Open calcaneal fractures are uncommon, but potentially
devastating traumatic hindfoot injuries. Compound fractures comprise 3%-6% of
all os calcis fractures.1,2 Published series are limited in number;
they generally consist of multiply injured patients referred to regional trauma
centers.3-6 A wide continuum of injury patterns have been documented
with an equal array of treatments and outcomes.3-6
Although the initial, emergent treatment of an open
fracture-disruption has become fairly standardized,7 subsequent
treatment addressing the injury’s osseochondral component remains
controversial. A thorough review of the available literature assists in
establishing a knowledge base on this devastating hindfoot injury. A treatment
protocol is proposed to provide a basis for future treatment advances.
Few published reports detail the treatment and outcomes following
compound calcaneal fractures. Furthermore, a critical review of the few
published series demonstrates therapeutic interventions, timings,
complications, and outcomes.
Siebert et al3 reported 36 open calcaneal fractures
managed over a 5-year period. In this series, a majority of the patients were
referred after initial care was provided elsewhere. Specifically, in 29 of 36
fractures, the initial intervention was not dictated by the authors. The
overall complication rate was remarkably high—>60% of patients
developed wound complications. Nine of 17 patients with Gustilo III type wounds
developed osteomyelitis or joint sepsis. Five limbs were amputated for
uncontrolled infection; 1 limb required joint arthrodesis. Severe functional
deficits and chronic pain resulted in most patients. After documenting the poor
outcomes and high complication rate, the authors recommend that management of
the soft-tissue disruption and avoidance of infection should be the initial
treatment focus, rather than fracture stabilization.3
Aldridge et al4 reported 19 open os calcis fractures
treated over a 10-year period. In this series, 17 fractures underwent some form
of internal fixation, yet the overall complication rate was only 11%. The
number of days to internal fixation averaged 7 days post-injury (range: 0-22
days). One patient required a below-the-knee amputation. Four free flaps were
performed. At 26-month follow-up, the average American Orthopedic Foot and
Ankle Society hindfoot score was 82 points. In accordance with Siebert et
al,3 the authors concluded that these open injuries be initially
managed with aggressive wound care followed by delayed fracture
Heier et al5 reported 43 fractures treated over a
9-year period. Various forms of stabilization were undertaken in approximately
70% of cases. Approximately 25% underwent a primary arthrodesis. Six limbs were
amputated. Eight flaps and 5 split-thickness skin grafts were performed. All 8
Gustilo I type injuries fared well. Overall, a 37% infection rate was reported.
Furthermore, in Gustilo IIIB wounds, 11 complications developed in 12 patients.
Therefore, complication rates appeared to correlate to the severity of the
soft-tissue injury. The authors concluded that patients with high-grade open
calcaneal fractures be informed of the likelihood of chronic debilitating pain
and dysfunction. They should be forewarned that an amputation may be necessary,
especially if significant complications arose.5
Lawrence and Grau6 reported 48 open fractures treated
over a 7-year period. The ratio of blunt to penetrating trauma was 7:1. Of the
blunt trauma patients, >90% sustained multiple orthopedic and nonorthopedic
injuries. Two below-the-knee amputations were performed as primary
intervention. Of patients with open calcaneus fractures, 23% sustained a local
neurovascular injury and >40% sustained concomitant ipsilateral foot and
ankle fractures. In this series, 42% underwent some form of internal fixation.
Five wounds required free flap coverage. The overall complication rate was
approximately 5%. Unfortunately, long-term functional outcomes were not
The orthopedic literature remains controversial regarding the
optimal management of compound calcaneal fractures. Nonetheless, considerable
insight into the injury can be derived from the limited number of reported
series. Isolated open calcaneal fractures are relatively rare and appear to be
associated with multiple-injured patients with high-energy injuries (Figure 1).
Commonly, patient resuscitation is necessary prior to management of
musculoskeletal injuries. Following hemodynamic stabilization, a thorough wound
evaluation and detailed neurovascular assessment of the limb are necessary
(Figure 2). Hindfoot radiographs and computed tomography are recommended to
assess fracture comminution and displacement.
|Figure 1: Lateral radiograph demonstrates a severe open calcaneus fracture with
talonavicular joint subluxation and extreme deformity.
Figure 2: Clinical
photograph of the wound associated with an open calcaneal fracture.
The fundamental tenets of open fracture care7 remain
the cornerstone of initial management for these hindfoot fracture-disruptions.
Tetanus prophylaxis is administered, if indicated. Emergent serial irrigation
and debridement is performed and repeated every 48 hours until a stable, clean
wound results. Antibiotic coverage with cefazolin and gentamycin is appropriate
in most instances; however, contaminated wounds resulting from marine or
barnyard injuries are best managed with triple antibiotic coverage until
culture-based sensitivities are available.
In a majority of instances, the traumatic wound can be closed
primarily or secondarily. Closure by secondary intent is appropriate if viable
wound edges are not opposable and no exposed osseous or neurovascular
structures are present. In this instance, local wound care is instituted. A
recent addition to nonsurgical options is the vacuum-assisted
closure,8 a treatment modality that promotes secondary wound healing
by augmenting the rapid in-growth of granulation tissue. In severely disrupted
wounds, a free microvascular tissue transfer may be necessary, especially in
exposed bony or neurovascular elements. In such instances, internal fixation of
the osseochondral injury should be performed prior to the free tissue transfer
Means to stratify injury severity have not been established. By
default, the Gustilo-Anderson7 and Sanders classification9
schemes have been applied, either singularly or in combination, by most
clinicians to describe the injury patterns. Neither scheme, unfortunately, is
intended for this purpose. Overall, the severity of the soft-tissue disruption
and fracture subtypes appear to parallel the prognosis, outcome, and
Distinct treatment phases need to be defined, as the timing of
treatment may be as important as the treatment type. As highlighted by several
series,3-5 overzealous attempts at fracture stabilization frequently
result in wound difficulties, infection, or both. On the other hand, delays
>3 weeks may be hampered by early fracture healing. Delineation of specific
phases is intended to guide the timing of intervention for these complex
The University of Kentucky hospital’s experience with open
os calcis fracture management has been reported previously.6
Considerable value exists in dividing treatment into three phases—acute,
subacute, and reconstructive (Table). The acute phase comprises the initial 10
days following injury; the subacute follows the acute and extends to day 21;
the reconstructive stage begins at 3 weeks and continues indefinitely.
During the acute phase, the priority of the initial treatment is
soft-tissue management. Meticulous but aggressive debridement of devitalized
tissues with wound irrigation is a critical component of care—this appears
to minimize the risk of complications such as deep infection. Occasionally,
after open fracture care has been successfully completed, no further operative
care is necessary, except for fracture immobilization until healing. However,
this is a rare occurrence. During the acute stage, due to traumatized
soft-tissue envelope, traditional forms of plate and screw osteosynthesis are
best avoided. However, osseous stabilization with minimal internal fixation,
such as Kirschner wires, percutaneous cannulated screws, or application of an
external fixator, appears to be valuable while invoking a minimal increased
risk of infection.6 However, these techniques are generally
undertaken on severely disrupted fractures where anatomic reduction of the
articular surface is not possible (Figure 3). The fixation is used to
circumvent superior migration of the tuberosity fragment due to the unbridled
effect of the Achilles tendon.
|Figure 3: CT of the hindfoot demonstrating a severely
comminuted posterior facet of an open calcaneal fracture. This severe chondral
injury precludes surgical reconstruction.
Formal plate and screw osteosynthesis is probably best reserved
for the subacute phase. This time period follows stabilization of the scant
soft-tissue envelope, but proceeds prior to bony consolidation. Fracture
subtypes amenable to reconstruction were found in >60% of a large series of
open os calcis fractures (Figures 4 and 5).10 Therefore, many
tongue-type, one-, two-, and three-part fractures of the posterior facet may be
appropriate for delayed reconstruction in the subacute phase (Figures 6 and 7).
|Figure 4: Lateral
photograph demonstrating a tongue-type fracture with secondary articular
involvement. Figure 5: Semi-coronal plane CT cut through the posterior
facet, demonstrating a two-part fracture of the posterior facet.
|Figure 6: Lateral
radiograph of the hindfoot following open reduction and internal fixation of an
open calcaneal fracture. Open reduction and internal fixation followed serial
irrigation and debridement. Formal plate and screw osteosynthesis was
undertaken on day 11. An extensile lateral incision with a low-profile plate
and screw fixation was used. Figure 7: A Harris view of the hindfoot
following open reduction and internal fixation demonstrating excellent
restitution of calcaneal height and the medial column of the os calcis.
The third, or reconstructive, phase extends beyond the critical
3-week “fracture repair” period; therefore, open reduction and
internal fixation of a comminuted calcaneal fracture with a disrupted subtalar
joint should not be attempted in this phase. Open reduction and internal
fixation of the body of the os calcis combined with arthrodesis is
recommended.9 Additionally, fractures with non-reconstructible
(?4-part) fractures of the posterior facet are probably best treated
during this phase with a subtalar arthrodesis (Figure 8). Arthrodesis may be
undertaken with minimal risk during this phase, as the soft-tissue condition
has stabilized, the risk of infection is no longer a concern, and consolidation
of multiple tuberosity fracture fragments has begun, facilitating a
“compression” arthrodesis of the subtalar joint.
|Figure 8: Intraoperative radiograph demonstrating
open reduction and internal fixation and primary subtalar fusion for an open
calcaneal fracture with severe articular damage.
As recommended by Heier et al,5 all patients should be
forewarned that extensive and protracted series of staged surgical procedures
may be necessary. They should understand that chronic pain and ambulatory
dysfunction are relatively common, especially with high-grade injuries.
Unfortunately, disastrous outcomes may result despite appropriate treatment.
The exact role of limb amputation for high-grade open calcaneal
fractures remains controversial. Sound clinical judgment is necessary to
predict whether a series of complex reconstructive procedures will likely
result in a more functional outcome than amputation. This procedure may be
necessary in any of the three treatment phases. Circumstances such as severe
fracture comminution with articular damage, combined with adjacent ipsilateral
foot and ankle injuries, neurovascular defects, advanced age, severe patient
compliance issues, or severe systemic medical comorbidities may favor ablative
Open calcaneal fractures can be managed with an array of
treatment techniques and result in a wide range of outcomes. Due to the
fracture’s relative obscurity, the optimal form of intervention remains
controversial. Consequently, treatment for these hindfoot fracture-disruptions
continues to evolve. Timing of intervention may be a key factor in decreasing
The goals of open calcaneal fracture management include timely
healing of the soft-tissue envelope without infection and maintenance of bony
alignment. Unfortunately, restoration of joint congruence may be impossible.
Unsatisfactory outcomes may result from neurogenic pain, infection, malunion,
arthrosis, and bony impingement. Future advancements in treatment are
anticipated and will depend on an improved understanding of this devastating
From the Division of Orthopedics, University of Kentucky,
Dr Lawrence has no industry relationships to declare.
Reprint requests: Steven J. Lawrence, MD, Division of Orthopedics,
University of Kentucky, Kentucky Clinic, 740 S Limestone, Ste 401, Lexington,
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