Elevation and mobilisation only
Non-surgical treatment was promoted by Bohler, based on the principle of mobilisation of an injured part and the belief that prior reconstruction does not improve the result. The foot is elevated with ice packs. Passive and active mobilisation begin as soon as patient can tolerate them. The patient is mobilised NWB when swelling has sufficiently resolved. Weight bearing usually begins at 6-12 weeks.
The place of non-surgical, functional, treatment has fluctuated inversely with the popularity of surgical fixation. The best current evidence (Buckley et al 2002) suggests that surgical treatment is of benefit in selected patients only. Non-surgical treatment as outlined above is therefore the management of many of our patients, who do not fall into the groups that Buckley's study suggested benefit from surgery.
Some authors have used cast immobilisation, either initially or after a period of elevation and mobilisation, producing 56% satisfactory results (Rowe et al 1963). Gurkan (2011) reported reasonable non-surgical results by such methods even in highly comminuted fractures: 84 patients followed up at 2-6 years had a mean AOFAS score of 72/100 although 90% had significant subtalar OA.
Crosby and Fitzgibbons (1993) reviewed 30 intra-articular fractures treated by mobilisation, traction or closed reduction. All patients had CT before treatment and at follow-up.
- 13 had undisplaced articular fragments, and all obtained good or excellent results
- 10 had displacement of intra-articular fragments, but without comminution; two got good results, the rest were fair or poor
- 7 had comminuted fractures; all had poor results, and all but one had had or awaited a subtalar arthrodesis.
Closed manipulation
Disimpaction can be performed with a large hammer if necessary (!) followed by manipulative reduction of the deformity. A Böhler clamp may be used to correct heel broadening and the foot is immobilised in cast for up to 10 weeks.
Rowe et al (1963) obtained 47% satisfactory results in intra-articular fractures with these methods. Hermann (1937) obtained 73% satisfactory results and Aitken (1963) 75%, although it is impossible to define their patient populations. These techniques are not normally used in current practice.