Most calcaneal fractures occur in male industrial workers, making the economic importance of this injury substantial. Many authors have reported that patients may be totally incapacitated for as long as three years and partially impaired for as long as five years after the injury. Although modern operative intervention has improved the outcome in many patients, there still is no real consensus on classification, treatment, operative technique, or postoperative management. In this article, the current thinking regarding the treatment of these very difficult fractures will be reviewed.

Historical Treatment
As early as 1908, Cotton and Wilson suggested that open reduction of a calcaneal fracture was contraindicated. McLaughlin agreed, likening attempts at operative fixation to the “nailing of a custard pie to the wall.”76 Cotton and Wilson recommended closed treatment with use of a medially placed sandbag, a laterally placed felt pad, and a hammer to reduce the lateral wall and “reimpact” the fracture. Although initially they were enthusiastic about this technique, by the 1920s they had abandoned the treatment of acute fractures altogether and had turned instead to the treatment of healed malunions. Despite the fact that Böhler advocated open reduction in 1931, the principal reasons for the predominance of nonoperative treatment were the technical problems associated with operative treatment. Anesthesia was not always effective, radiography and fluoroscopy were not well developed, antibiotics did not exist, and a sound understanding of the principles of internal fixation was lacking. The resulting complications of infection, malunion, and nonunion, and the possible need for amputation, made most surgeons believe that treatment should be nonoperative.