Treatment of Extra-Articular Calcaneal Fractures
For extra-articular calcaneal fractures, non-surgical management with immobilization is the appropriate treatment approach, using either cast immobilization or a fixed-ankle walker device. 1
Initial Assessment and Imaging
- Obtain standard three-view radiographs (anteroposterior, lateral, and oblique) plus an axial Harris-Beath view to confirm the extra-articular nature of the fracture and rule out intra-articular extension. 1
- Assess soft tissue status carefully for skin compromise, abrasions, or signs of compartment syndrome before proceeding with treatment, as approximately 10% of calcaneal fractures develop compartment syndrome. 2
- Avoid manipulating the ankle prior to radiographs unless neurovascular deficit or critical skin injury is present. 1
Treatment Algorithm by Fracture Subtype
Non-Displaced Extra-Articular Fractures
- Immobilize with cast or fixed-ankle walker device and maintain non-weight-bearing status. 1
- This represents the standard of care for stable extra-articular fractures. 3
Displaced Extra-Articular Fractures
- Percutaneous fixation is the treatment of choice for displaced extra-articular fractures. 4
- This minimally invasive approach provides adequate fracture control while avoiding extensive soft tissue dissection. 4
Calcaneal Tuberosity Avulsion Fractures (Böhler Type 1c)
- These require urgent surgical attention, not delayed treatment, due to high risk of posterior heel skin necrosis. 5
- Delayed treatment of avulsion fractures can lead to skin breakdown and tissue necrosis over the thin posterior skin covering the Achilles insertion. 5
- Consider soft anchor bridge technique combined with lag screws for fixation, particularly effective even in osteoporotic bone. 6
- Surgery should be performed urgently to prevent skin compromise, unlike other calcaneal fractures where surgery can be delayed. 5
Critical Pitfall to Avoid
Do not delay treatment of posterior tuberosity avulsion fractures. While most calcaneal fractures can be managed with delayed surgery to allow swelling to subside, avulsion fractures compromise the posterior heel skin and require urgent intervention within 24 hours to prevent skin necrosis. 5 This represents a distinct subset requiring different management than other extra-articular fractures.
Post-Treatment Protocol
- Maintain non-weight-bearing status for 8-12 weeks until radiographic evidence of healing. 7
- Transition to removable boot after initial immobilization period. 8
- Initiate physical therapy for range of motion restoration and strength training once appropriate. 7, 8
- Monitor for complications including chronic pain, functional limitations, and in surgical cases, wound complications. 8
Compartment Syndrome Monitoring
- Maintain high clinical suspicion, as compartment syndrome occurs in approximately 10% of calcaneal fractures. 2
- Diagnosis is clinical, but compartment pressure monitoring can confirm suspicion. 2
- Untreated compartment syndrome leads to devastating long-term disability including claw toes, chronic pain, motor weakness, and fixed foot deformities. 2
- Emergent surgical decompression is required if compartment syndrome develops. 2