What is the initial treatment for a 14-year-old male with a calcaneal fracture?

Initial Treatment of Calcaneal Fracture in a 14-Year-Old Male

For a 14-year-old male with a calcaneal fracture, initiate non-weight-bearing immobilization immediately, obtain standard three-view foot radiographs plus an axial Harris-Beath view, assess for soft tissue compromise and associated spinal injuries, and determine whether the fracture is displaced/intra-articular (requiring surgical consultation) or non-displaced/extra-articular (managed conservatively with cast or fixed-ankle walker). 1

Immediate Assessment Protocol

Clinical Evaluation

• Assess the mechanism of injury—calcaneal fractures typically result from axial loading through the heel during a fall from height 1
• Examine soft tissue status meticulously for skin compromise, abrasions, or signs of impending compartment syndrome, as these findings dictate urgency of treatment 1
• Screen for concomitant spinal fractures, particularly in the lumbar spine, which occurs in approximately 7% of calcaneal fractures, with 80% involving the lumbar region 2
• Do not manipulate the ankle prior to obtaining radiographs unless neurovascular deficit or critical skin injury is present 1

Initial Imaging

• 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 calcaneal fractures to determine intra-articular extent and increase diagnostic sensitivity 1
• Consider CT imaging without IV contrast to fully characterize the fracture pattern, as radiographs have only 87% sensitivity for calcaneal fractures 3

Treatment Algorithm Based on Fracture Type

Non-Displaced or Extra-Articular Fractures

• Initiate non-surgical management with immobilization using either cast immobilization or a fixed-ankle walker device 1
• Limit complete immobilization to a maximum of 3-5 days to avoid muscular atrophy and worsened functional recovery 4
• After initial immobilization period, commence active exercise and early weight-bearing as tolerated to facilitate faster recovery 4
• Maintain non-weight-bearing status until radiographic evidence of healing, typically 8-12 weeks 3

Displaced Intra-Articular Fractures

• Refer urgently for surgical consultation, as open reduction and internal fixation (ORIF) improves functional outcomes and reduces chronic pain compared to conservative management 1, 5
• Optimal surgical timing is within 2 days of injury when soft tissues permit 1
• Anatomic reduction of the overall calcaneal shape and subtalar joint congruity are critical prognostic factors that must be achieved 5

Tongue-Type Fractures (High-Risk Variant)

• Require urgent surgical attention within 24 hours due to high risk of skin compromise and necrosis 1
• This represents a surgical emergency that cannot be managed conservatively 1

Management of Soft Tissue Compromise

When Medial Foot Abrasion or Injury Present

• Clean the abrasion with simple saline solution 1
• Initiate antibiotic prophylaxis with cefazolin 1
• Delay surgery if significant soft tissue swelling or abrasion is present until conditions improve 1
• Consider negative pressure wound therapy for high-risk surgical incisions to reduce deep surgical site infection 1

Postoperative/Immobilization Protocol

• Use a removable boot after initial immobilization period 1
• Initiate physical therapy focusing on range of motion restoration and strength training once appropriate 3
• Combine mobilization therapy with exercise therapy for range of motion deficits, as mobilization alone is insufficient 4
• Use semirigid braces over tape for functional support during rehabilitation 4

Critical Pitfalls to Avoid

• Do not overlook associated spinal fractures—always examine and image the spine, particularly the lumbar region 2
• Avoid excessive immobilization beyond 3-5 days, as this causes muscular atrophy and deconditioning 4
• Do not miss tongue-type fractures requiring urgent intervention within 24 hours 1
• Ensure reexamination at 3-5 days post-injury, as excessive swelling and pain can limit the initial examination within 48 hours 4

When to Escalate Care

• If no improvement after 6-8 weeks of appropriate conservative treatment, refer to orthopedic or podiatric foot and ankle surgery 4
• Consider advanced imaging (MRI or bone scan) if clinical suspicion remains high despite negative radiographs 4
• Any displaced intra-articular fracture requires surgical consultation, as anatomic reduction is mandatory for optimal outcomes 5, 6