From the Guidelines
Treatment for a comminuted body fracture of the calcaneus typically involves surgical management with open reduction and internal fixation, as it allows for better restoration of the bone's anatomy and articular surface, which is crucial for minimizing the risk of post-traumatic arthritis and chronic pain. The initial assessment of such fractures often requires a CT scan of the ankle without intravenous contrast to accurately evaluate the extent of the fracture and any associated soft-tissue abnormalities, as radiographs may not fully capture the complexity of the fracture, particularly for calcaneal fractures where sensitivity is only about 87% compared to CT 1.
When considering treatment options, the severity of the fracture, patient factors, and the potential for restoring the calcaneus's shape and function are critical. Non-surgical management may be considered for non-displaced or minimally displaced fractures, involving immobilization, non-weight bearing for an extended period, and gradual rehabilitation. However, for comminuted fractures, especially those involving the subtalar joint or significantly altering the heel's shape, surgical intervention is generally recommended to achieve the best possible outcome in terms of morbidity, mortality, and quality of life.
Pain management is a crucial component of both surgical and non-surgical treatments, often involving NSAIDs like ibuprofen or naproxen, and possibly opioids for acute severe pain, alongside elevation and immobilization to reduce swelling. The rehabilitation process is lengthy, typically lasting 6-12 months, with a focus on gradual weight bearing and physical therapy to restore function and strength to the ankle and foot. Despite these efforts, complications such as post-traumatic arthritis, chronic pain, and altered gait mechanics can occur, emphasizing the importance of optimal initial treatment to minimize these risks.
From the Research
Treatment Options for Comminuted Body Fracture of the Calcaneus
- Open reduction and internal fixation (ORIF) is a common treatment approach for displaced intra-articular calcaneal fractures, including comminuted body fractures 2, 3.
- The extended lateral approach is often used for ORIF, allowing for good exposure of the fractured lateral wall, subtalar, and calcaneocuboid joints 4.
- Primary arthrodesis is also considered a viable treatment option for severely comminuted intra-articular calcaneal fractures, with good functional outcomes reported in several studies 5.
- Less invasive procedures, such as percutaneous reduction and internal fixation, may also be used to reduce wound complications, but exact anatomic reduction remains a crucial factor 4.
Postoperative Care and Rehabilitation
- Postoperative immobilization in a cast for 4-6 weeks is typically recommended, followed by gradual weight-bearing and rehabilitation 2, 4.
- The use of bone grafting or bone substitutes for defect filling is not usually necessary, but may be considered in certain cases 4.
- Prognostic factors that can be influenced by the surgeon, such as anatomical reduction of the overall shape of the calcaneus and congruity of the subtalar joint, are critical for optimal treatment outcomes 4.
Complications and Considerations
- Wound complications, including infection and wound healing problems, are potential risks associated with ORIF and primary arthrodesis 5, 4.
- Smoking, high body mass index, and severity of injury are adverse prognostic factors that can affect treatment outcomes 4.
- Early, stable soft tissue coverage with pedicled or free flaps may help reduce infection rates and improve functional results after open fractures 4.