What is the recommended management for a patient with an undisplaced calcaneal fracture, possibly with a history of osteoporosis?

Management of Undisplaced Calcaneal Fracture

For undisplaced calcaneal fractures, immobilization with protected weight-bearing is the appropriate treatment, as simple immobilization is specifically indicated when fracture fragments are small, nonarticular, or minimally displaced. 1

Acute Management

Immobilization Strategy

• Apply an immobilization cast or fixed-ankle walker-type device to protect the fracture and allow healing 1
• Maintain immobilization for 6-8 weeks, as this timeframe aligns with standard conservative treatment protocols for calcaneal stress fractures 1
• Protected weight-bearing is appropriate during this period, avoiding full unprotected loading 1

Pain Control

• Start acetaminophen as first-line analgesia 2
• Avoid NSAIDs if cardiovascular or renal comorbidities exist 2
• Use short-term narcotic medications only if necessary for severe pain 2

Critical Pitfall to Avoid

• Do not allow prolonged bed rest beyond what is absolutely necessary for acute pain control, as it accelerates bone loss, muscle weakness, and increases risk of deep vein thrombosis and pressure ulcers 2, 3

Rehabilitation Protocol

Early Phase (First 2 Weeks)

• Begin range-of-motion exercises for ankle and foot within the first postoperative days 3
• Initiate early mobilization as tolerated to prevent complications of immobility 2

Progressive Phase (Weeks 2-8)

• Implement early post-fracture physical training and muscle strengthening 2
• Progress weight-bearing as pain and healing allow 1
• Identify individual goals and needs before developing the rehabilitation plan 2

Long-Term Phase (After 8 Weeks)

• Establish long-term balance training and multidimensional fall prevention programs, which reduce fall frequency by approximately 20% 2
• Continue weight-bearing and resistance training exercises 2

Management of Underlying Osteoporosis

Given the context of possible osteoporosis, addressing bone health is critical to prevent future fractures.

Calcium and Vitamin D Supplementation

• Prescribe calcium 1000-1200 mg/day plus vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20% 2, 3
• Avoid high pulse dosages of vitamin D as they are associated with increased fall risk 2

Pharmacological Treatment for Osteoporosis

• Oral bisphosphonates (alendronate or risedronate) are first-choice agents because they reduce vertebral, non-vertebral, and hip fractures, are well-tolerated, cost-effective, and widely available as generics 2, 3
• These agents demonstrated reduction in vertebral fractures, non-vertebral fractures, and hip fractures in primary analyses 2
• Prescribe bisphosphonates for 3-5 years initially, with longer duration for patients who remain at high risk 2
• For patients with oral intolerance, dementia, malabsorption, or non-compliance, zoledronic acid (intravenous) or denosumab (subcutaneous) are alternatives 1

Non-Pharmacological Interventions

• Encourage smoking cessation and limiting alcohol intake to improve bone mineral density, bone quality, and reduce fall risk 2
• Implement weight-bearing exercise programs to improve BMD and muscle strength 3
• Address environmental hazards in the home 3
• Review medications that may increase fall risk 3

Monitoring and Follow-Up

Clinical Assessment

• Monitor regularly for medication tolerance and adherence, as long-term adherence is typically poor 2
• Use risk communication and shared decision-making to improve adherence 2
• Implement a five-step plan: identify patients with recent fracture, invite for fracture risk evaluation, perform differential diagnosis, initiate therapy, and establish follow-up 2

Imaging Follow-Up

• Obtain follow-up radiographs at 6-8 weeks to confirm healing 1
• If symptoms persist beyond 6-8 weeks, consider advanced imaging such as MRI or bone scan to evaluate for occult fracture or delayed healing 1, 4

Subspecialist Referral

• If symptoms do not improve within 6-8 weeks, refer to a podiatric foot and ankle surgeon for further evaluation 1
• Establish collaboration between orthopedic surgery, rheumatology/endocrinology, and primary care for comprehensive osteoporosis management 3

Key Distinction from Displaced Fractures

The evidence is clear that undisplaced fractures have a fundamentally different treatment algorithm than displaced intra-articular fractures. While displaced fractures may require surgical intervention with open reduction and internal fixation 5, 6, undisplaced fractures are specifically managed with simple immobilization 1, 7. The prospective study by 7 documented that undisplaced fractures treated conservatively had slightly better results than displaced fractures, reinforcing the appropriateness of conservative management for this fracture pattern.