Treatment of Avulsion Fracture of the Lateral Aspect of the Calcaneus
For a possible avulsion fracture of the lateral aspect of the calcaneus, initial treatment should include immobilization with a walking boot, non-weight bearing status for 4-6 weeks, followed by progressive rehabilitation based on radiographic evidence of healing. 1
Diagnosis Confirmation
Before initiating treatment, proper diagnosis is essential:
- Radiographs are the mainstay of initial imaging for suspected calcaneal fractures 2
- Standard three-view foot radiographs (anteroposterior, lateral, and oblique) should be obtained 2
- An additional axial calcaneal view increases specificity in diagnosing calcaneal fractures 2
- MRI may be indicated if there are concerns about associated soft tissue injuries 1
Treatment Algorithm
1. Conservative Management (for small, non-displaced fragments)
- Immobilization: Walking boot for 4-6 weeks 1
- Weight-bearing status: Non-weight bearing initially, progressing based on healing 1
- PRICE protocol: Protection, Rest, Ice, Compression, and Elevation 1
- Pain management: NSAIDs for pain and inflammation control 1
2. Surgical Management (for larger or displaced fragments)
Surgical intervention is indicated when:
- Fragment is large or significantly displaced 1
- Fracture is intra-articular 1
- Patient fails to respond to conservative treatment with persistent pain after 6-8 weeks 1
Surgical options include:
- Cannulated cancellous screws with titanium wire for elderly/osteoporotic patients 3
- Suture anchor fixation for better stability in osteoporotic bone 4
Rehabilitation Protocol
After initial immobilization period:
- Progressive weight bearing as tolerated when radiographic evidence of healing is present 1
- Proprioceptive training to prevent chronic instability 1
- Regular radiographic follow-up at 3 weeks and at cessation of immobilization 1
Important Considerations and Pitfalls
- Displacement is a critical factor: Fracture displacement ≥2cm is associated with significantly higher complication rates (90.9% vs 30%) 5
- Osteoporosis risk: These fractures are more common in elderly or osteoporotic patients, who may require special fixation techniques 3, 4
- Secondary displacement: There is risk of secondary displacement after initial fixation, particularly in osteoporotic bone 6
- Healing time: Typical healing time is 6-8 weeks with proper immobilization 1
Follow-up Care
- Regular radiographic assessment to confirm healing progression
- Evaluate for complications such as malunion, nonunion, or chronic pain 1
- Consider advanced imaging (CT or MRI) if healing is delayed or complications are suspected 2, 1
Boot walkers are generally preferred over traditional casts as they provide protection while allowing controlled mobility and superior patient comfort 1.