Interventions for treating calcaneal fractures.

BACKGROUND: Fracture of the calcaneus (os calcis or heel bone) comprises one to two per cent of all fractures.

OBJECTIVES: To identify and evaluate randomised trials of treatments for calcaneal fractures.

SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, the Cochrane Controlled Trials Register, and the Cochrane Musculoskeletal Injuries Group Trials Register were searched. We checked reference lists of relevant articles and contacted trialists and experts in the field. Date of the most recent search: October 1998.

SELECTION CRITERIA: Randomised and quasi-randomised trials comparing interventions for treating patients with calcaneal fractures.

DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, using a 12 item scale, and extracted data. Wherever appropriate and possible, results were pooled.

MAIN RESULTS: Of the six relevant randomised trials identified, four were included, one excluded and one is ongoing. All four included trials had methodological flaws. Three trials, involving 134 patients, compared open reduction and internal fixation with non-operative management of displaced intra-articular fractures. Pooled results showed no apparent difference in residual pain (24/40 versus 24/42; Peto odds ratio 0.90, 95% confidence interval 0.34 to 2.36), but a lower proportion of the operative group was unable to return to the same work (11/45 versus 23/45; Peto odds ratio 0.30, 95% confidence interval 0.13 to 0.71), and was unable to wear the same shoes as before (12/52 versus 24/54; Peto odds ratio 0.37, 95% confidence interval 0.17 to 0.84). One trial, involving 23 patients, evaluated impulse compression therapy. At one year there was a mean difference of 1.40 pain units on a visual analogue score (scale 0-10) (95% confidence interval 0.02 to 2.82) in favour of the treated group. The impulse compression group had greater subtalar movement (mean difference 14.0 degrees, 95% confidence interval 3.2 to 24.6) at three months. On average, patients in the impulse compression group returned to work three months earlier than those in the control group.

REVIEWER'S CONCLUSIONS: Randomised trials of management of calcaneal fractures are few, small and generally of poor quality. Even where there is some evidence of benefit of operative compared with non-operative treatment, it remains unclear whether the possible advantages of surgery are worth its risks. Given this it seems best to wait for the results of one large ongoing trial on open reduction and internal fixation against conservative treatment. One very small trial suggests that impulse compression therapy for intra-articular calcaneal fractures may be beneficial. More large-scale, high quality randomised controlled trials are needed to confirm these results, and to test other interventions in the treatment of calcaneal fractures.