Nonoperative management of calcaneus fractures is frequently utilized, in part because of the difficulty of fracture repair surgery in restoring normal joint function. Calcaneus fractures with intra-articular fragment displacement, significant loss of height (Figure 60.1), and avulsion type fractures, especially those with posterior distal leg skin compromise (Figure 60.2). are appropriately treated with surgical intervention. Certain patient characteristics—such as smoking history, impaired vascular supply, poorly controlled diabetes, and inability to follow postoperative instructions—may be contraindications to surgical intervention. Additionally, severe intra-articular comminution frequently portends poor outcome; nonoperative intervention or acute subtalar arthrodesis may be performed in specific cases.

ORIF of the calcaneus has traditionally been performed through an extensile approach to the hindfoot. This L-shaped approach includes a vertical limb centered between the Achilles and the peroneal tendons, overlying the sural nerve at its proximal extent. The horizontal limb is extended parallel and just dorsal to the glabrous skin (Figure 60.3). The soft-tissue flap is elevated in a full-thickness fashion and includes the peroneal tendons. The peroneal tendons must be evaluated at the completion of fracture reduction and fixation to assess for potential dislocation from within the sheath at their retrofibular location. The primary at-risk structures are lateral and superficial
to the bone. However, fixation screws may impinge on structures medial to the calcaneus, especially if they are excessively long or malpositioned relative to the sustentaculum tali (Figure 60.4). Wound closure is performed in layers and great care is taken to minimize any damage to the soft tissue, which could potentially lead to healing delay, necrosis, or infection.

Alternate approaches to the calcaneus for ORIF have gained popularity. One of these is the sinus tarsi approach. This approach is of variable length, oriented along a line from the tip of the distal fibula to the fourth metatarsal base (Figure 60.5). The extensor digitorum brevis muscle is encountered and elevated dorsally. The peroneal tendons are again encountered in the flap of tissue overlying the calcaneus, but should be elevated with the skin and subcutaneous tissue, minimizing dissection of the full-thickness tissue bed. Care must be taken to preserve the tendons and the superior peroneal retinaculum with proximal extension of this incision.

In certain cases, the posterior facet has sustained such damage that subtalar arthrodesis is performed in conjunction with ORIF of the displaced fracture. This may be performed via either approach and entails removal of the remaining articular cartilage, preparation of subchondral bone, and compressive fixation between the calcaneus and talus.

Tongue-type or posterior avulsion patterns involve fracture with displacement between the proximal Achilles insertion site and the remainder of the calcaneus, and may involve part of the posterior facet. Displaced fractures may place posterior skin under pressure, requiring urgent reduction and fixation. These are often addressed with a percutaneous technique or a posterior approach. Anterior process avulsion fractures occur at the dorsal anterior aspect of this portion of the calcaneus. They usually are produced with an inversion injury of the foot. The superior portion of the calcaneocuboid joint may be involved with large fragments. Treatment for small fragments is usually non-operative, but may occasionally involve resection if persistent pain can be attributed to nonunion. Larger fragments may be best treated with ORIF. All these fractures should be considered distinct from the displaced, intra-articular calcaneus fracture, especially with respect to the focus of rehabilitation efforts.