Calcaneal fractures account for approximately 1.2% of all fractures and 60% of all tarsal bone fractures. Almost 75% present as displaced, intra-articular fractures. Because of the complex articular and osseous anatomy, the vulnerable soft-tissue envelope, and the technically challenging approach needed for fixation, these fractures are often treated nonoperatively, resulting in poor outcomes. These poor outcomes can include entrapment of the posterior tibial and sural nerves, impingement, dislocation or entrapment of peroneal tendons, a widened heel with a loss of height, hindfoot varus or valgus, formation of painful exostoses, development of posttraumatic arthritis of the subtalar and calcaneocuboid joints, and impingement of the ankle joint.
The current scientific literature supports fixation of displaced, intra-articular fractures. The principles of surgical fixation consist of reconstructing the height (obtained by improving the Böhler angle), narrowing the width, reconstructing the length, correcting any varus deformity of the tuberosity, and anatomically reducing the joint. However, at the time of initial presentation, there is often substantial swelling, with or without fracture blisters, that needs to be resolved prior to surgical fixation. During this waiting period, radiographic and computed tomography (CT) evaluations should be performed to assess the fracture pattern. Once re-epithelialization of the blisters and wrinkling of the skin are noted, open reduction and internal fixation (ORIF) can be performed.
The steps to an ORIF consist of (1) the use of an extensile lateral incision, with a subperiosteal dissection, that develops a full-thickness fasciocutaneous flap; (2) removal of the lateral wall, to allow visualization of the impacted joint; (3) removal of the lateral third or half of the joint to allow visualization of the medial two-thirds or half of the joint; (4) disimpaction of the medial half of the joint to its normal height, along with medialization of the tuberosity; (5) anatomic reduction of the posterior facet and fixation with lag screw(s); (6) possible use of a bone graft and replacement of the lateral wall; (7) spanning the calcaneus with a plate and screws; and (8) closure of the fasciocutaneous flap and skin over a drain.