Treatment of calcaneal fractures has evolved over the last 25 years from primarily nonoperative care to a more aggressive approach involving open reduction and internal fixation, with a recent rejuvenation of limited exposure and percutaneous fixation in select fractures. Many of the treatment recommendations have evolved from the type and rate of complications that have been seen as the result of various treatments of calcaneal fractures, both operative and nonoperative. Complications range from wound problems to malunion, whether treated open or closed [1–3], (Tables 17.1 and 17.2).

Anatomy certainly plays a significant role in predisposing the patient with a calcaneal fracture to possible complication. When the complex and variable arrangement of the articular facets of the subtalar joint is combined with the limited soft tissue envelope of the hind foot and ankle, as well as the surrounding tendon and neurovascular structures coursing medially and laterally along the calcaneus, it is easy to appreciate why an array of complications can occur regarding the treatment of calcaneal fractures (Fig. 17.1a, b). Fractures of the calcaneus may also involve the calcaneocuboid joint, and post-traumatic arthritis of this joint may also be seen. Resultant gait abnormalities are not uncommon.

Possibly the most frequent and significant complication of calcaneal fractures is malunion, which can lead to its own subset of problems. Wound complications , primarily from open treatment of calcaneal fractures, present unique challenges of their own. Advanced diagnostic imaging, in addition to plain radiographs, is necessary for proper fracture evaluation especially in the case of intra-articular fractures [4, 5]. Complications from calcaneal fractures can be arbitrarily divided into nonoperative and operative complications, although certainly some overlap does occur.

Nonoperative complications primarily are a result of malunion of displaced calcaneal fractures. Fracture malunion may produce an array of problems. Non-union, although extremely rare, can occur, but if present, it is usually associated with a degree of malunion. Direct complications from malunion may include heel shortening, loss of heel height, varus deformity of the hind foot, and displacement of the lateral calcaneal wall which can produce peroneal tendon impingement, sural neuritis, fibular impingement, and increased heel width with resultant shoe fit problems [4]. Chronic edema, tendinopathy (including peroneal, flexor hallucis, and flexor digitorum longus), peroneal subluxation/dislocation, posterior heel pain (especially with tongue or avulsion fractures), Achilles tendon dysfunction, and even compartment syndrome with resultant toe flexion deformities may occur [6–8]. Intra-articular step-off may lead to both subtalar and calcaneocuboid joint arthritis [1]. Failure to recognize and timely reduce displaced tongue-type or avulsion fractures with tenting of the posterior soft tissues can result in significant skin necrosis and breakdown [9, 10], (Fig. 17.2a, b). Neurovascular injury may occur from displaced sharp osseous fragments and, if left untreated, may result in permanent nerve impairment. The sustentaculum tali area is of most concern regarding displaced fracture fragments due to its close proximity to the medial neurovascular bundle [11] (Fig. 17.3).

One of the most frequent complications following operative treatment of calcaneal fractures is wound healing problems involving the incisional approach. These may result from ill timing of surgical intervention, inappropriate placement or performance of lateral flap development if using a lateral extensile approach , or other patient issues such as a history of smoking [12–15]. Wound breakdown runs the full spectrum from superficial only to deep wounds with hardware exposure and possible associated infection, including calcaneal osteomyelitis (Figs. 17.4, 17.5). Fracture blisters and their sequelae should be allowed to resolve and skin wrinkles observed before surgical intervention is undertaken to help in prevention of postoperative wound breakdown (Fig. 17.6a, b). Placing hardware along and under incision lines or subtalar joint penetration of hardware (so-called in-out-in of the posterior facet) must be avoided (Fig. 17.7). Medial neurovascular and tendon injury can also result from inappropriately long screws or drill bit penetration into the medial soft tissues during internal fixation maneuvers [16]. Mal-reduction of operatively treated calcaneal fractures can lead to all of the same issues as described for malunion of nonoperatively treated calcaneal fractures, including post-traumatic arthritis. Sural nerve injury, including neuroma, paresthesia, and permanent impairment, as well as peroneal tendon injury can occur during surgical exposure of the lateral calcaneal wall [17–20]. Side to side plantar pressure mismatch has been reported 2 years after open reduction of calcaneal fractures, even with improvement of Bohler’s angle [21].

Management of complications stemming from calcaneal fractures ranges from fairly straightforward treatments to more complex surgical procedures. In the acute setting, one must be observant for compartment syndrome which has been reported in up to 10% of cases [22–24]. If fasciotomy is indicated, release should be performed emergently of the affected compartments to prevent permanent neuromuscular impairment and its resultant toe contractures as well as possible resultant chronic pain issues. Post-traumatic arthritis and its subsequent symptom complex is often an end result of calcaneal fractures [1]. If the fracture is well reduced, and little to no deformity is present, bracing, orthotic control, shoe modifications, corticosteroid injections, and medical management may be sufficient to control symptoms associated with arthritis. If nonoperative treatment is unsuccessful, in situ arthrodesis of the subtalar joint in the well-aligned fracture may be performed (Fig. 17.8a, b). If peroneal tendon or sural nerve pathology is present, this may be addressed simultaneously. If calcaneocuboid joint arthritis is also present, extended hind foot arthrodesis may be required. However, in many cases of post-traumatic arthritis following intra-articular fractures of the calcaneus, alignment is less than satisfactory and varying degrees of malunion may be present making in situ arthrodesis not an option. Malunion can be found both in the nonoperatively unreduced fracture and with mal-reduction in the operatively treated fracture (Figs. 17.9 and 17.10). Malunion results in a variety of problems that may produce symptoms. Some of the most disabling of these problems include arthritis, loss of heel height, increased heel width, shortening, varus deformity, peroneal tendon/fibular impingement, and anterior ankle impingement [25] (Fig. 17.11a, b). Diagnostic imaging workup is absolutely necessary in determining type and degree of deformity and condition of the articular surfaces. Bohler’s angle is determined from standard lateral views and comparison views to the uninjured contralateral side help establish the normal value for the patient and assist in preoperative planning to determine the amount of correction which may be necessary [26]. In addition to standard radiographic views and CT imaging of the hind foot and ankle, calcaneal axial and long leg axial as well as hind foot alignment views may be beneficial in evaluating the patient with late complications of calcaneal fractures [4]. MRI may be helpful in cases of suspected associated soft tissue pathology.