Treatment of open intra-articular calcaneal fractures: Evaluation of a treatment protocol based on wound location and size

Background: Effective treatment algorithms for open, displaced, intra-articular calcaneal fractures and their potential early complications have not yet been established. This is a retrospective review of the management of open displaced calcaneal fractures at a Level I trauma center and their resulting soft-tissue complications in an effort to establish guidelines for management. Method: Between November, 1994, and April, 2002, 31 open intra-articular calcaneal fractures in 29 patients were treated at our institution. All fractures were treated with a standard protocol based on the appearance of the traumatic wound after initial debridement and stabilization. Fracture stabilization was determined by the wound characteristics and was either standard internal fixation or percutaneous fixation. Data on associated injuries, comorbidities, smoking, and subsequent soft-tissue complications were collected and reviewed. Results: Overall there was a 29% soft-tissue complication rate with this protocol. Two of the four laterally based traumatic wounds had complications. Twenty-seven wounds were medial. Nine were considered unstable and were treated with aggressive wound management and percutaneous fixation of the tuberosity reduction; two developed deep infections and required amputation and seven were salvaged with patients returning to full weightbearing. Eighteen fractures with medial wounds were treated with standard internal fixation; soft-tissue complications occurred in five. Initial size greater than 4 cm was associated with an increased complication rate in this group. Conclusion: Management of open calcaneal fractures and the risk of complications depend on the size and position of the traumatic wound. Lateral wounds are rare and in this review, two of the four had complications using this protocol. Medial wounds of less than 4 cm can be treated with open reduction and standard internal fixation if the wound can be closed and remain stable off antibiotics. Larger wounds (more than 4 cm) or unstable wounds should not be treated with open reduction and internal fixation but can he reduced and held in alignment with percutaneous wire fixation.