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.
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.
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.
Key medicines
ParacetamolGive 1 g orally up to four times in 24 hours as required, separated by at least 4 hours; use a lower maximum in adults under 50 kg or with frailty, malnutrition, chronic alcohol excess or hepatic impairment.
Intravenous prophylaxis for an open hindfoot fractureAdminister the major-trauma network's specified intravenous antibiotic and weight-based adult dose immediately and ideally within 1 hour of injury; document the time and continue or broaden only through the open-fracture and contamination protocol.