What is the treatment for a distal lateral calcaneal (heel bone) evulsion fracture and a possible medial malleolus (inner ankle bone) evulsion fracture?

Treatment of Distal Lateral Calcaneal Avulsion Fracture and Possible Medial Malleolus Avulsion Fracture

For small, non-articular, minimally displaced calcaneal avulsion fractures, conservative management with protective immobilization is the appropriate first-line treatment, while the medial malleolus fracture requires radiographic confirmation and assessment of ankle stability before determining treatment. 1

Initial Assessment and Imaging

Calcaneal Avulsion Fracture

• Confirm diagnosis with standard ankle and foot radiographs to evaluate fracture size, displacement, and articular involvement 1
• Consider axial Harris-Beath view specifically for calcaneal fractures to determine intra-articular extent 2
• Advanced imaging (CT or MRI) is reserved for cases where the extent of fracture or soft tissue injury needs further evaluation 1

Medial Malleolus Fracture

• Obtain weight-bearing radiographs if possible to assess ankle stability, as this is the most important criterion for treatment decisions 2
• A medial clear space <4 mm confirms stability 2
• Look for clinical indicators of instability: medial tenderness, bruising, swelling, or associated fibular fracture above the syndesmosis 2
• The gravity stress view is more reliable than manual stress views for detecting deltoid ligament disruption in suspected unstable injuries 2

Treatment Algorithm for Calcaneal Avulsion Fracture

Conservative Management (First-Line)

Simple immobilization is appropriate when fracture fragments are small, non-articular, or minimally displaced 2, 1

• Immobilization method: Walking boot or cast for protective immobilization 1
• Pain management: NSAIDs for symptomatic relief 2, 1
• Activity modification: Reduce weight-bearing stress during healing phase 1
• Duration: Continue immobilization until clinical and radiographic evidence of healing 1

Rehabilitation Phase

• Gradual return to weight-bearing with supportive footwear after immobilization period 1
• Physical therapy to restore range of motion and strength 1

When Surgery Is Indicated

• Involvement of weight-bearing surfaces warrants surgical consideration 1
• For displaced intra-articular fractures requiring anatomic reconstruction, minimally invasive reduction and fixation via sinus tarsi approach is preferred over extensile lateral approaches 3

Treatment Algorithm for Medial Malleolus Avulsion Fracture

Stable Fractures

• If ankle is stable (medial clear space <4 mm, no clinical indicators of instability): Rigid cast immobilization 2
• Rigid immobilization is preferred over removable splints for displaced fractures 2

Unstable Fractures

• Surgical fixation is indicated if there is evidence of instability on weight-bearing films or clinical examination 2
• Avulsion fractures in the setting of severe ankle injury have a 66% association with ligamentous pathology requiring surgical intervention 4

Critical Pitfalls to Avoid

Calcaneal Fracture

• Do not allow premature return to high-impact activities before adequate healing is confirmed 1
• Do not overlook the need for advanced imaging if conservative management fails after 6-8 weeks 2
• Minimally invasive techniques should be considered for patients with medical comorbidities (diabetes, peripheral vascular disease, smoking) to reduce wound complications 5

Medial Malleolus Fracture

• Do not miss associated instability: Avulsion fractures are markers for significant ligamentous injury and may predict failure of conservative treatment 4
• In children and patients over 40, avulsion fractures are more common than ligament ruptures and require a high index of suspicion 6
• Nonoperative treatment of avulsion fractures without adequate stability assessment may lead to chronic instability 6

Special Considerations

• Osseous union occurs in only 65% of conservatively treated ankle avulsion fractures, but functional outcomes remain satisfactory if stability is maintained 6
• For persistent pain after adequate conservative management, re-evaluate with advanced imaging 1
• The combination of calcaneal and medial malleolar avulsion fractures suggests a high-energy injury mechanism requiring careful assessment for additional injuries 2