What is the approach to treating fractures of the calcaneus?

Management of Calcaneus Fractures

For displaced intra-articular calcaneus fractures, surgical treatment with open reduction and internal fixation (ORIF) should be pursued as it improves functional outcomes and reduces chronic pain compared to non-surgical management, though it carries increased risk of wound complications that can be mitigated with careful soft tissue management and consideration of negative pressure wound therapy. 1, 2

Initial Assessment and Fracture Classification

Immediate evaluation priorities:

• Mechanism of injury - typically fall from height causing axial loading through the heel 3
• Soft tissue status - assess for skin compromise, abrasions, or impending compartment syndrome 1
• Fracture displacement and articular involvement - CT imaging is essential to characterize fracture pattern and subtalar joint involvement 4
• Tongue-type fractures require urgent attention within 24 hours due to high risk of skin compromise 1

Treatment Decision Algorithm

For Displaced Intra-Articular Fractures:

Surgical management is preferred because it:

• Improves functional outcomes at 6-24 months (AOFAS score improvement of 6.58 points) 2
• Reduces chronic pain by 44% (295 fewer per 1000 patients experience chronic pain) 2
• Improves physical quality of life (6.49 point improvement on SF-36 physical component score) 2

For Non-Displaced or Extra-Articular Fractures:

Non-surgical management with immobilization is appropriate:

• Cast immobilization or fixed-ankle walker device 3
• Simple immobilization for small, nonarticular, or minimally displaced fragments 3

Surgical Approach Selection

Primary surgical options:

Open Reduction and Internal Fixation (ORIF):

• Extended lateral approach is the standard, providing excellent exposure of lateral wall and subtalar joint 5
• Medial approach can be used for sustentacular fractures or when lateral soft tissues are compromised 6
• Achieves anatomic reduction which is the most important surgeon-controlled prognostic factor 5

Minimally Invasive Techniques:

• 2-point distractor method reduces wound complications from 16.7% to 2.7% compared to traditional ORIF 7
• Percutaneous fixation lowers wound complication rates but anatomic reduction remains challenging 5

Management of Compromised Soft Tissues

When medial foot abrasion or soft tissue injury is present:

1. Clean abrasion with simple saline solution (no additives) 1
2. Initiate antibiotic prophylaxis:
   • Cefazolin as first-line 1
   • Clindamycin if penicillin-allergic 1
   • Add gram-negative coverage for severe injuries 1
3. Apply negative pressure wound therapy to high-risk surgical incisions (calcaneus fractures specifically mentioned) to reduce deep surgical site infection 3, 1
4. Delay definitive fixation until soft tissue conditions improve 1

Surgical Timing

Optimal timing considerations:

• Within 2 days of injury when soft tissues permit (88.7% of cases in successful series) 7
• Within 24 hours for tongue-type fractures to prevent skin necrosis 1
• Delay if significant soft tissue swelling or abrasion present until conditions improve 1

Postoperative Protocol

Immobilization phase:

• 4 weeks non-weight bearing in cast 6
• Pin removal at 4 weeks if used 6

Mobilization phase:

• 4 weeks weight bearing in walking cast (weeks 4-8) 6
• Transition to shoe at 8 weeks with initiation of physical therapy 6
• Removable boot may be used after initial immobilization 1

Physical therapy focus:

• Range of motion restoration 1
• Strength training 1

Complications and Their Management

Wound complications (most significant surgical risk):

• Superficial infection occurs in 14% of surgical patients 2
• Deep infection in 5.3% requiring debridement 2
• Implant removal needed in 3.4% 2
• Risk minimized by:
  • Meticulous soft tissue handling 5
  • Negative pressure wound therapy for high-risk incisions 3
  • Appropriate surgical timing 7

Late complications:

• Subtalar arthrodesis may be needed but rates are similar between surgical (4.7%) and non-surgical treatment 7, 2
• Chronic pain and functional limitations occur less frequently with surgical treatment 3, 2

Prognostic Factors

Factors adversely affecting outcomes:

• High body mass index 5
• Smoking 5
• Bilateral fractures 5
• Open fractures 5
• Severity of initial injury 5

Surgeon-controlled factors for optimal outcomes:

• Anatomic reduction of calcaneal shape 5
• Restoration of subtalar joint congruity 5
• Intraoperative verification of reduction quality 5

Return to Work

Expected timeline:

• Mean 4.9 months for return to work after surgical treatment 6
• No significant difference in return-to-work rates between surgical and non-surgical treatment at 24 months 2