Fracture reduction is the key for this case and we planned on using an escalating approach to obtain an appropriate reduction. Ideally this could be done percutaneously, but, if that were not possible we would escalate to a mini-open approach followed by a more extensile approach if needed. The key is to what is to what is necessary to take the pressure off the soft tissues while trying to protect the blood supply of the fracture fragments. In this case we were able to use small percutaneous incisions for reduction, clamp placement, and fixation.

The patient was placed in the prone position on a radiolucent foot extension so C-arm imaging cold be used intraoperatively, and both sides of the calcaneus are accessible. The patient’s foot was positioned at the end of the table to help facilitate access to the foot and for proper imaging. Either blankets or “bone foam” can be used to elevate the injured extremity above the other to facilitate obtaining a lateral image. This setup facilitates access to the posterior aspect of the patient’s foot for reduction and fixation of the fracture. Alternatively, the lateral position could be used, but makes access to the medial side of the foot difficult if needed during the procedure.

We began by unroofing and debriding the skin blisters. Fluoroscopy was then used to help plan our incisions by localizing and marking the positions of the fracture line and both fragments. The foot plantar-flexed to see how much that maneuver reduced the displaced tuberosity fragment. Once the fragments were closer together we used a combination of palpation and fluoroscopy to determine the positions of the superior and inferior aspects of the calcaneal tuberosity. The tines of a large Weber clamp were placed where we thought they would clamp the fragments together and their positions checked using a lateral fluoroscopic image prior to making stab incisions. Four 1-cm stab incisions were then made so we could place the tines of two large Weber clamps on the medial and lateral sides of the calcaneus to reduce and compress the fracture fragments. The clamps were positioned so they did not place any pressure on the already compromised soft tissues. The first time we clamped the fracture together we caused skin puckering on the medial side where soft tissue was trapped within the fracture site. After unclamping we made a small incision over this area and used an elevator to sweep the soft tissues out the fracture site. We were then able to re-clamp the fracture site without any soft tissues being trapped within the fracture site. We then obtained lateral and Harris heel views to check our reduction. 1.6 mm K-wires were then placed to help hold the reduction.