From the Research
The optimal timing for open reduction internal fixation (ORIF) in displaced intra-articular calcaneal fractures is typically 7-14 days after injury, once soft tissue swelling has subsided. This recommendation is based on the need to balance the risks of wound complications from operating through swollen tissue against the increasing difficulty of anatomic reduction as the fracture begins to heal 1.
Key Considerations
- Surgery should be delayed until wrinkling of the skin (positive wrinkle test) is visible and edema has decreased sufficiently.
- During this waiting period, patients should be managed with elevation of the extremity, ice application, and non-weight bearing status.
- Some surgeons use the "10-finger" test, proceeding with surgery when ten fingerprints can be made on the lateral aspect of the foot without leaving indentations.
- Early surgery (within 3 days) may be considered for open fractures or compartment syndrome, while surgery beyond 3 weeks may lead to increased difficulty with reduction due to early callus formation.
Evidence Summary
- A study published in 2016 compared the outcomes of ORIF and percutaneous surgical procedures for displaced intra-articular calcaneal fractures, and found that ORIF resulted in better clinical and radiological outcomes 1.
- Another study published in 2015 found that ORIF for displaced intra-articular calcaneal fractures in children resulted in good short-term outcomes, with a mean AOFAS score of 95.8 2.
- However, it is essential to note that the evidence is not entirely consistent, and some studies have reported equivalent outcomes between operative and nonoperative treatment for displaced intra-articular calcaneal fractures 3.
Clinical Implications
- Premature surgery through edematous tissue significantly increases the risk of wound dehiscence, infection, and potential need for additional procedures including flap coverage or amputation.
- Delaying surgery until soft tissue swelling has subsided can help minimize these risks and improve outcomes.
- The decision to proceed with ORIF should be made on a case-by-case basis, taking into account the individual patient's condition and the severity of the fracture.