What is the treatment for an acute comminuted fracture of the calcaneal body?

Treatment of Acute Comminuted Fracture of the Calcaneal Body

The treatment for an acute comminuted fracture of the calcaneal body requires CT imaging for proper evaluation followed by either surgical fixation or conservative management based on fracture characteristics, with percutaneous subtalar joint screw fixation being an effective option for highly comminuted fractures.

Initial Evaluation and Imaging

• Initial radiographs are the first step in evaluation, but they have limited sensitivity (87%) for calcaneal fractures compared to CT 1
• CT without intravenous contrast is essential for proper evaluation of comminuted calcaneal fractures as it can identify occult fractures, particularly those involving the posterior facet 1
• MRI without contrast may be useful for evaluating associated soft tissue injuries but is not the primary imaging modality for acute calcaneal fractures 1

Treatment Options

Surgical Management

• For comminuted calcaneal fractures, percutaneous subtalar joint screw fixation has shown good outcomes with restoration of calcaneal anatomy in over 80% of cases and low complication rates 2
• Multiplanar variable-angle locked plating or interlocked nailing with longitudinal strut provides superior stability for comminuted intraarticular calcaneal fractures compared to lateral plating alone 3
• For highly comminuted fractures, primary subtalar joint arthrodesis with combined internal and external fixation may be beneficial, especially in patients with diabetes 4

Conservative Management

• Simple immobilization is appropriate when fracture fragments are small, non-articular, or minimally displaced 1
• Protective immobilization with a cast or fixed-ankle walker-type device is indicated for less severe fractures 1

Treatment Algorithm

1. Initial assessment:

   • Evaluate for open vs. closed fracture 1
   • Assess comminution and intra-articular involvement via CT imaging 1
   • Check for associated injuries 1

2. For open fractures:

   • Immediate wound management with saline solution (without additives) 1
   • Early antibiotic administration (cefazolin or clindamycin for all types, with additional gram-negative coverage for Gustilo/Anderson Type III) 1
   • Consider negative pressure wound therapy 1

3. For closed comminuted fractures:

   • If minimally displaced and non-articular: immobilization with cast or walker boot 1
   • If significantly displaced or intra-articular: surgical fixation 2, 3

4. Surgical options based on fracture pattern:

   • For highly comminuted fractures: percutaneous subtalar joint screw fixation 2
   • For intra-articular fractures: multiplanar variable-angle locked plating or interlocked nailing 3
   • For severely comminuted fractures with poor bone quality: consider primary subtalar arthrodesis 4

Common Pitfalls and Considerations

• Calcaneal fractures can be easily missed on initial radiographs; CT is essential for proper evaluation 1
• Occult osteochondral fractures of the subtalar joint may only be visualized on CT, particularly in patients with fractures involving the posterior facet 1
• Failure to recognize the extent of comminution can lead to inadequate treatment and poor outcomes 2
• Wound complications are a significant concern with open surgical approaches; percutaneous techniques may reduce this risk 2

Follow-up and Rehabilitation

• Regular radiographic follow-up is necessary to assess fracture healing and maintenance of reduction 2
• Weight-bearing restrictions should be maintained until radiographic evidence of healing 1
• Physical therapy should be initiated once appropriate to restore range of motion and strength 1
• Hardware removal may be necessary if symptomatic (approximately 20% of patients experience heel pain from screws) 2