Calcaneus Fractures: Non-operative Management Pearls

Sam C. Roberts, MBChB, FRCSEd (Tr&Orth)
Fellow, Foot and Ankle Surgery, Orthopaedic Surgery,
Dalhousie University

Chad P Coles, M.D., FRCSC
Associate Professor, Orthopaedic Surgery
Dalhousie University

Mark Glazebrook MSc, PhD, M.D., FRCSC
Associate Professor, Orthopaedic Surgery
Dalhousie University
Halifax, NS

The treatment of calcaneal fractures remains a significant challenge and frequently results in poor outcomes. Calcaneal fractures are not a single entity, and like many fractures, both patient and fracture characteristics may affect the outcome. An understanding of these factors is critical in deciding the best course of treatment for your patient.

There are numerous patient-related risk factors which are thought to increase the risk of wound complications and deep infection: smoking, diabetes, high body mass index, increasing age, social deprivation and substance abuse. These risk factors are well-documented, although the literature is contradictory1-5 and as such, it is difficult to know which of these factors are important. While there exists no high-level evidence in the literature to provide precise recommendations, we would suggest that surgeons should be cautioned to recommend operative treatment in a patient who has two or more of these risk factors. In this situation, non-operative treatment probably represents the best treatment. Buckley et al. reported low satisfaction scores in patients claiming workers compensation, but improved satisfaction scores after operative treatment in: patients aged between 20-29, female gender, a Bohler's angle of 0˚-14˚, a Sanders type II fracture, a light work load and a unilateral fracture6. While these findings have not been currently corroborated in other high-quality studies they may serve as relative indications for operative treatment.

Generally speaking, all types of intra-articular (joint depression, tongue-type) and extra-articular (sustentacular, anterior process, tuberosity, body) calcaneal fractures, if minimally displaced, are suitable for non-operative treatment. Anterior process fractures involving up to 10mm of the articular surface may be treated non-operatively9. Likewise, most body fractures can be treated non-operatively. Traditionally sustentacular fractures have been treated non-operatively, but there is little literature on the subject. Some authors advocate operative treatment for displaced sustentacular fractures10. Great respect should be given to displaced tuberosity fractures, as there is a significant risk of further displacement, due to the pull of the tendo-achilles on the tuberosity fragment. Therefore, displaced tuberosity fractures should be treated operatively. Lateral calcaneal fracture dislocation and the displaced tongue-type fracture causing local pressure and risking necrosis of the skin are two other fracture types that are not usually suitable for non-operative treatment11,12.

The treatment of displaced intra-articular calcaneal fractures is controversial. A recent Cochrane review13 indicated no difference between non-operative and operative management, but despite this some authors have questioned the ability of the statistical tests employed to detect a clinically-significant difference14. There is extensive literature on the subject, but there are only four well-conducted randomized controlled trials published comparing operative fixation and non-operative treatment of displaced intra-articular calcaneal fractures6,15-17. Thordarson's paper included only thirty patients and found in favour of surgery. The other three trials, which between them totalled 572 patients, showed no difference in the outcomes of non-operative versus operative management at a minimum of two years6, 15, 16.

Described non-operative treatment protocols involved a short period of rest, elevation +/- ice, and a period of six to eight weeks of non-weight bearing during which time no cast or other form of immobilization was applied to the limb6,15,16. Early mobilization was encouraged from the time of injury in the two smaller studies15, 16 whereas physiotherapy was commenced at the six-week mark by Buckley et al. Parmar performed CT scans on patients at the time of injury and at three months post injury, showing no further displacement of the fracture fragments in both the non-operative and the operative group despite early mobilization. Based on these studies, the authors would recommend the non-operative rehabilitation protocol as detailed in Table 1.

In conclusion, non-operative management is a good option for the treatment of calcaneal fractures. While there are certain fracture patterns requiring surgical intervention, the majority may be considered for non-operative treatment, particularly when patient risk factors are present. An early mobilization and non-weight-bearing protocol is important to improve success.

Table 1: Authors' Recommended Non-operative Treatment Protocol

Duration of time post injury

Management

Immediately-48hours

Elevation/Ice

Temporary immobilisation in backslab

Day 3-7

Continue elevation/ice

Removable slab.

Non-weight bearing

Commence ankle and subtalar range of motion (ROM) exercises

Week 2-Week 6

Continue non-weight bearing

Progress with ankle and subtalar ROM exercises

Removable slab if required for pain relief

Week 7-10

Commence graduated weight bearing in cast boot - increase 25% per week

Continue ROM exercises

Week 11 onwards

Wean from cast boot

Continue physiotherapy - ROM/strengthening and proprioceptive exercises

References

  1. Court-Brown C.M., Schmied M., Schutte B.G. Factors affecting infection after calcaneal fracture fixation. Injury. 2009; 40(12): 1313-5.
  2. Abidi N.A., Dhawan S., Gruen G.S., Vogt M.T., Conti S.F. Wound-healing risk factors after open reduction and internal fixation of calcaneal fractures. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 1998; 19(12): 856-61.
  3. Tennent T.D., Calder P.R., Salisbury R.D., Allen P.W., Eastwood D.M. The operative management of displaced intra-articular fractures of the calcaneum: a two-centre study using a defined protocol. Injury. 2001; 32(6): 491-6.
  4. Koski A., Kuokkanen H., Tukiainen E. Postoperative wound complications after internal fixation of closed calcaneal fractures: a retrospective analysis of 126 consecutive patients with 148 fractures. Scandinavian journal of surgery: SJS: official organ for the Finnish Surgical Society and the Scandinavian Surgical Society. 2005; 94(3): 243-5.
  5. Kwon J.Y., Diwan A., Susarla S. Effect of surgeon training, fracture, and patient variables on calcaneal fracture management. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2011; 32(3): 262-71.
  6. Buckley R., Tough S., McCormack R., Pate G., Leighton R., Petrie D., et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. The Journal of bone and joint surgery American volume. 2002; 84-A(10): 1733-44.
  7. Marsh J.L., Slongo T.F., Agel J., Broderick J.S., Creevey W., DeCoster T.A., et al. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. Journal of orthopaedic trauma. 2007; 21(10 Suppl): S1-133.
  8. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg. 1952; 39(157): 395-419.
  9. Berkowitz M.J., Kim D.H. Process and tubercle fractures of the hindfoot. J Am Acad Orthop Surg. 2005; 13(8): 492-502.
  10. Della Rocca G.J., Nork S.E., Barei D.P., Taitsman L.A., Benirschke S.K. Fractures of the sustentaculum tali: injury characteristics and surgical technique for reduction. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2009; 30(11): 1037-41.
  11. Gardner M.J., Nork S.E., Barei D.P., Kramer P.A., Sangeorzan B.J., Benirschke S.K. Secondary soft tissue compromise in tongue-type calcaneus fractures. Journal of orthopaedic trauma. 2008; 22(7): 439-45.
  12. Turner N.S., Haidukewych G.J. Locked fracture dislocation of the calcaneus treated with minimal open reduction and percutaneous fixation: a report of two cases and review of the literature. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 2003; 24(10): 796-800.
  13. Bruce J., Sutherland A. Surgical versus conservative interventions for displaced intra-articular calcaneal fractures. The Cochrane database of systematic reviews. 2013; 1: CD008628.
  14. Younger A. A calcaneal fracture study illustrates a need for better statistical methods for orthopaedic outcomes: Commentary on an article by Per-Henrik Agren, MD, et al.: "Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures. a prospective, randomized, controlled multicenter trial". The Journal of bone and joint surgery American volume. 2013; 95(15): e111.
  15. Agren P.H., Wretenberg .P, Sayed-Noor A.S. Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. The Journal of bone and joint surgery American volume. 2013; 95(15): 1351-7.
  16. Parmar H.V., Triffitt P.D., Gregg P.J. Intra-articular fractures of the calcaneum treated operatively or conservatively. A prospective study. The Journal of bone and joint surgery British volume. 1993; 75(6): 932-7.
  17. Thordarson D.B., Krieger L.E. Operative vs. nonoperative treatment of intra-articular fractures of the calcaneus: a prospective randomized trial. Foot & ankle international / American Orthopaedic Foot and Ankle Society [and] Swiss Foot and Ankle Society. 1996; 17(1): 2-9.

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