What is the treatment plan for a patient with a calcaneal fracture, possibly with associated injuries or underlying conditions like osteoporosis?

Treatment of Calcaneal Fractures

Begin with standard three-view radiographs including an axial Harris-Beath view to determine if the fracture is intra-articular, and proceed with open reduction and internal fixation (ORIF) for displaced intra-articular fractures once soft tissue conditions permit, while tongue-type fractures require urgent intervention within 24 hours due to skin compromise risk. 1, 2

Initial Diagnostic Imaging

• Obtain standard radiographs as the first-line imaging modality, including anteroposterior, lateral, oblique, and crucially the axial calcaneal (Harris-Beath) view, which increases specificity for diagnosing calcaneal fractures and sensitivity for distinguishing intra-articular involvement 1
• CT is reserved for complex fractures to evaluate the true extent of osseous injury and surgical planning, not as initial screening 1
• MRI and ultrasound have no role in acute calcaneal fracture evaluation 1

Immediate Management (First 24 Hours)

Pain Control

• Administer paracetamol regularly unless contraindicated 2
• Use opioid analgesia cautiously, particularly in trauma patients with renal dysfunction (approximately 40% have GFR <60 mL/min/1.73m²) 2
• Consider single-shot or continuous femoral/fascia iliaca nerve blocks for superior pain relief 2

Urgent Fracture Assessment

• Tongue-type calcaneus fractures demand intervention within 24 hours due to potential skin compromise from the displaced posterior fragment 2
• Evaluate for open fractures, which carry 8% amputation risk and require immediate surgical debridement, intravenous antibiotics (Cefazolin or clindamycin if penicillin-allergic), and tetanus prophylaxis 2, 3

Soft Tissue Management

• Clean any abrasions with simple saline solution without additives 2
• Initiate antibiotic coverage: Cefazolin or clindamycin (penicillin allergy), adding gram-negative coverage for severe soft tissue injuries 2
• Apply negative pressure wound therapy to abrasions to promote healing 2

Assessment for Associated Injuries

Open calcaneal fractures result from high-energy mechanisms and have extremely high rates of concomitant injuries that must be systematically evaluated: 3

• Vascular injury: Check for posterior tibial artery transection (occurs in 6.4% of open fractures) 3
• Ipsilateral lower extremity fractures: Ankle fractures (22.5%), metatarsal fractures (25.8%), talus fractures (19.3%), cuboid fractures (8%), femoral shaft fractures (12.9%) 3
• Spinal fractures: Present in 14.5%, with lumbar spine most commonly affected (9.6%) 3
• Upper extremity fractures: 24.1% of patients 3
• Thoracic injuries: Pneumothorax and other pulmonary injuries in 20.9% 3
• Closed head injury: 16.1% of patients 3
• Abdominal injuries: 9.6% of patients 3

Definitive Treatment Strategy

Displaced Intra-articular Fractures (Most Common)

• Proceed with ORIF once soft tissue swelling subsides (typically 7-14 days), as anatomic reduction of calcaneal shape and subtalar joint congruity correlates with satisfactory functional outcomes 2, 4, 5
• The sinus tarsi approach is preferred for most displaced intra-articular fractures, offering less invasive access with lower wound complication rates compared to extended lateral approaches 6
• Extend the approach along the "lateral utility" line if calcaneocuboid joint involvement or fracture-dislocations are present 6
• The extended lateral approach remains an option but carries higher wound complication risk despite providing excellent visualization 5

Severely Comminuted Fractures (Sanders Type IV)

• Consider primary subtalar arthrodesis for severely comminuted intra-articular fractures not amenable to reconstruction, which provides 97% union rate and average AOFAS scores of 77.4 with 75-100% return to work 7
• This approach avoids the futility of attempting anatomic reconstruction in unreconstructable fractures and provides definitive treatment 7

Extraarticular Fractures

• Percutaneous fixation is the treatment of choice for displaced extraarticular fractures with adequate fluoroscopic control 6

Tongue-Type Fractures

• Require urgent reduction and fixation within 24 hours via appropriate approach based on displacement pattern 2

Postoperative Management

• Immobilize initially in a splint or cast 2
• Transition to removable cast boot when soft tissues permit 2
• Initiate physical therapy focusing on range of motion restoration and progressive strengthening 2
• Non-weightbearing period varies by fracture pattern and fixation stability (typically 8-12 weeks)

Complications Monitoring

• Surgical site infections, particularly with compromised soft tissues—the most common serious complication 2
• Chronic pain and functional limitations occur frequently even with optimal treatment 2
• Subtalar arthritis development requiring delayed arthrodesis 5
• Wound dehiscence, especially with extended lateral approaches 5

Special Populations

Osteoporosis Considerations

• Perform individualized osteoporosis risk assessment in patients >65 years, evaluating age >70, low BMI (<20-25 kg/m²), weight loss >10%, physical inactivity, corticosteroid use, and previous fragility fractures 1
• Obtain DXA scanning for patients at increased osteoporosis risk who are candidates for drug therapy 1
• Calcaneal fractures from low-energy mechanisms suggest underlying osteoporosis requiring treatment 1

High-Energy Open Fractures

• Type III open injuries carry significantly increased amputation risk 3
• Combat-related open calcaneal fractures show 43% amputation rate, necessitating realistic discussions about salvage versus amputation in catastrophic injuries 2

Prognostic Factors

Surgeon-modifiable factors: Anatomic reduction of overall calcaneal shape and subtalar joint congruity 5

Adverse prognostic factors: Severity of injury, open fractures, bilateral fractures, high BMI, smoking, inadequate reduction 5