The calcaneus is the most commonly fractured tarsal bone and can be very challenging to treat. Injury is usually the result of direct axial loading to the heel most commonly due to falls from height or motor vehicle collisions. Spine fractures or contralateral calcaneus fractures can occur in 10–15% of patients. Functionally, the calcaneus is important in support of the entirety of body weight with ambulation, hindfoot range of motion through the subtalar joint, and appropriate force transmission from the hindfoot to the midfoot during normal gait.

Obtaining appropriate imaging is essential to characterizing the fracture pattern and developing a plan for reduction and fixation. Basic imaging should include AP, lateral, and Harris axial heel view radiographs as well as computed tomography (CT scans). One should evaluate the obtained imaging for the following characteristics: posterior facet joint depression, coronal malalignment and diastasis, the extent of calcaneal tuberosity shortening and angulation as well as the presence and extent of intra-articular involvement. Intraoperatively, contralateral lateral and Harris view fluoroscopic images are helpful for comparative purposes when assessing reduction.

All displaced calcaneus fractures are amenable to open reduction and internal fixation. Contraindications to surgical treatment may include smokers who are unwilling to abstain from smoking, vasculopathic patients, uncontrolled diabetic patients, and elderly, low-demand patients. Nondisplaced or minimally displaced fractures may also be managed nonoperatively [3]. Relative indications for surgery include poor heel position and shape, displaced articular involvement, no medical contraindications to operative care, open fractures, compliant patients younger than 60 years of age, and nonsmokers [4].

Surgical fixation aims to reduce the fractured calcaneus to its normal anatomy, restore the critical angle of Gissane as well as Bohler’s angle, and recreate the congruity of the subtalar joint [3]. Anatomic reduction of the articular surface and correction of the typical deformities affecting the tuberosity (varus angulation, shortening, flattening, and widening) are the surgical goals with the goal of minimizing the long-term risk of symptomatic subtalar arthritis and facilitating normal shoe wear and hindfoot mechanics [5]. Rigid internal fixation allows for early motion of the ankle and subtalar joints.

Most calcaneal fractures are associated with significant soft tissue injury often the result of high energy trauma. In addition to the osseous injury, the soft tissues are significantly affected resulting in a tender, ecchymotic, swollen, and deformed heel [5]. Oftentimes fracture blisters will develop around the hindfoot. Some authors suggest leaving these closed for as long as possible. Our approach is to unroof the blisters early and begin dressing changes to facilitate epithelial repair and potentially shorten the time course to definitive surgery. If still present at the time of definitive fixation, blisters should be unroofed prior to surgical prep to minimize risk of inoculating the surgical wound with bacterial species which frequently colonize the blister fluid.

The blood supply to the calcaneus and its overlying soft tissue may predispose it to avascular necrosis and wound healing complications. The calcaneus receives its blood supply from medial and lateral calcaneal arteries [6].

Disruption of the lateral blood supply may result from both the inciting trauma or possibly in during the surgery. Interruption of this blood supply may cause a significant nutrient deficiency in the lateral half of the calcaneus. The remaining blood supply therefore is reliant on the medial penetrating vascularization [6].