Initial diagnostics and quality criteria
At the initial stage of diagnostics, the orthopedic trauma surgeon performs a physical examination, assessing the condition of the skin and the neurotrophic status of the lower extremities. To objectify the condition, all patients are mandatorily evaluated for the functional capabilities of the foot and ankle joint using a specialized Questionnaire and the Foot Function Index.
Quality criteria for diagnostic imaging (evaluated using a Yes/No system):
- Foot radiography performed in the lateral projection (baseline study in a single projection).
- Computed tomography (CT) of the calcaneus and/or radiography in additional projections performed (indicated if lateral projection data are insufficient to assess the nature of the fracture).
Hospitalization in a medical organization is indicated for severe pain syndrome, severe post-traumatic edema, the threat of soft tissue compression, as well as when additional workup and surgical treatment are required.
Imaging guidance in conservative treatment
The essence of the conservative method is closed reduction of fragments under adequate anesthesia followed by immobilization. The main goal of the manipulation is to account for the initial traumatic deformation and eliminate gross fragment displacement. The quality of reduction is mandatorily monitored by radiography in the anteroposterior and lateral projections.
Follow-up radiograph schedule:
- On day 7 (acceptable interval: 5–10 days) after the injury. Purpose: to rule out secondary displacement of bone fragments.
- Then every 4–6 weeks until reliable radiological signs of fusion appear.
On average, the duration of immobilization and axial load restriction is 3–4 months. With prolonged plaster immobilization, a critically important condition is strict monitoring of the soft tissue edema state and preservation of blood supply to the distal extremities. The patient must remain in constant contact with the outpatient physician.
Alternative tactics and immobilization rules
If closed reduction fails, severe edema is present, or there are contraindications to surgery, alternative tactics are applied. The patient may undergo temporary skeletal traction by the calcaneus or a fixing bandage that prevents soft tissue compression as edema increases.
Types of bandages after manual reduction:
- Two lateral plaster splints combined with a posterior plaster splint.
- Initially incised circular plaster cast (application borders: from the upper third of the thigh to the toes of the foot).
Surgical treatment and postoperative monitoring
Surgical intervention is indicated for patients diagnosed with a calcaneal fracture with significant displacement of bone fragments.
Quality criteria at the surgical stage:
- Postoperative foot radiography performed in two projections (in additional projections if necessary) or foot/bone CT.
- Perioperative antibiotic prophylaxis administered within 24 hours.
- Patient medical rehabilitation services provided.
Discharge from the hospital is possible upon regression of pain syndrome, an uneventful postoperative period, patient mobilization, and the initiation of a rehabilitation course.
Active surveillance
Upon completion of the main treatment stage, patients are subject to follow-up observation by an orthopedic trauma surgeon. The recommendation strength grade is C (level of evidence reliability: 5).
- Adult patients: examinations are performed at 1–2 months, 6 months, and 1 year. The purpose is to monitor recovery and timely changes in load. Physical examinations should be supplemented with follow-up foot radiography in the lateral and anteroposterior projections.
- Children: follow-up visits are scheduled at 1–3 months, 6 months, and 1 year. The main goal is timely detection of anatomical disorders and determination of further management tactics.
For quick memorization of indications for hospitalization, use the "BOS" rule: Pain (severe pain syndrome), Edema (and risk of soft tissue compression), Complexity (need for additional workup and surgical treatment).
Class and exam questions
In which projection is it mandatory to take the initial radiograph?
Initial foot radiography is mandatorily performed in the lateral projection. If these data are insufficient, CT of the calcaneus or imaging in additional projections is prescribed.
When is it necessary to take follow-up radiographs during conservative treatment?
The first radiological control is performed on day 7 (acceptable from days 5 to 10) to rule out secondary fragment displacement. Subsequently, radiographs are repeated every 4–6 weeks until signs of fusion appear.
What is the difference between follow-up observation in children and adults?
In adults, the focus is on monitoring recovery and changing loads (examinations at 1–2, 6, and 12 months). In children, the main goal is the timely detection of anatomical disorders (examinations at 1–3, 6, and 12 months).
What to do in case of severe edema and failure of closed reduction?
In such cases, temporary skeletal traction by the calcaneus is used or a special fixing bandage is applied to prevent soft tissue compression.
What else to study on this topic
- Assessment of the functional state of the foot: application of the Foot Function Index and questionnaires
- Technique of applying plaster splints and circular casts to the lower extremity
- Perioperative antibiotic prophylaxis in traumatology
- Medical rehabilitation after musculoskeletal system surgeries
- Skeletal traction by the calcaneus: indications and performance technique
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