From the Guidelines
For a comminuted left calcaneal fracture with mild displacement of bone fragments (Type 4 according to Sanders classification), the best management approach is typically non-operative, focusing on pain management, immobilization, and early mobilization, as surgery is usually reserved for more complex or displaced fractures 1.
Recommendation:
- Immobilize the affected foot in a neutral position using a well-padded cast or a walker boot for 6-8 weeks to allow for fracture healing.
- Manage pain with acetaminophen 650-1000 mg every 4-6 hours as needed, or with tramadol 50-100 mg every 4-6 hours as needed for moderate to severe pain.
- Apply ice for 15-20 minutes, 3-4 times a day, to reduce swelling.
- Elevate the affected leg above the level of the heart to minimize swelling.
- Gradually introduce weight-bearing activities after 6-8 weeks, starting with partial weight-bearing and progressing to full weight-bearing as tolerated.
- Consider physical therapy after 8-10 weeks to improve range of motion, strength, and functional ability, with a focus on early postfracture introduction of physical training and muscle strengthening, as well as long-term continuation of balance training and multidimensional fall prevention 1.
It's crucial to closely monitor the fracture for any signs of complications or worsening displacement, which may necessitate surgical intervention. Regular follow-up with a healthcare provider is essential to assess healing progress and adjust the management plan as needed.
From the Research
Management of Comminuted Left Calcaneal Fracture with Mild Displacement
Overview of Treatment Options
The management of comminuted left calcaneal fractures with mild displacement, classified as Sanders Type 4, is a complex issue with various treatment options available. The choice of treatment depends on several factors, including the severity of the fracture, the patient's overall health, and the presence of any complications.
Non-Operative Treatment
- Non-operative treatment, including closed reduction and immobilization, may be considered for patients with mild displacement and no significant complications 2.
- A study published in 2011 found that non-operative treatment of Sanders Type 4 fractures resulted in a mean AOFAS score of 72 at a mean follow-up of 51 months, with osteoarthritis evident in 90% of patients on x-ray and 100% on CT scans 2.
Operative Treatment
- Operative treatment, including open reduction and internal fixation (ORIF), may be considered for patients with more severe displacement or complications 3, 4.
- A study published in 2008 found that ORIF using a calcaneal locking compression plate from an extended lateral approach resulted in excellent or good Rowe scores in 86.2% of patients, with a mean follow-up of 18.2 months 3.
- Another study published in 2021 suggested that anatomic reconstruction of the calcaneal shape and joint surfaces is mandatory for most displaced intraarticular fractures, and that less invasive reduction and fixation via a sinus tarsi approach may be used for most cases 5.
Primary Arthrodesis
- Primary arthrodesis may be considered for severely comminuted intraarticular fractures that are not amenable to reconstruction 6.
- A systematic review published in 2012 found that primary arthrodesis resulted in a weighted average modified AOFAS score of 77.4, with a union rate of 97% and an average follow-up time of 28 months 6.
Complications and Considerations
- Complications, such as wound dehiscence, necrosis, and infection, can occur with operative treatment 3.
- The timing of surgery and consideration of indications and contraindications are of principal importance to minimize complications 3.
- The presence of osteoarthritis and other complications, such as compartment syndrome, should be carefully evaluated and managed accordingly 2, 3.