Comminuted Calcaneum Fracture - Post ORIF + K-Wire Fixation Management

Classification Context

Immediate Post-Operative Phase (0-2 Weeks)

• Posterior slab splint with a stirrup placed intraoperatively; maintained for 6 weeks
• Surgical drains removed at 48 hours
• Strict limb elevation - leg elevated continuously through the first 2-3 weeks to control swelling
• Ice application for edema management
• NWB (non-weight-bearing) strictly maintained

• The extensile lateral approach (ELA) carries significant wound complication risk. The soft tissue envelope of the lateral heel is unforgiving
• Inspect for: wound edge necrosis, dehiscence, blistering, erythema
• High-risk patients (diabetics, smokers, peripheral vascular disease) require extra vigilance
• Any wound breakdown: early surgical debridement + IV antibiotics; consider flap coverage if deep tissue involved

• Keep wire entry sites clean and dry with sterile dressings
• Monitor for pin-site infection (redness, discharge, pain at pin site)
• K-wires are typically removed at 6-8 weeks (once articular reduction is stable and callus forming)

Early Phase (Weeks 2-6)

• Continue posterior slab/splint
• Patient remains NWB - crutches or wheelchair

• Ankle range-of-motion exercises can begin as early as 2-5 days postoperatively if fixation is stable (AO Foundation recommendation)
• Gentle active and passive ankle dorsiflexion/plantarflexion
• Subtalar joint motion as tolerated
• Foot pumping to reduce DVT risk

• X-ray (lateral + axial views) at 6 weeks

Transition Phase (Weeks 6-12)

• K-wires removed around 6-8 weeks under fluoroscopic guidance or in clinic
• After removal, wound care at pin sites

• At 6 weeks, the posterior slab is replaced with a removable boot
• Boot allows range-of-motion exercises between sessions

• Active ankle ROM - full dorsiflexion, plantarflexion, inversion, eversion
• Soft-tissue mobilization of peroneals and FHL
• Scar mobilization begins
• Open-chain exercises: theraband resistance work
• Subtalar mobilization if ORIF was performed (grade 1-2 joint mobilization)
• Patient must avoid aggressive kicking or deep water walking

• For standard ORIF: progressive weight bearing begins at 8-12 weeks, depending on degree of comminution and adequacy of fixation
• For ORIF + primary subtalar arthrodesis (severely comminuted): patient kept NWB in serial short-leg casts for 10-12 weeks until radiographic fracture and arthrodesis healing confirmed
• X-ray review at 12 weeks before initiating WB

Rehabilitation Phase (Weeks 12-20+)

• Begin with partial WB in walking boot
• Transition to regular shoes at ~12-14 weeks once full WB in boot achieved
• Gradual wean out of boot at 10-12 weeks per surgeon orders

• Balance and proprioceptive training (single-leg stance, rocker board, dynadisc)
• Closed-chain strengthening: weight shifts, heel raises, lunges, step-ups
• Progressive calf stretching
• Hip and knee strengthening (proximal chain rehabilitation)
• Gait training - normalize gait pattern
• Orthotics assessment (custom heel cup or arch support may be needed)

• Advanced gait and balance training
• STJ and ankle stretching
• Functional assessment: timed single-leg stance, heel raise testing, stair step-ups
• Higher-impact activities cleared after surgeon review
• X-ray at 26 weeks (6 months) for final healing assessment

Complications to Monitor and Manage

Wound Complications (Most Common - 10-25%)

• Wound dehiscence/necrosis: Most common with ELA in smokers, diabetics, and those with peripheral vascular disease
• Management: serial debridements, VAC therapy, local flap, or rarely fasciocutaneous flap (lateral arm flap) for severe cases
• Calcaneal osteomyelitis: hospitalization, serial debridements, IV antibiotics; may eventually require bone flap or amputation

Posttraumatic Subtalar Arthritis

• Radiographic arthritis approaches 100% after intra-articular fractures; symptomatic arthritis ~30%
• Sanders III: 47% eventually require subtalar fusion; Sanders IV: even higher rates
• Average time from ORIF to fusion: ~44 months
• Management: NSAIDs, physiotherapy, intra-articular steroid injection (diagnostic + therapeutic under fluoroscopy)
• Surgical: secondary subtalar arthrodesis for refractory symptomatic arthritis; outcomes better than those treated non-operatively initially

Peroneal Tendon Problems

• Tenosynovitis/stenosis: lateral impingement from extruded calcaneal wall or prominent implants
• NSAIDs, manual physiotherapy, eversion strengthening; if failed - peroneal tenolysis ± implant removal
• Tendon dislocation: repair SPR intraoperatively if identified; if missed - late surgical SPR reconstruction

Subtalar Stiffness

• Very common; affects gait and ankle mechanics
• Inversion/eversion forces borne by ankle (not designed for this) - causes lateral ankle pain
• Management: NSAIDs, lace-up ankle brace, physiotherapy; arthroscopic debridement of adhesions for refractory cases

Calcaneal Malunion (Stephens-Sanders Classification)

Other Complications

• Sural nerve injury (from lateral approach) - dysesthesia along lateral foot; usually resolves, rarely needs nerve exploration
• Heel pad pain - damaged heel pad architecture; no effective treatment beyond heel cushioning
• DVT/PE - chemical prophylaxis (LMWH) during NWB period

Expected Outcomes

• 65% of patients remain limited in vigorous or sporting activities
• 50% able to ambulate over any surface
• ~40% unable to return to prior employment (particularly manual laborers)
• Patients who undergo initial ORIF (even if they later need subtalar fusion) have significantly better outcomes than those treated non-operatively who develop malunion - ORIF preserves calcaneal height, width, and shape which benefits long-term reconstruction if needed

Radiological Follow-Up Schedule (AO Foundation)

• Campbell's Operative Orthopaedics 15th Ed 2026, Technique 93.3 and Chapter 93
• Rockwood and Green's Fractures in Adults 10th Ed 2025, Chapter 67
• AO Foundation ORIF aftertreatment protocol
• Kaiser Permanente Calcaneal Fracture Rehabilitation Guidelines
• Lewis SR et al. (2023). Surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures. Cochrane Database Syst Rev. PMID: 37933733
• Giuliani A et al. (2026). Primary subtalar arthrodesis in displaced intra-articular calcaneal fracture. Musculoskelet Surg. PMID: 40375052