Treatment of Distal Lateral Calcaneal Avulsion Fracture
For small, minimally displaced distal lateral calcaneal avulsion fractures, conservative management with protective immobilization in a walking boot or cast is the appropriate first-line treatment. 1, 2
Initial Diagnostic Workup
- Obtain standard three-view ankle radiographs (anteroposterior, lateral, and mortise) to confirm the diagnosis and assess fracture characteristics 3
- Add an axial Harris-Beath view specifically for calcaneal fractures to determine intra-articular extent 3, 1
- Reserve CT or MRI for cases requiring further evaluation of fracture extent or associated soft tissue injuries 1, 2
- Obtain weight-bearing radiographs when possible to assess ankle stability, as this is the most critical factor determining treatment 1
Treatment Algorithm
Conservative Management (First-Line for Most Cases)
Indications for conservative treatment:
Conservative treatment protocol:
- Immobilize with a walking boot or cast 1, 2
- Prescribe NSAIDs for pain management 1, 2
- Modify activity to reduce weight-bearing stress during healing 1, 2
- Continue immobilization until clinical and radiographic evidence of healing is confirmed 1, 2
- After immobilization, initiate gradual return to weight-bearing activities with supportive footwear 2
- Consider physical therapy to restore range of motion and strength 2
Surgical Management
Indications for surgery:
- Large fragments (≥15mm) requiring anatomic reduction 4
- Displacement >2mm 4
- Involvement of weight-bearing surfaces 2
- Intra-articular extension with displacement 4
- Persistent pain after 6-8 weeks of adequate conservative management 1
Surgical techniques for calcaneal avulsion fractures:
- For elderly or osteoporotic patients, transosseous suture anchor fixation provides stronger fixation than lag screws alone 5
- Cannulated cancellous screws combined with titanium wire through screw holes offers strong internal fixation and prevents secondary displacement 6
- For cases with poor heel skin condition or superficial necrosis, use a plate lacking the anterior component with percutaneously inserted screws to reduce soft tissue complications 7
Post-operative protocol:
- Non-weight bearing for 6-8 weeks 4
- Progressive weight bearing only after radiographic confirmation of adequate healing 4
Critical Pitfalls to Avoid
- Do not allow premature return to high-impact activities before adequate healing is confirmed 1, 2
- Do not overlook the need for advanced imaging if conservative management fails after 6-8 weeks 1
- Do not rely solely on lag screw fixation in osteoporotic bone, as secondary displacement can occur even with adequate initial reduction 5
- Do not misdiagnose as a simple ankle sprain—maximal tenderness below the anterior talofibular ligament suggests anterior calcaneal process avulsion 8
Special Considerations
- Avulsion fractures of the lateral ankle ligament complex are more common than previously recognized (26% incidence in severe inversion injuries) and are particularly prevalent in children and patients over 40 years of age 9
- These fractures are often undetected on early radiographs, requiring a high index of suspicion 9
- Unlike lateral ligament ruptures, avulsion fractures may not yield satisfactory results with simple casting alone if fragments are large or displaced 9
- Re-evaluate with advanced imaging if persistent pain continues despite adequate conservative management 1, 2