What is the treatment for an impacted calcaneal fracture?

Treatment of Impacted Calcaneal Fractures

For impacted calcaneal fractures with minimal displacement and non-articular involvement, immobilization with a cast or fixed-ankle walker boot for 4-8 weeks followed by progressive weight-bearing is the appropriate treatment approach. 1, 2

Initial Assessment and Imaging

• Obtain CT imaging immediately to properly evaluate the fracture, as plain radiographs have only 87% sensitivity and frequently miss the extent of comminution, posterior facet involvement, and occult osteochondral injuries. 2
• Assess specifically for: intra-articular extension into the subtalar joint, degree of comminution, displacement of fragments, and soft tissue injury. 2
• Look for point tenderness over the lateral calcaneal wall (slightly posterior to the subtalar joint facet) and perform the calcaneal squeeze test (medial-to-lateral compression), which is highly suspicious for calcaneal fracture. 1

Treatment Algorithm

For Minimally Displaced, Non-Articular Impacted Fractures:

• Immobilize immediately with a cast or fixed-ankle walker-type device. 2
• Limit complete immobilization to maximum 3-5 days to prevent muscular atrophy and worsened functional recovery. 3
• Apply cryotherapy and prescribe NSAIDs (ibuprofen 400 mg every 4-6 hours) for pain control. 3
• After 3-5 days, commence active exercise and early weight-bearing as tolerated while maintaining protective immobilization. 3
• Continue protective immobilization for 4 weeks total, then transition to full weight-bearing in a walking cast for an additional 4 weeks. 4
• At 8 weeks post-injury, remove the walking cast and transition to regular shoe wear. 4

For Displaced or Intra-Articular Fractures:

• These require surgical consultation for potential open reduction and internal fixation, as impaction with articular involvement leads to subtalar joint stiffness and severe disability without anatomic restoration. 5
• Temporizing external fixation within 48 hours may be considered for severely displaced fractures to maintain reduction while awaiting definitive surgery when soft tissue swelling subsides. 6

Critical Pitfalls to Avoid

• Never rely solely on plain radiographs for treatment planning—CT is essential to identify the true extent of injury, particularly posterior facet involvement. 2
• Avoid prolonged complete immobilization beyond 3-5 days, as this causes muscular atrophy and worse functional outcomes. 3
• Reexamine at 3-5 days post-injury, as excessive initial swelling and pain can limit the accuracy of the first examination. 1, 3
• Do not miss associated injuries—always assess for bilateral symptoms, other joint involvement, or signs of compartment syndrome. 1

When to Refer

• No improvement after 6-8 weeks of appropriate conservative treatment warrants orthopedic or podiatric foot and ankle surgery referral. 3
• Any fracture with significant displacement, comminution involving the posterior facet, or intra-articular extension requires immediate surgical consultation. 2
• Consider advanced imaging (MRI) if clinical suspicion remains high despite negative or equivocal CT findings. 2, 3

Expected Recovery Timeline

• Return to work averages 4.9 months for operatively treated displaced fractures. 4
• For conservatively managed impacted fractures, symptoms may persist for variable periods after cast removal, but most resolve with appropriate initial treatment. 7
• Weight-bearing typically begins at 8-12 weeks, with radiographic union occurring around 9.5 weeks. 6, 8