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Calcaneal fractures
1 INTRODUCTION
Treatment of displaced intra-articular fractures and surgical management of post-traumat-
ic calcaneal deformities are among the most challenging procedures in traumatology and or-
thopaedic surgery. Already in the past, L. Böhler and R. Watson–Jones considered calcaneal
fractures as the most severe and in general insoluble injury to the bones of the human body.
Many methods had been developed during the history of treatment of these fractures but
none of them had brought satisfactory results.
Actually, no consensus has been reached yet on the optimal method of reduction and
fixation of these fractures. Most trauma surgeons dealing with calcaneal fractures had to cope
with various pitfalls of numerous operative techniques. On the one hand, percutaneous tech-
niques using Kirschner wires or screws were less invasive, but the constructs were not stable
and often resulted in displacement of bone fragments during treatment. On the other hand,
accurate open reduction and internal fixation were associated with a risk of wound infection.
The current trend in treatment of calcaneal fractures remains geared towards the patient-
specific therapeutic concept with the choice of an optimal method in view of the fracture
pattern and the patient´s individuality.
However, no matter what method of treatment is used, the main goal is always an an-
atomical reconstruction of the shape of the calcaneus and the articular surfaces, which is
a guarantee of a well-functioning foot.
The basis of a proper treatment is an exact diagnosis and a maximum amount of informa-
tion about the fracture pattern. The currently most valuable imaging method is CT scanning
with 3D reconstruction, showing exactly the course of fracture lines and extent of displace-
ment of fragments. Based on a CT finding, the surgeon classifies the fracture and decides
about the method of treatment. Treatment of calcaneal fractures requires a good spatial ori-
entation, with a clear concept for restoration not only of articular surfaces but also of the
entire external configuration of the calcaneus. A profound knowledge of biomechanics of the
foot and anticipation of the impact of the surgery on other joints and the foot are critical to
an effective repair of the calcaneus.
A good result of the treatment requires reconstruction of bones as well as adequate soft
tissue management. Soft tissues require delicate manipulation as they can be easily further
damaged after the injury. An inconsiderate surgical intervention causing damage to the skin,
subcutaneous tissue and other soft structures, as well as improper timing of the surgery often
result in severe wound healing complications.
Of no less importance is cooperation with a physiotherapist, particularly in case of opera-
tive treatment. Rehabilitation therapy can eliminate sequelae of the injury and support the re-
sults of our surgical efforts. Another important issue are socioeconomic aspects of calcaneal
fractures. Of 96% of working-age patients in our series, 12% became disabled. A total of 31%
of patients had to change their job; duration of treatment and inability to work for more than
half a year was recorded in 85% of patients and up to 34% of patients developed permanent
sequelae.
