Synopsis
Recognise high-energy hindfoot injury and associated trauma, protect threatened heel skin, reduce talar dislocation urgently, use CT to define articular anatomy, and anticipate avascular necrosis, arthritis and prolonged rehabilitation.
- Treat high-energy hindfoot trauma as a whole-patient injury: complete ABCDE and examine the thoracolumbar spine, pelvis, knees, both heels and the entire ipsilateral limb.
- Inspect posterior heel and medial and lateral skin early and repeatedly; a displaced tongue-type or tuberosity fragment can cause urgent posterior skin necrosis.
- A talar dislocation needs urgent reduction after rapid neurovascular documentation and analgesia or anaesthesia; do not postpone reduction for CT when skin or circulation is threatened.
- Obtain ankle and hindfoot radiographs, including lateral and calcaneal axial views where feasible; use CT after provisional alignment for intra-articular calcaneal, talar-neck, talar-body and process-fracture mapping.
- Open wounds receive sterile cover, prompt intravenous network antibiotics, tetanus assessment, alignment and orthoplastic management without emergency-department probing or repeated irrigation.
- Non-operative care is reserved for selected stable extra-articular or acceptably aligned patterns and patients in whom operative harm exceeds benefit; it still needs strict loading, motion and imaging instructions.
- Definitive fixation or primary fusion decisions depend on articular displacement, joint congruity, soft tissue, contamination, comorbidity and function, not a classification label alone.
- Warn that talar osteonecrosis, subtalar arthritis, heel widening, stiffness and prolonged inability to work on uneven ground can occur despite correct emergency care.
Key red flags
Blanching, tenting, blistering or threatened necrosis over the posterior heel with a displaced tuberosity or tongue fragment requires immediate reduction or fixation rather than delayed routine clinic care.
A dislocated talus, extruded bone, open wound, absent pulse, cold foot or progressive nerve deficit needs emergency reduction and coordinated orthopaedic, plastic and vascular management.
Severe escalating hindfoot pain, tense swelling, pain on passive toe motion or new sensory change raises foot compartment syndrome; palpable pulses do not exclude it.
An axial-load hindfoot fracture should trigger examination for calcaneal injury on the other side and thoracolumbar, pelvic, tibial-plateau and other load-transmission injuries.
Investigation priorities
Identify fracture, gross displacement and joint malalignment.
Management branches
The hindfoot is open, dislocated, neurovascularly compromised or pressing on posterior heel skin.
- Complete trauma assessment and inspect both heels, spine and whole limb while documenting skin, pulses and named nerve function.
- Cover any open wound, give immediate protocol antibiotics and tetanus care and avoid repeated probing or emergency-department washout.
- Urgently reduce talar or hindfoot dislocation and relieve a skin-threatening posterior fragment, using theatre when safe closed reduction is blocked.
- Splint, elevate without impairing perfusion, repeat examination, obtain post-reduction films and CT, and continue frequent tissue surveillance.