What is the best management for a small calcaneal fracture?

Management of Small Calcaneal Fractures

For small, minimally displaced calcaneal fractures, conservative non-operative management with immobilization, pain control, and early mobilization is the recommended approach, reserving surgery only for displaced intra-articular fractures or those with significant soft tissue compromise. 1

Initial Diagnostic Evaluation

• Obtain standard radiographs including anteroposterior, lateral, and axial Harris-Beath views to assess fracture displacement and intra-articular involvement 2, 1
• The axial calcaneal view specifically increases specificity in diagnosing calcaneal fractures and sensitivity in distinguishing intra-articular from extra-articular patterns 2
• CT scanning is reserved for complex fractures requiring surgical planning, not for initial evaluation of small fractures 2

Conservative Management Protocol

For small, non-displaced or minimally displaced calcaneal fractures, non-operative treatment is the standard of care. 3, 4

Pain Management

• Prescribe paracetamol (acetaminophen) regularly unless contraindicated 1
• Use opioid analgesia cautiously, particularly in patients with renal dysfunction (approximately 40% of trauma patients have GFR <60 mL/min/1.73m²) 1
• Consider peripheral nerve blocks for severe pain, though this is more commonly needed for displaced fractures 2

Immobilization and Weight-Bearing

• Immobilize initially in a cast or removable boot 1
• The evidence shows that systematic reviews have found no clear superiority of operative versus non-operative treatment for many calcaneal fractures 3, 4
• Transition to protected weight-bearing as pain allows, typically over 6-8 weeks 2

Indications for Surgical Consideration

Surgery should be considered only when specific criteria are met:

Absolute Indications

• Tongue-type fractures with skin compromise requiring urgent intervention within 24 hours 1
• Displaced intra-articular fractures where anatomic reconstruction is achievable 5
• Open fractures requiring soft tissue management 1

Surgical Approach Selection (When Surgery is Indicated)

• Minimally invasive techniques via sinus tarsi approach are preferred for most displaced intra-articular fractures, showing significantly lower wound complication rates (2.7%) compared to open reduction and internal fixation (16.7%) 6
• Purely percutaneous fixation is appropriate for displaced extra-articular fractures and simple intra-articular fractures 5

Soft Tissue Management

• 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 significant abrasions 1

Key Clinical Pitfalls

The most important caveat is that the evidence base for calcaneal fracture management remains limited. Multiple systematic reviews demonstrate no definitive evidence that operative treatment is superior to conservative management for most fractures 3, 4. The potential advantages of surgery must be weighed against risks including:

• Wound complications (significantly higher with open approaches at 16.7% versus 2.7% for minimally invasive techniques) 6
• Surgical site infections, particularly with compromised soft tissues 1
• Secondary arthrodesis rates of approximately 4.7% regardless of treatment method 6

Rehabilitation

• Initiate physical therapy once immobilization period ends to restore range of motion and strength 1
• Expect subtalar joint stiffness as a common sequela even with optimal treatment 4, 7
• Monitor for chronic pain and functional limitations as long-term complications 1

Outcome Expectations

For small, non-displaced fractures managed conservatively, outcomes are generally favorable. However, even with operative treatment of displaced fractures, evidence shows no significant difference in residual pain between operative and non-operative groups, though operative patients may have better return-to-work rates and ability to wear previous footwear 3.