Nonoperative Treatment

A common theme among prospective trials of operative versus nonoperative treatment for displaced intra-articular calcaneal fractures is that the hindfoot becomes stiff when immobilized. Because of this, nonoperative care was thought best without immobilization.^{2,6, 7} One small, randomized, controlled trial was quick to dismiss nonoperative care because operative care was much better in their Level II trial.⁹ However, nonoperative care has withstood the test of time in certain patient populations, especially those patients who are elderly, presenting with multiple medical problems, distal vascular insufficiency, or incorrigible smoking habits. This means ice, elevation, tensoring, and early range of motion establishing full weight bearing by 6 weeks. These patients, especially sedentary patients,^1,6 have reasonable long-term results with nonoperative care.

Percutaneous Fixation

No Level I or II trials exist showing efficacy for percutaneous fixation versus operative care in those patients where surgery has been chosen as the best option for treatment. In situations where the medical circumstance dictates that less surgery may be a better option for an individual patient, percutaneous fixation done with the aid of fluoroscopy, usually from the lateral or medial side, may result in rational care for an individual patient.

Operative Reduction

The debate has raged over whether operative care is better than nonoperative care in many randomized clinical trials.^{2,6, 7, 9} However, one thing becomes clear with careful review of well-performed Level II studies with good follow-up and computerized tomography. Those cases where an operative reduction has been done perfectly end in a better result.^6,10 Nonoperative care, when compared with operative care, has consistently less successful results. Interestingly, the worst outcomes appear to be in those patients who have had operative reduction and internal fixation with a less than optimal anatomic reduction proved by computerized tomography.^6,10 This is also reinforced by a study¹¹ in which all prospective randomized trials were reviewed to judge operative reduction. This study suggests that there was only weak evidence to support open reduction and internal fixation versus nonoperative care. There was weak evidence to show an improved plain radiographic anatomic alignment in this group of radiographic studies.^{7,9, 12}

A common theme with these studies and the earlier-mentioned randomized, controlled trials is that patient selection is important. Simple, displaced fractures that can be easily reduced (Sanders type II)¹² are best reduced surgically. Sanders type III and IV fractures (comminuted) are more difficult to reduce accurately and to maintain reduction.¹³

Another article has stated the significance of avoiding complications.¹⁴ Complications will often result in a less than optimal long-term result with problems such as pain, stiffness, or infection lessening the long-term outcome.^{1,6, 14} It is clear that complications occur regardless of management strategy (even by experienced surgeons). Complications are a cause of significant morbidity, especially failure to obtain and maintain a reduction, infection, and late and long-term stiffness.¹⁴ Surgeon decision making was thought to be crucial for patient outcome. The right patient must receive surgery to minimize possible complications (long-term problems from nonoperative care). The right patient should also be treated without surgery (to minimize operative complications in that patient deemed more suitably treated without surgery).^1,14 The patient and fracture factors thought to be important include age, sex, smoking history, compensation claim information, workload on foot, fracture classification, bilaterality, and description of whether the calcaneus is an open or closed fracture.

Nonoperative Treatment

No Level I evidence provides guidance for treatment of displaced intra-articular calcaneal fractures. There are combinations of demographic groups or types of patients who are best treated by nonoperative care.^1,6 Older patients (.60 years), medically unwell patients or unrepentant smokers, sedentary workers, or those with simple fractures patterns such as extra-articular type can be treated without surgery.^1,6