A 45-year-old male presents with persistent mid-foot pain following a motor vehicle accident. Clinical examination reveals significant soft tissue swelling on the dorsum of the foot. You are presented with the following radiograph. Describe your findings and outline the principles of your surgical management strategy for this fracture.
Candidate: "This is a calcaneal fracture. It looks depressed. I would perform an ORIF with a lateral plate after the swelling goes down."
Candidates often fail to describe the specific articular involvement or the Böhler’s angle reduction. Missing the "wrinkle sign" or the critical soft tissue delay is a common, often fatal, error in a trauma viva setting. Simply saying "ORIF" without addressing the soft-tissue envelope shows a lack of clinical maturity.
The candidate should state: "This is a calcaneal fracture. I note the collapse of the posterior facet and the loss of Böhler’s angle. My management is staged: 1. Immediate: Elevation, ice, and neurovascular assessment. 2. Soft Tissue: Admit, splint, and elevate until the 'wrinkle sign' is present (typically 10-14 days). 3. Planning: CT scan to assess articular involvement (Sanders classification). 4. Definitive: ORIF via an extended lateral approach once the soft tissue envelope is ready, focusing on restoring Böhler's angle and anatomical reduction of the posterior facet."
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