What are the considerations with calcaneal (heel bone) fractures?

From the Guidelines

Calcaneal fractures should be managed with careful consideration of the fracture pattern, with non-displaced fractures often managed conservatively and displaced intra-articular fractures potentially requiring surgical fixation, as evidenced by the most recent and highest quality study 1. When considering calcaneal fractures, it is essential to prioritize morbidity, mortality, and quality of life as the outcome. The management of these fractures is crucial due to their complexity and potential for long-term disability.

Key Considerations

• Initial assessment should include a thorough neurovascular examination, as compartment syndrome can develop in the foot.
• Plain radiographs, including lateral, axial, and Broden's views, are essential for initial imaging, but CT scanning is the gold standard for detailed fracture characterization and surgical planning, as noted in 1.
• Treatment depends on the fracture pattern, with non-displaced fractures often managed conservatively with non-weight bearing for 6-8 weeks, followed by progressive weight bearing in a walking boot.
• Displaced intra-articular fractures may require surgical fixation, typically through an extended lateral approach with plate and screw fixation, though minimally invasive techniques are increasingly used, as discussed in 1.

Important Imaging Considerations

• Radiographs are indicated by positive Ottawa rules with 99% sensitivity in determining the presence of a foot fracture, as stated in 1.
• Additional views, such as axial calcaneal view, can be useful in patients with suspected calcaneal fracture, as they increase specificity in diagnosing calcaneal fractures and sensitivity in distinguishing intra-articular calcaneal fractures, as mentioned in 1.
• Weight-bearing radiographs, if possible, provide important information, particularly with fractures of uncertain stability, as noted in 1.

Rehabilitation and Complications

• Rehabilitation focuses on early range of motion exercises, followed by strengthening and proprioception training.
• Complications include wound healing problems, infection, subtalar arthritis, peroneal tendon impingement, and chronic pain, as discussed in the example answer.
• Patients should be counseled that recovery is prolonged, often taking 12-18 months, and that some degree of permanent functional limitation is common even with optimal treatment, as stated in the example answer.

From the Research

Considerations with Calcaneal Fractures

• Displaced, intra-articular fractures of the calcaneus represent a surgical challenge, and the ideal choice of treatment remains a subject of continued debate 2
• Open reduction and stable internal fixation without joint transfixation has been established as the standard treatment for most of these fractures with good to excellent results in more than two thirds of patients in larger clinical series 2
• The extended lateral approach respects the neurovascular supply to the heel and allows a good exposition of the fractured lateral wall, the subtalar and calcaneocuboid joints, but wound healing problems cannot be completely avoided despite meticulous soft tissue handling 2

Treatment Options

• Percutaneous and less invasive procedures have successfully lowered the rates of wound complications but exact anatomic reduction remains an important issue 2
• Minimally invasive technique (MIT) and open reduction internal fixation (ORIF) are commonly employed, but there is no clear consensus on the optimal approach 3
• Conservative therapy (CT) shows higher functional complications, while surgical treatment is preferable to conservative treatment due to better anatomical reduction and a slightly better functional outcome 3

Prognostic Factors

• Prognostic factors that can be influenced by the surgeon are anatomical reduction of the overall shape of the calcaneus and congruity of the subtalar joint which should both be controlled intraoperatively 2
• Treatment results are adversely affected by severity of injury, open fractures, bilateral fractures, a high body mass index and smoking 2
• Risk factors for complications in the wound after calcaneal open reduction and internal fixation include single layered closure, high BMI, extended time between injury and surgery, and smoking 4

Rehabilitation

• Earlier rehabilitation after OR/IF is recommended for the treatment of calcaneal fracture 5
• Early weight-bearing and rehabilitation after open reduction and internal fixation of calcaneal fracture can lead to good clinical and functional results 5
• The average foot and ankle outcome score (FAOS) was 86.1 points, and the highest score was "function" (mean 92.5 points) 5