What is the recommended treatment for a patient with a posterior calcaneus fracture?

Treatment of Posterior Calcaneus Fracture

For displaced intra-articular posterior calcaneus fractures, surgical treatment with open reduction and internal fixation (ORIF) is the preferred approach, as it improves functional outcomes and reduces chronic pain compared to non-operative management. 1

Initial Assessment and Imaging

• Obtain standard three-view radiographs (anteroposterior, lateral, and oblique) with an axial Harris-Beath view as the initial imaging study to assess for fracture and soft tissue compromise. 1
• CT imaging without IV contrast is essential to fully characterize the fracture pattern, as radiographs have only 87% sensitivity for calcaneal fractures and frequently miss the extent of comminution and articular involvement. 2, 3
• Assess soft tissue status for skin compromise, abrasions, or compartment syndrome before proceeding with treatment planning. 2, 1
• Do not manipulate the ankle prior to radiographs unless neurovascular deficit or critical skin injury is present. 1

Treatment Algorithm Based on Fracture Type

Displaced Intra-articular Fractures

• Surgical treatment with ORIF is preferred for displaced intra-articular fractures to restore anatomical alignment and joint congruity. 1
• The sinus tarsi approach is appropriate for most displaced intra-articular fractures, which may be extended along the "lateral utility" line for calcaneocuboid joint involvement or calcaneal fracture-dislocations. 4
• Anatomical reduction and stable internal fixation using calcaneal plates are essential, as post-operative displacement of the posterior facet greater than 2 mm results in poor outcomes regardless of fracture type. 5

Non-displaced or Extra-articular Fractures

• Non-surgical management with immobilization using a cast or fixed-ankle walker device is appropriate for non-displaced or extra-articular fractures. 1
• Purely percutaneous fixation is the treatment of choice for displaced extraarticular fractures and simple intraarticular fractures with adequate control of joint reduction. 4

Surgical Timing Considerations

• Tongue-type fractures require urgent surgical attention within 24 hours due to high risk of skin compromise and necrosis. 1
• The optimal timing for surgery is within 2 days of injury when soft tissues permit. 1
• Surgery should be delayed if significant soft tissue swelling or abrasion is present until conditions improve. 1
• For subacute fractures (3 weeks to <6 months post-injury), surgery should be performed as soon as soft tissue conditions permit, though anatomical reduction may be more technically challenging than acute intervention. 3

Management of Compromised Soft Tissues

• When medial foot abrasion or soft tissue injury is present, clean the abrasion with simple saline solution and initiate antibiotic prophylaxis with cefazolin. 1
• Apply negative pressure wound therapy to high-risk surgical incisions to reduce deep surgical site infection rates. 1

Postoperative Protocol

• Maintain non-weight-bearing status until radiographic evidence of healing, typically 8-12 weeks for fractures. 2, 3
• Immobilize in a cast for 4 weeks postoperatively, then transition to full weight bearing in a walking cast for an additional 4 weeks. 6
• At 8 weeks post-surgery, remove the walking cast and transition to walking in a shoe. 6
• A removable boot may be used after initial immobilization. 1
• Monitor pin sites daily for signs of infection if skeletal traction or external fixation is used. 2
• Initiate physical therapy for range of motion restoration and strength training once appropriate. 2, 1, 3

Common Pitfalls

• Inadequate initial CT imaging leads to underestimation of fracture complexity and poor surgical planning. 2, 3
• Proceeding with surgery in the presence of significant soft tissue swelling increases wound complication rates. 1
• Accepting residual articular displacement greater than 2 mm results in poor functional outcomes regardless of other factors. 5
• Delaying tongue-type fracture treatment beyond 24 hours significantly increases the risk of skin necrosis. 1