What is the initial treatment for a 14-year-old patient with a calcaneal (calcaneous) fracture?

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

For a 14-year-old with a calcaneal fracture, begin with immediate immobilization and non-weight-bearing status, obtain standard three-view foot radiographs plus an axial Harris-Beath view, assess urgently for soft tissue compromise, and base definitive treatment on fracture type—with extra-articular and non-displaced fractures managed non-surgically, while displaced intra-articular fractures require surgical fixation given this patient's skeletal maturity. 1, 2

Immediate Assessment and Imaging

Initial Clinical Evaluation

• Assess soft tissue status immediately for skin compromise, abrasions, or impending compartment syndrome, as these complications can be devastating if not addressed promptly 1, 3
• Look specifically for tongue-type fractures, which require urgent intervention within 24 hours due to high risk of skin necrosis 1
• Evaluate for point tenderness over the calcaneus and inability to bear weight, which are key Ottawa Ankle Rule criteria 4

Imaging Protocol

• Obtain standard three-view foot radiographs (anteroposterior, lateral, and oblique) plus an axial Harris-Beath view as the initial imaging study 1
• The axial Harris-Beath view is critical for determining intra-articular extent and increases diagnostic sensitivity 1
• Do not manipulate the ankle prior to radiographs unless neurovascular deficit or critical skin injury is present 1
• Consider CT without IV contrast to fully characterize the fracture pattern, as radiographs have only 87% sensitivity for calcaneal fractures 5

Treatment Algorithm Based on Fracture Type

For Extra-Articular Fractures

• Treat non-surgically with immobilization using cast immobilization or a fixed-ankle walker device 1
• All extra-articular fractures in pediatric patients have satisfactory outcomes with non-surgical treatment 2
• Maintain non-weight-bearing status initially 5

For Intra-Articular Fractures in This 14-Year-Old

This is the critical decision point: At age 14, this patient is approaching skeletal maturity, which fundamentally changes treatment recommendations.

• Non-displaced intra-articular fractures: Manage non-surgically with immobilization 1
• Displaced intra-articular fractures: Surgical treatment with open reduction and internal fixation (ORIF) is preferred, as it improves functional outcomes and reduces chronic pain 1

The evidence strongly supports this age-based distinction: a long-term comparative study found that articular fractures in skeletally immature children (3-14 years) had satisfactory results regardless of treatment type, but those in children with skeletal maturity (15-17 years) had satisfactory results only with surgical treatment, while non-surgical treatment yielded mainly poor outcomes 2. At age 14, err toward surgical management for displaced intra-articular fractures given the proximity to skeletal maturity.

Management of Soft Tissue Compromise

If Medial Foot Abrasion or Soft Tissue Injury Present

• Clean the abrasion with simple saline solution 1
• Initiate antibiotic prophylaxis with cefazolin 1
• Consider negative pressure wound therapy for high-risk surgical incisions to reduce deep surgical site infection 1

Surgical Timing Considerations

• Optimal timing is within 2 days of injury when soft tissues permit 1
• Tongue-type fractures require intervention within 24 hours to prevent skin necrosis 1, 3
• Delay surgery if significant soft tissue swelling or abrasion is present until conditions improve 1

Initial Immobilization and Non-Weight-Bearing

• Institute immediate non-weight-bearing status 5
• Use appropriate immobilization (cast or fixed-ankle walker) pending definitive treatment decision 1
• Maintain non-weight-bearing until radiographic evidence of healing, typically 8-12 weeks 5

Common Pitfalls to Avoid

• Do not assume all pediatric calcaneal fractures can be treated non-surgically—age 14 is a transition point where skeletal maturity matters 2
• Do not delay treatment of tongue-type fractures—these require urgent intervention within 24 hours 1, 3
• Do not overlook soft tissue assessment—compartment syndrome and skin compromise are limb-threatening complications 1, 3
• Do not obtain inadequate imaging—the axial Harris-Beath view is essential and standard radiographs alone miss 13% of fractures 1, 5