A 35-year-old man is brought to the emergency department after jumping to the ground from a 10-foot wall while being pursued by the police. He complains of bilateral heel pain.

1.    Describe this x-ray.

This is a lateral radiograph of the ankle and hindfoot. It shows an intra-articular, displaced and comminuted fracture of the calcaneus with an increased angle of Gissane and a decreased Bohler angle.

2.    With this mechanism of injury, what other injuries might you suspect?

This injury has resulted from axial loading. Vertebral fractures, ligamentous inju- ries around the knee, tibial plateau fractures as well as pilon fractures should be suspected and looked for. Patients may also present with injuries to the contralateral calcaneus.

3.    How would you treat this calcaneus fracture?

In making this judgement it would be essential to consider patient factors including general health, diabetes, neuropathy, peripheral vascular disease, smoking status and patient reliability or compliance. It would also be important to consider the personality of the injury. Open wounds, threatened skin, soft tissue swelling and the degree of comminution will all influence management and outcome. Further

imaging in the form of a CT would provide additional information about the frac- ture pattern, degree of comminution and amenability to fixation of the fracture.

There is some debate about the benefits of surgery however, the evidence for non- operative treatment of displaced fractures is contentious. For this displaced intra- articular fracture, in a suitable patient I would recommend surgery. The aim is to restore the articular surface while restoring calcaneal height, length and heel width. I would give prophylactic antibiotics, position the patient in the lateral position with the foot on a radiolucent table and a thigh tourniquet in place.

I would approach the calcaneus by raising full thickness flaps using a lateral approach centred halfway between the fibular and Achilles tendon and curving anteriorly around the lateral malleolus along the border between the glabrous and non-glabrous skin, keeping the corner angle of the incision greater than 100 degrees. The sural nerve is protected and the lateral calcaneal wall is exposed and lifted out, providing access to the constant medial fragment which bears the sustentaculum tali. I would lever and reduce the constant fragment into position through the frac- ture and then pass a Steinmann Pin into the calcaneal tuberosity through a separate stab incision adjacent to the Achilles tendon. The Steinmann Pin is used to lever the calcaneal tuberosity into a reduced position and to correct any varus deformity before it is advanced to secure the tuberosity to the constant medial fragment.

The posterior facet articular surface is then reduced, depressed fragments are elevated and the joint surface restored and provisionally held with K-wires before it is fixed definitively with one or more lag screws. I would then replace the lateral wall and secure it with a lateral locking plate and screws. I would perform the proce- dure using image intensification to allow accurate reduction. I would maintain this patient in a below knee non-weight bearing cast for at least 6 weeks after surgery.

4.    What are the complications of surgery, and are there any situations where non- operative management might be preferred?

The immediate complications of surgery include bleeding, malreduction and iatrogenic injury to the cutaneous nerves and peroneal tendons. Open wounds, con- tused or threatened soft tissues, poor vascular status and diabetes may predispose to wound breakdown, dehiscence and infection. Soft tissue injury and subsequent management strongly influence outcome and fixation may need to be delayed or avoided in some cases. Marked soft tissue swelling should be treated with formal elevation and ice treatment. The wrinkle test is widely used to determine when the soft tissues may be safely tackled, although evidence for this is not strong. Open wounds should be treated with staged debridement, negative pressure dressings, intravenous antibiotic therapy and wound closure or coverage. Smoking has been shown to predispose to non-union, and patients should be encouraged to give it up. In the long term, patients may suffer subtalar arthritis, chronic infection or osteo- myelitis, chronic heel pain and complex regional pain syndrome.

Non-operative management is appropriate for undisplaced fractures, minimally displaced extra-articular fractures, anterior process fractures involving less than 25% of the calcaneocuboid joint and patients who are unfit for surgery or where the associated risks are judged to be too high. One randomised control study has suggested that non-operative treatment is appropriate for a broader section of these fractures but this is debated and the study examined a highly selected group of frac- tures only.