Calcaneum Traction for Calcaneal Fractures
Calcaneal pin insertion for skeletal traction is indicated primarily for displaced intra-articular calcaneal fractures requiring reduction, but definitive surgical fixation (ORIF) or minimally invasive techniques are preferred over prolonged traction alone for achieving optimal functional outcomes. 1, 2
When Calcaneal Traction is Appropriate
Calcaneal pin insertion serves specific roles in fracture management:
- Temporary reduction aid: Skeletal traction through a calcaneal pin is used for displaced intra-articular fractures requiring reduction, particularly as a temporizing measure before definitive fixation or as part of external fixation constructs 1
- Soft tissue management: When significant soft tissue swelling, abrasions, or impending compartment syndrome is present, surgery should be delayed until conditions improve, and traction may help maintain length during this waiting period 2
- Urgent tongue-type fractures: These require attention within 24 hours due to high risk of skin compromise and may benefit from immediate traction to prevent further soft tissue damage 2
Definitive Treatment Algorithm
The treatment decision should follow this pathway based on fracture characteristics:
For displaced intra-articular fractures:
- Surgical treatment with open reduction and internal fixation (ORIF) is preferred, as it improves functional outcomes and reduces chronic pain compared to non-operative management 2
- Optimal surgical timing is within 2 days of injury when soft tissues permit, and within 24 hours for tongue-type fractures to prevent skin necrosis 2
- Minimally invasive reduction and fixation (MIRF) using threaded K-wires and Steinmann pins offers shorter operative time (mean 35 minutes), can be performed safely even with extensive soft tissue swelling, and has low infection risk—making it suitable for patients with significant comorbidities like diabetes, smoking, or peripheral vascular disease 3
For non-displaced or extra-articular fractures:
- Non-surgical management with immobilization using cast immobilization or a fixed-ankle walker device is appropriate 2
Pre-Procedure Requirements for Pin Insertion
Before placing a calcaneal pin for traction:
- Obtain CT imaging without IV contrast to fully characterize the fracture pattern, as radiographs have only 87% sensitivity for calcaneal fractures 1
- Assess soft tissue status for skin compromise, abrasions, or compartment syndrome 1
- If medial foot abrasion or soft tissue injury is present, clean with saline solution and initiate antibiotic prophylaxis with cefazolin 2
Post-Traction/Post-Fixation Management
Regardless of whether traction or definitive fixation is used:
- Maintain non-weight-bearing status until radiographic evidence of healing, typically 8-12 weeks for fractures 1
- Monitor pin sites daily for signs of infection 1
- A removable boot may be used after initial immobilization 2
- Initiate physical therapy for range of motion restoration and strength training once appropriate 1, 2
Critical Pitfalls to Avoid
Prolonged traction as definitive treatment: Traction alone does not achieve the anatomical reduction of overall calcaneal shape and subtalar joint congruity that surgical fixation provides—factors that directly influence long-term outcomes 4. Open reduction with stable internal fixation has demonstrated good to excellent results in more than two-thirds of patients in larger clinical series 4.
Delayed surgical intervention: When surgery is indicated, delaying beyond the optimal 2-day window (except for soft tissue reasons) can compromise outcomes, particularly for tongue-type fractures where 24-hour intervention is critical 2.
Overlooking patient-specific factors: Patients with significant medical comorbidities (smokers, diabetics, peripheral vascular disease) benefit from minimally invasive techniques rather than extensile lateral approaches, as these reduce wound complications while maintaining reduction quality 3.