What is the medical management for calcaneal fractures?

Medical Management of Calcaneal Fractures

For displaced calcaneal fractures, prioritize initial soft tissue management with saline wound cleaning, appropriate antibiotic coverage (Cefazolin or clindamycin), and staged surgical fixation once soft tissue conditions permit, as definitive surgical intervention provides superior outcomes compared to conservative management alone. 1

Initial Assessment and Imaging

• Obtain standard radiographs including the axial Harris-Beath view specifically for suspected calcaneal fractures to determine intra-articular extent 2
• CT scanning provides more accurate diagnosis and surgical planning for displaced intra-articular fractures 3
• Tongue-type calcaneus fractures require urgent attention within 24 hours due to potential skin compromise 1

Immediate Medical Management

Pain Control

• Administer opioid analgesia with caution, particularly in patients with renal dysfunction (approximately 40% of trauma patients present with GFR <60 mL/min/1.73m²) 2
• Prescribe paracetamol regularly unless contraindicated 2
• Consider single-shot or continuous femoral/fascia iliaca nerve blocks for effective pain relief 2

Soft Tissue Management (Critical for Displaced Fractures)

• Clean any associated abrasions with simple saline solution without additives 1
• Initiate antibiotic coverage with Cefazolin or clindamycin (if penicillin-allergic) 1
• Add gram-negative coverage for more severe soft tissue injuries 1
• Consider negative pressure wound therapy for abrasions to promote healing 1

Definitive Treatment Strategy

Surgical Intervention

• Proceed with open reduction and internal fixation (ORIF) once soft tissue conditions improve 1
• Minimally invasive reduction and fixation (MIRF) using threaded K-wires and Steinmann pins offers an alternative for patients with significant medical comorbidities (smokers, diabetics, peripheral vascular disease), with mean operative time of 35 minutes and low infection risk 4
• MIRF can be safely performed even with extensive soft tissue swelling in the immediate post-injury period 4

Timing Considerations

• Mean time to surgery is typically 6 days (range 1-10 days) to allow soft tissue recovery 4
• Tongue-type fractures require more urgent intervention within 24 hours 1

Postoperative Management

• Immobilize initially, then transition to removable cast or boot 1
• Initiate physical therapy to restore range of motion and strength 1
• External fixation with "kickstand" modification can relieve direct pressure and optimize flap survival for complex reconstructions 5

Special Considerations

Anterior Process Fractures

• Most anterior process fractures respond successfully to cast immobilization 6
• Surgical excision is reserved for persistent symptoms after conservative treatment, though early excision is not advisable 6
• Missed diagnosis leading to non-union may result in poor outcomes even after delayed excision 6

Complications to Monitor

• Surgical site infections, particularly with compromised soft tissues 1
• Chronic pain and functional limitations are common long-term outcomes 1
• Subtalar joint stiffness and severe disability can occur despite optimal treatment 3

Common Pitfalls

The evidence shows discrepancies in outcomes between civilian and military populations, with combat-related open calcaneal fractures showing a 43% amputation rate and better outcomes in amputated patients 2. This highlights the importance of early recognition of severe soft tissue compromise and realistic expectations regarding salvage versus amputation in catastrophic injuries.