The complex pathology in this scenario includes: incongruous subtalar joint, loss of calcaneal body height, and likely decreased lateral talocalcaneal angle. Complications of this injury include pain, shoe wear difficulties, and foot deformity. Foot deformity (collapse of the talus into the posterior facet) can result in tibiotalar neck impingement.
Carr et al described a subtalar fusion technique for late complications of calcaneus fractures that were treated conservatively. The subtalar fusion technique involves distraction of the subtalar joint, insertion of a bone block, and rigid screw fixation. The distraction allows correction of the talocalcaneal relationship and regains lost hindfoot height. (A subtalar fusion would address the pain issue but not the other factors).
Chandler et al states that distraction arthrodesis should be considered only if findings of anterior ankle impingement are present, as is true in this case.
Results Among 140 randomized patients (mean age, 58 [SD, 8] years, 75 women [54%]), 119 (85%) completed the study. Intra-articular triamcinolone resulted in significantly greater cartilage volume loss than did saline for a mean change in index compartment cartilage thickness of − mm vs − mm (between-group difference, − mm; 95% CI, − to − mm); and no significant difference in pain (− vs −; between-group difference, −; 95% CI, − to ). The saline group had 3 treatment-related adverse events compared with 5 in the triamcinolone group and had a small increase in hemoglobin A 1c levels (between-group difference, −%; 95% CI, −% to −%).
Intramuscular Injection: Provides an extended duration of therapeutic effect and fewer side effects of the kind associated with oral corticosteroid therapy, particularly gastro-intestinal reactions such as peptic ulceration. Studies indicate that, following a single intramuscular dose of 80 mg triamcinolone acetonide, adrenal suppression occurs within 24 - 48 hours and then gradually returns to normal, usually in approximately three weeks. This finding correlates closely with the extended duration of therapeutic action of triamcinolone acetonide.