What is the management for a calcaneus fracture with displacement and medial foot abrasion?

Management of Displaced Calcaneus Fractures with Medial Foot Abrasion

Displaced calcaneus fractures with medial foot abrasion require urgent surgical intervention with initial external fixation followed by definitive internal fixation once soft tissue conditions improve.

Initial Assessment and Management

• Displaced calcaneus fractures represent a surgical challenge requiring careful management to prevent long-term disability and complications 1
• For calcaneus fractures with displacement and medial foot abrasion, immediate attention to both the fracture and soft tissue injury is essential 1
• Tongue-type calcaneus fractures specifically require more urgent attention (within 24 hours) due to their potential for skin compromise 1

Staged Surgical Approach

Step 1: Initial Stabilization (Within 24-48 hours)

• Apply a temporizing external fixator medially to restore calcaneal height, length, and alignment 2, 3
• Clean the abrasion with simple saline solution without additives (strong recommendation) 1
• Initiate appropriate antibiotic coverage:
  • Cefazolin or clindamycin (if penicillin-allergic) 1
  • Consider additional gram-negative coverage for more severe soft tissue injuries 1

Step 2: Soft Tissue Monitoring

• Allow soft tissue swelling to subside while maintaining fracture reduction with the external fixator 2
• Monitor for return of normal skin turgor, typically taking 3-7 days 2
• Consider negative pressure wound therapy for the abrasion to promote healing 1

Step 3: Definitive Fixation

• Once soft tissue conditions improve, proceed with open reduction and internal fixation (ORIF) 1
• The surgical approach should be determined based on fracture pattern:
  • Sinus tarsi approach for less severe fractures to minimize wound complications 2, 4
  • Medial approach for fractures with significant medial wall involvement 5, 6
  • Extended lateral approach for complex fractures requiring visualization of the subtalar joint 4

Postoperative Management

• Non-weight bearing for approximately 8 weeks 2
• Consider removable cast or boot after initial immobilization period 1
• Progressive weight bearing once radiographic evidence of healing (typically 8-12 weeks) 2
• Physical therapy to restore range of motion and strength 1

Special Considerations and Pitfalls

• Soft tissue complications: The medial foot abrasion increases infection risk and requires meticulous wound care 1
• Timing is critical: Delaying definitive fixation until soft tissue conditions improve reduces wound complications while the external fixator maintains reduction 2, 3
• Anatomic reduction: Restoration of Bohler's angle and calcaneal width is essential for good functional outcomes 2, 4
• Avoid smoking: Smoking significantly increases wound complications and should be strongly discouraged 4
• High BMI patients: Obesity adversely affects outcomes and may require modification of the treatment approach 4

Potential Complications to Monitor

• Surgical site infections (particularly with compromised soft tissues) 1
• Malunion or nonunion requiring secondary procedures 4
• Post-traumatic arthritis of the subtalar joint 4
• Chronic pain and functional limitations 1

The staged approach with initial external fixation followed by definitive internal fixation has been shown to reduce wound complications while achieving good anatomic reduction and functional outcomes in displaced calcaneus fractures with compromised soft tissues 2, 3.