What is the initial management for a patient presenting with a calcaneum (heel bone) fracture?

Initial Management of Calcaneum Fracture

For a patient presenting with a suspected calcaneum fracture, obtain standard radiographs including an axial Harris-Beath view as the initial imaging study, assess for soft tissue compromise and associated injuries (particularly spine and lower extremity), and initiate appropriate immobilization with urgent orthopedic consultation for displaced intra-articular fractures. 1, 2

Immediate Assessment and Imaging

Clinical Evaluation

• Assess soft tissue status immediately for skin compromise, abrasions, or impending compartment syndrome, as these findings dictate urgency of treatment 2
• Examine for point tenderness over the calcaneus, inability to bear weight, and mechanism of injury (typically fall from height causing axial loading) 1, 2
• Evaluate for associated injuries systematically: lumbar spine fractures occur in 80% of concomitant vertebral injuries with calcaneal fractures, ipsilateral ankle fractures in 22.5%, metatarsal fractures in 25.8%, and talus fractures in 19.3% 3, 4
• Check posterior tibial artery pulse, as arterial transection occurs in 6.4% of open calcaneal fractures 3

Initial Imaging Protocol

• Obtain standard three-view radiographs of the foot (anteroposterior, lateral, and oblique views) as the first-line imaging study 1
• Add an axial Harris-Beath view specifically for suspected calcaneal fractures to determine intra-articular extent and increase diagnostic sensitivity 1
• Radiographs have 87% sensitivity for calcaneal fractures, so CT without IV contrast should follow to fully characterize fracture patterns before definitive treatment 5
• Obtain lumbar spine imaging given the 7-14.5% incidence of concomitant vertebral fractures, with lumbar spine involvement in 80% of cases 3, 4

Immediate Treatment Measures

Open Fractures

• Administer intravenous antibiotics immediately (cefazolin is recommended), provide tetanus prophylaxis, and perform urgent irrigation and debridement 2, 3, 6
• Clean any medial foot abrasions with simple saline solution 2
• Open calcaneal fractures carry an 8% amputation risk and 20.9% rate of pulmonary injuries, requiring vigilant monitoring 3
• Delay definitive hardware placement until soft tissue coverage is fully assessed; average time to definitive fixation is 7 days (range 0-22 days) 6

Closed Fractures - Fracture Type-Specific Management

Tongue-type fractures:

• Require urgent attention within 24 hours due to high risk of skin necrosis from posterior displacement 2
• These represent a surgical emergency even when closed

Displaced intra-articular fractures:

• Surgical treatment with open reduction and internal fixation (ORIF) is preferred as it improves functional outcomes (AOFAS score improvement of 6.58 points), reduces chronic pain by 44% (RR 0.56), and improves physical quality of life by 6.49 points on SF-36 2, 7
• Optimal surgical timing is within 2 days of injury when soft tissues permit 2
• Surgery should be delayed if significant soft tissue swelling or abrasion is present 2

Non-displaced or extra-articular fractures:

• Manage non-surgically with cast immobilization or fixed-ankle walker device 2

Initial Immobilization

• Apply appropriate splinting or casting based on fracture pattern and soft tissue status
• Maintain non-weight-bearing status until radiographic evidence of healing, typically 8-12 weeks 5

Critical Pitfalls to Avoid

• Do not manipulate the ankle prior to radiographs unless neurovascular deficit or critical skin injury is present, to avoid complications 1
• Do not miss associated injuries: systematically evaluate spine (14.5% fracture rate), ipsilateral lower extremity (up to 25.8% metatarsal fractures), and check for closed head injury (16.1%) and pneumothorax (12.9%) 3
• Do not place definitive hardware at initial debridement for open fractures; wait for soft tissue assessment 6
• Recognize that tongue-type fractures cannot wait for routine orthopedic follow-up and require intervention within 24 hours 2
• Apply negative pressure wound therapy to high-risk surgical incisions to reduce deep surgical site infection rates 2