 3 essential ankle joints, i.e. the step-free joint reconstruction plays an essential role. Post-traumatic arthrosis in the hindfoot joints can therefore be poorly compensated.

Therapy choice

Fractures of the rear foot are usually treated surgically, as the most physiological foot function possible can only be expected with an anatomical restoration.

Conservative therapy is recommended for fractures that are stable in a plaster cast and repositioned joints with only slight step formation of the joint surfaces (<2 mm). The conservative approach is also indicated in the case of fundamental contraindications to the operation.

In the evaluation of the findings after the accident injury, a subtle examination of the foot with clinical assessment of the soft tissue covering and the findings-oriented compartment monitoring are required. An impending compartment syndrome, relevant dislocations, also with the risk of vascular compromise (Fig. 5), and open fractures are an indication for surgery in emergency care. In polytrauma patients, it is important not to overlook the hindfoot fractures and to include them in the overall treatment concept.

Talar fractures

Due to the limited blood flow to the talus, timely fracture reduction and retention are necessary to avoid avascular talar necrosis. The aim is primarily a definitive osteosynthesis, which enables post-treatment that is stable with practice. Alternatively, after the significant dislocation has been reduced, a temporary Kirschner wire or external fixator restoration is possible if an optimized anatomical restoration can be guaranteed in the further course. The treatment of accompanying soft tissue damage is of equal importance and a basic requirement for consolidating all anatomical structures of the hindfoot. In the case of open dislocation fractures, the choice of the surgical access route will also be determined by the topography of the lesion of the skin-soft tissue mantle. Even if the primary, tension-free wound closure should be aimed for after the reconstruction of the bony anatomy, standardized treatment principles with vacuum bandages up to plastic-surgical measures are to be maintained.

Treatment goals of surgical care are the anatomical reconstruction of the fractured joint surfaces and the adjustment of the talus in the adjacent joints with restoration of the shape of the talus. For this purpose, 3 operative access routes have been established:

Anteromedial access

It is guided laterally to the tendon of the extensor hallucis longus muscle and, as a standard access point for talus head and neck fractures, provides a good view of the anterior, lateral and medial parts of the talus.

Posterolateral approach

It runs along the lateral edge of the Achilles tendon and is suitable for performing dorsolateral screw osteosynthesis for talus neck and posterior tali process fractures.

Combines anteromedial and lateral access.

A good indication, depending on the fracture geometry in the talus body (medial talus shoulder), are talus dome and comminuted fractures. It also allows an internal ankle osteotomy to be performed.

The operative strategy is to be structured according to the fracture geometry and follows a well-defined scheme. Simple talar neck fractures are openly reduced, with 3 to 4 mm Schanz screws being inserted into the talar head and body from the dorsal side as a reduction aid. This avoids further exposure to place a reduction forceps and allows all components of the dislocation to be reduced. The fracture retention is done with 2 small fragment screws. Partially threaded screws, which should preferably be cannulated (cannulated screw system 4.0–5.0 mm) and made of titanium (option for MRI diagnostics), are biomechanically advantageous (Fig. 6).

Complex talar fractures involving the talar dome may require a V-shaped (chevron osteotomy) medial ankle osteotomy and possibly a combined approach if the medial and lateral parts of the talus body need to be instrumented.In individual cases, transarticular screws must be applied to the talar shoulder and side surface to retain fragments, in which the screw heads should be countersunk below the level of the cartilage with a headspace bur.

Fractures of the articular processes (processus lateralis tali, processus posterior tali) are treated either conservatively in an immobilizing plaster cast or surgically, depending on the fragment size, dislocation and fragmentation. For surgical treatment of larger fragments, anatomical reconstruction and screw osteosynthesis (cannulated screw system 3.0–4.0 mm) using either a covered or open technique (e.g. modified Ollier approach, posterolateral parachillary approach in prone position) should be selected. Smaller fragments that cannot be adequately grasped with screws should be removed.

The surgical procedure is usually the treatment of choice for talus fractures, as even minor dislocations in the talus neck and body area lead to permanent disorders of the biomechanics of the upper and lower ankle and can be classified as pre-arthrosis. A secondary dislocation or instability of an initially considered stable fracture can also promote the development of avascular bone necrosis. The conservative treatment option is therefore reserved for a few selected types of fracture: fissures or stable, undislocated fractures. In cases of doubt, a covered screw connection with the advantage of earlier mobilization of the adjacent joints is recommended for these types of fractures as well.

Calcaneus fractures

The surgical procedure is largely determined by the accompanying skin and soft tissue damage. In any case, he specifies the timing of the intended surgical intervention and often also the operative strategy (open vs. covered procedure). If surgical treatment is not possible in the first few hours after the accident, the reconstruction of the calcaneus must be sought after the initial swelling has subsided (between the 5th and 10th day). Despite all therapeutic care, wound healing disorders are common complications. Bony healing is usually unproblematic due to the good blood supply to the calcaneus, pseudarthroses are rare.

Treatment goals of the operative care are the stepless reconstruction of the joint surfaces as well as the restoration of the tuberosity joint angle (Böhler angle) and the hindfoot anatomy with stable osteosynthesis. Immediate emergency care must be initiated in the case of open fractures, soft tissue compromising malpositions and an impending compartment syndrome.

Due to the further development of implants - the angle-stable plate systems are mentioned as an example - and better intraoperative visualization with modern X-ray technology (imaging systems with 2D fluorine and integrated 3D scan mode), the operative treatment concept for intra-articular calcaneus fractures is preferable to the conservative functional one, even if the study situation with around 50 internationally published papers in the scientific literature is still inadequate [2].

Intra-articular fractures are the most common fractures with a share of 75%, mostly compromise the posterior joint facet and almost always require surgical treatment, since joint steps over 1 mm should not be tolerated in order to avoid secondary osteoarthritis. The surgical procedure includes the reduction of the tuberosity fragment by traction using a Schanz screw (Westhues maneuver) and the reduction of the sunken posterior joint facet to the sustentacular fragment. This rebuilds the calcaneus from medial to lateral. To visualize the bony pathology, in addition to a lateral approach (modified according to Palmer [10] or extended lateral approach), an additional medial incision (approach according to McReynolds [9]) to instrument the sustentacular fragment and the medial joint facet is occasionally made (Fig. 7) .

Minimally invasive techniques are increasingly being discussed and have shown good functional treatment results for selected types of fractures in smaller case series. This means that the possibility of a minimally invasive approach will have to be examined more intensively. Certain types of fractures (fractures in the classification according to Sanders IIA and IIB) represent, from today's perspective, if the practitioner has sufficient expertise, an indication for covered screwing with partially threaded screws (4.0–6.5 mm) [12]. The advantages of this procedure can be seen in terms of soft tissue management and improved hindfoot mobility in the postoperative course (Fig. 8).

Extra-articular fractures with relevant misalignment of the fragments (processus anterior calcanei, sustentaculum tali, tuber calcanei) are openly reduced and screwed. Undislocated articular processes can be covered with screws or treated conservatively and functionally.

In extra-articular fractures, the bony avulsion fracture of the Achilles tendon is an indication for emergency treatment due to the compromise of the soft tissue sheath (Fig. 9). The anterior process fracture is often overlooked in the initial radiological diagnosis due to the complex polyarticular anatomical system of the tarsus and should be screwed (covered) in the case of larger fragments. This also restores the stability of the bifurcate ligament in the Chopart joint. Tuberosity fractures as a result of a high-speed trauma can be treated conservatively, as can biomechanically unproblematic processus medialis-tuberis-calcanei fractures. The undislocated sustentaculum tali fracture can be treated conservatively with 6 weeks of relief, but it can also be covered with screws - especially as an accompanying injury.

Due to the outlined, structured treatment concept, which is geared towards the gentlest possible soft tissue management, contraindications for an operative procedure are seen less frequently. These include life-threatening accompanying injuries (multiple trauma), critical soft tissue conditions with a high risk of infection and a lack of compliance, in particular the combination of arterial vascular disease, diabetes mellitus and nicotine dependence.

Aftercare

The basic requirement for a good functional result with successful rehabilitation of the accident injured person is a well-structured, consistently implemented follow-up treatment concept.

After surgical treatment, an early functional therapy should be started immediately postoperatively with the practice-stable osteosynthesis. Immobilization in a plaster cast is obsolete in order to avoid secondary damage to the skin-soft tissue jacket during surgical and conservative procedures after fracture of the calcaneus. In the first few days until the wound has healed, the focus is on the consolidation of the skin and soft tissue covering with suitable measures, including in particular lymphatic drainage and, if possible, AV pump treatment (pump system for external pneumatic compression of the plantar foot plexus). In some centers with an attached pressure chamber, adjuvant hyperbaric oxygen therapy (HBO) plays a central role in the treatment concept for hindfoot fractures.

The partial weight-bearing of the injured lower extremity of 15–20 kg allows limited mobility and is gradually guided to full weight-bearing according to CT diagnostics. A special feature is the long partial load phase in the case of central talus fractures, which has to be set at 12 weeks due to the slower bone healing. In the first 4 weeks, a relatively strict immobilization of the plantigrad set foot in the removable plaster cast is advantageous to avoid a contracted equinus foot position. Subsequently, joint mobility can be better restored from this physiological foot position. Peripheral and undislocated talus fractures, like intra-articular calcaneus fractures, are relieved for 8 to 10 weeks. The use of a vacuum walker ensures the reconstructed bony anatomy and mobility of the patient. At the time of loading, the supplementary prescription of orthopedic foot insoles to support the dynamic and static foot stabilizers and compression stockings (compression class II made-to-measure) is an effective accompanying measure.

The treatment goal of the rehabilitation phase is to restore the best possible mobility of the joints of the rear foot (foot as a mobile adapter) with pain-free full load with good coordination and strength endurance. Professional reintegration should be feasible after 3 to 5 months. The removal of inserted implants can be indicated after 1 year based on the findings, if necessary with additional arthrolysis.

Results

Talus

A major complication of talus fractures is the avascular necrosis of the talus due to the limited blood flow to the bone, which affects an average of 11–20% of patients and can occur in more than half of the cases with higher-grade talus fractures. In many cases, bone healing can also be delayed or not take place at all (pseudarthrosis rate up to 12%). Due to the function of the talus as a switching bone of the hindfoot with articular surfaces for the upper and lower ankle joint, the development of secondary arthritic changes in the mentioned joints is problematic in about 47-97% of cases. The causes are, on the one hand, direct damage to the joint surfaces as well as possibly remaining incongruences and step formations with disruption of the biomechanics of the joints. As a result, the rate of necessary primary arthrodesis in the further course is relatively high at around 15% [1]. The fact that an infection occurs in every fourth case of open talar fractures underscores the need for complex soft tissue management.

Knowledge of the high rate of potential complications after talus fractures should always be present in the management of the acute injury. Only then is it possible to adapt the treatment strategy in a diagnosis-oriented manner and on the basis of this knowledge in good time, and to optimize it for the individual case. An early prognostic assessment is also helpful in controlling the healing process and determining private and professional reintegration.

Calcaneus

Even with calcaneus fractures, the list of possible complications is long and needs to be integrated into the treatment concept. The basic requirement for a good functional result is the most anatomical restoration of the bony structures, v. a. the elimination of the incongruities of the subtalar articular surface [11], but the result remains difficult to predict. At the same time, the rate of secondary arthrosis can be reduced, which is reported in the literature with a frequency of less than 5% after surgical therapy. In the early phase of treatment, the high rate of wound healing disorders (wound edge necrosis 10–13%) often delays further mobilization and rehabilitation of the patient and extends the hospital stay. The reasons for this are the problematic nutritional supply of the skin-soft tissue flap on the lateral hindfoot and the formation of lymphedema after trauma and surgery. Deep infections with bone involvement, which occur at a rate of 1.3–2.5%, are dreaded complications and require costly revision surgery. Serious functional deficits can also remain with an overlooked hindfoot compartment syndrome, which affects every 10th case and leads to ischemic contractures of the short toe flexors with hammer and claw toes that are difficult to treat [1].

The rehabilitation effort is analogous to the injury pattern in talus fractures and individually adapted to the respective case. By exhausting all measures from the operative and physical therapy spectrum, including the possibilities of shoe orthopedics, the treatment results have improved in recent years. This can also be seen in the declining MdE index (MdE: reduced earning capacity) for the commercial employers' liability insurance associations in a re-examined group [17]. In principle, long-term malfunctions must be depicted in an expert opinion for many people who have been injured in an accident. The proportion of insured persons who received a disability pension with an MdE ≥ 20% in the legal area of ​​statutory accident insurance in 1995 was 44.6% after a talus fracture and 73.1% after a calcaneus fracture. The MdE index was highest in calcaneus fractures with an average MdE of 25.5% [6].

For orientation purposes, the statutory accident insurance companies have relevant empirical values ​​for assessing impaired performance of the foot: A talus fracture with severe compression of the bone and significant osteoarthritis is classified as 20–30%. A calcaneus fracture that has healed with minor dysfunction is rated as MdE of up to 20%, and significant dysfunction and deformation up to 40% [13, 15].

Résumé

The best possible care and rehabilitation of hindfoot fractures remain a challenge for everyone involved in the treatment of the injured person from the areas of traumatology and physical therapy. Only an individually adapted treatment concept does justice to this often complex injury and, in the first step, includes a suitable, mostly operative strategy, which, in addition to the anatomical reconstruction of the bony structures of the hindfoot, also includes sophisticated soft tissue management. In the second step, based on the reconstructed structures, the restoration of the biomechanics and function of the foot through extensive rehabilitation measures must be the central task for therapists and patients.

Surgical care and patient treatment remain challenging. New surgical procedures adapted to the respective case, such as minimally invasive techniques and better pre- and intraoperative imaging and visualization, can help to improve the results of reconstruction of the complex three-dimensional bone structures of the hindfoot.

The consequences of accidents that remain in many cases, with permanent functional losses in private and professional life, must be minimized in order to maintain the quality of life and the ability to work of those affected. Good results can only be achieved with intensive follow-up treatment and an optimal supply of aids.

conclusion for practice

  • The best possible care and rehabilitation of hindfoot fractures require an individually adapted treatment concept.

  • Surgical procedures are usually required for the anatomical reconstruction of the bony structures of the rear foot.

  • Sophisticated soft tissue management is essential for a good result.

  • The aim of the extensive rehabilitation measures is to restore the biomechanics and function of the foot.

  • Good results can only be achieved with intensive follow-up treatment and an optimal supply of aids.

  • In many cases, the consequences of accidents remain with permanent functional losses in private and professional life.

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Compliance with ethical guidelines

Conflict of interest. J. Gabel states that it has no conflict of interest. This article does not include studies on humans or animals. The supplement containing this article is not sponsored by industry.

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Affiliations

  1. Department of Foot Surgery, BG-Unfallklinik Murnau, Prof.-Küntscher-Straße 8, 82148, Murnau, Germany

    Dr. J. Gabel

Corresponding author

Correspondence to Dr. J. Gabel.

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Gabel, J. Hindfoot Fractures. Trauma occupational disease17, 45-53 (2015). https://doi.org/10.1007/s10039-013-2032-8

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keywords

  • Bone fractures
  • Talus
  • Calcaneus
  • rehabilitation
  • Lowering of the ability to earn money

Keywords

  • Bone fractures
  • Talus
  • Calcaneus
  • rehabilitation
  • Reduction in earning capacity