Are calcaneal fractures typically treated with a cast?

Management of Calcaneal Fractures

Most calcaneal fractures are initially treated with cast immobilization, with surgical intervention reserved for specific cases such as displaced intraarticular fractures requiring anatomic reconstruction. 1, 2

Initial Management Approach

• Diagnosis requires proper imaging:
  • Standard radiographs (lateral, oblique, AP, and axial views)
  • CT scan for complex injuries or preoperative planning 3
  • MRI may be indicated if radiographs are negative but clinical suspicion remains high

Treatment Algorithm

Non-Displaced Fractures

• Cast immobilization is the primary treatment
• Most anterior process fractures respond well to cast immobilization 1
• Duration typically 4-6 weeks depending on fracture healing

Displaced Fractures

• Treatment depends on fracture type:

  1. Extraarticular fractures:

     • Primarily managed with cast immobilization
     • Percutaneous fixation may be considered for significantly displaced fragments 2

  2. Intraarticular fractures:

     • Simple intraarticular fractures with minimal displacement: Cast immobilization
     • Displaced intraarticular fractures: Surgical intervention may be indicated
       • Less invasive reduction and fixation via sinus tarsi approach 2
       • Minimally invasive reduction and fixation (MIRF) with threaded K-wires for patients not suitable for open reduction 4

Surgical Considerations

• Surgical intervention is indicated for:

  • Significantly displaced intraarticular fractures
  • Fractures with subtalar joint involvement requiring anatomic reconstruction
  • Calcaneal fracture-dislocations

• Surgical approach options:

  • Sinus tarsi approach (less invasive) for most displaced intraarticular fractures 2
  • Percutaneous fixation for simple fractures with adequate joint reduction control 2
  • MIRF technique with threaded K-wires for patients with medical comorbidities (smokers, diabetics, peripheral vascular disease) 4

Rehabilitation Protocol

• Early mobilization to prevent stiffness and promote healing
• Progressive weight-bearing based on fracture stability and healing
• Avoid prolonged immobilization to prevent deconditioning

Potential Complications

• Subtalar joint stiffness and disability 3
• Delayed union or non-union
• Infection (higher risk with open surgical approaches)
• Peroneal impingement
• Chronic pain

Important Considerations

• Examine for associated injuries, particularly lumbar spine fractures in cases of falls from height 5
• The optimal treatment remains controversial with no definitive evidence supporting one approach over another 3
• Surgical timing is important - MIRF can be performed even with soft tissue swelling in the immediate period following injury 4

While surgical techniques have advanced, the decision between conservative and surgical management must consider fracture pattern, patient factors, and surgeon experience. Early diagnosis and appropriate initial treatment are crucial for optimal outcomes, particularly for larger fracture fragments.