Now several objective studies recommend surgical treatment for some fractures.
Extraarticular (not involving the subtalar joint) .
Intraarticular (involving the subtalar joint .
Extraarticular fractures : the body, anterior process, or tuberosity .
should be treated with cast or brace immobilization .
Which serves as the attachment of the tendo calcaneus .
Open reduction and internal fixation
Threaded cancellous screw to restore the power of the tendo calcaneus
Prevent a wide heel with the ensuing difficulties of shoe-fitting
Another extraarticular fracture need early intervention :the anterior process of the calcaneus by the bifurcate ligament .
Minimally displaced fractures of the anterior process are easily missed
should be suspected in a patient who does not recover appropriately from a lateral ankle sprain .
If the fragment is small or diagnosis is delayed, this fragment can be simply excised.
Intraarticular fractures :75% of calcaneal fractures and poor functional outcome.
These fractures are uniformly caused by an axial load mechanism :
Fall or a motor vehicle accident and may be associated with other axial load injuries such as lumbar, pelvic, and tibial plateau fractures
Fractures of the posterior facet can be divided into two types, as described by Essex-Lopresti .
If the fracture line producing the posterior facet fragment exits behind the posterior facet and anterior to the attachment of the tendo calcaneus:called a joint depression type
If it exits distal to the tendo calcaneus insertion, it is called a tongue type .
Roentgenographic evaluation of the fracture should include five views .
A lateral roentgenogram is used to assess height loss (loss of Böhler angle) and rotation of the posterior facet .
The axial (or Harris) view is made to assess varus position of the tuberosity and width of the heel.
Anteroposterior and oblique views of the foot are made to assess the anterior process and calcaneocuboid involvement.
A single Brodén view, obtained by internally rotating the leg 40 degrees with the ankle in neutral, then angling the beam 10 to 15 degrees cephalad, is made to evaluate congruency of the posterior facet
CT scans are obtained to evaluate the injury completely. The scans should be ordered in two planes:
semicoronal plane, oriented perpendicular to the normal position of the posterior facet of the calcaneus, and the axial plane, oriented parallel to the sole of the foot .
The Essex-Lopresti system has been used for many years and is useful in describing the location of the secondary fracture line .
It does not describe the overall energy absorbed by the posterior facet, demonstrated by comminution or displaced fragments .
Sanders classification is its precision regarding the location and number of fracture lines through the posterior facet .
both systems lack descriptions of other important aspects of these fractures, namely, heel height and width, varus-valgus alignment, and calcaneocuboid involvement
Closed treatment of intraarticular calcaneal fractures includes closed manipulation and casting , compression dressing and early mobilization, traction-fixation, manipulation by Böhler.
P in fixation as recommended by Essex-Lopresti .
Open reduction and internal fixation can be expected to benefit only those patients with near-anatomical reconstruction.
Essex-Lopresti recommended : - C onservative treatment for nondisplaced or minimally displaced fractures with early range of motion,
- axial fixation with a metallic pin for tongue-type fractures , and (3) open reduction and internal fixation for joint depression fractures .
Open reduction can be obtained through a medial approach (McReynolds, Burdeaux)
Combined medial and lateral approach (Stephenson, Romash).
Lateral approach alone (Benirschke and Sangeorzan, and Sanders et al.).
Also, success after open reduction followed by immediate arthrodesis has been reported by several authors.
Restoration of congruency of the posterior facet of the subtalar joint,
Restoration of the height of the calcaneus (Böhler angle),
Reduction of the width of the calcaneus,
Decompression of the subfibular space available for the peroneal tendons,
Realignment of the tuberosity into a valgus position, and reduction of the calcaneocuboid joint if fractured.
An insensate limb caused by either trauma (sciatic or tibial nerve disruption) or disease (diabetes or other neuropathy) is a strong relative contraindication to open treatment.
Patients with limited ambulation as a result of other medical conditions likewise should be treated closed.
Sanders Type I or nondisplaced fractures should be treated closed.
Types II and III fractures can be treated with open reduction.
Type IV can be treated either closed or, in experienced hands, with open reduction and immediate arthrodesis .
Soft tissue injury
Fractures that are open : aggressive debridement >simple opening of the wound to wash out the soft tissue.
The medial spike should be exposed and debrided. It is better to wait 2 to 3 weeks until the wound is stable before internal fixation is attempted.
Open treatment should not be performed through tight, swollen soft tissues and certainly not in the region of fracture blebs.
Sanders et al. have confirmed that the learning curve for this fracture is somewhat steep.
Substantial literature supporting closed methods of treatment, a thorough knowledge of the anatomy and clearly defined goals are necessary for a successful outcome .