Clinical photograph of a patient’s left heel after application of a modified short leg cast with a posterior heel window and fiberglass-wrapped aluminum strut, which entirely eliminates heel pressure.
Courtesy of James W. Bubla, and Paul S. Whiting, MD


Published 5/1/2018

Protecting the Heel with a Novel Casting Technique

Annual Meeting poster presents a case example with good results
According to the authors of Scientific Poster P0980, which was on display at the AAOS 2018 Annual Meeting, the short casting technique they developed to help treat tongue-type calcaneus fractures with soft-tissue compromise relieves posterior heel pressure while adequately immobilizing the foot and providing access to the heel for monitoring and wound care.

The authors noted that urgent reduction and fixation of tongue-type calcaneus fractures is often required to prevent skin necrosis and other soft-tissue complications. If treatment is delayed, or if the initial fixation fails, skin necrosis may develop on the posterior heel, requiring close monitoring and intensive wound management. However, the use of a splint, cast, or prefabricated brace not only limits access to the posterior heel, but also may place additional pressure on the already compromised posterior soft tissues.

During casting, a gauze padding is applied over the heel wound and a foot plate is applied. The leg is wrapped in fiberglass casting material. After the fiberglass cast hardens, the bulge made by the padding is cut out and the gauze is removed so that the wound is visible through a “window” in the cast. The cut edges of the fiberglass are covered with tape, and 2-inch wide aluminum splinting material is contoured to provided a supporting arch posterior to the heel. This protects the heel skin from pressure and contact. The aluminum is then overwrapped with fiberglass and secured to the cast proximally and distally with additional layers of casting material.

In the case example, the patient sustained a displaced tongue-type calcaneus fracture due to a 10-foot fall from scaffolding. The fracture was reduced and fixed with two cortical screws, and a Jones splint was applied. The patient was discharged to home on postoperative day (POD) two, after a skin check confirmed benign-appearing posterior heel skin.

When the patient returned for his first follow-up visit on POD 10, the clinical exam revealed a 2 cm black eschar over the posterior heel. The patient admitted that he had fallen at home, and he underwent urgent revision surgery to remove the implants, reduce the fracture, and fix the fracture a second time. He was placed in resting plantarflexion in a custom bulky Jones splint with a posterior heel cutout and supporting arch, a splinting technique previously described by Hsu et al. The next day, a custom cast was applied in resting plantarflexion using the novel technique developed by the authors.

For the first three weeks, the patient returned on a weekly basis for skin checks and new dressings. On POD 20, a new custom cast was applied with the ankle in neutral dorsiflexion. At this point, the patient took responsibility for doing the weekly dressing changes at home. The eschar was allowed to fall off on its own, revealing healthy granulation tissue.

Radiographs at six weeks showed fracture healing, and the patient transitioned to weight bearing through the heel in his custom cast. Borderless absorptive dressings were changed weekly. By postoperative week 12, the fracture had healed completely, the wound had almost completely epithelialized, and the patient transitioned to regular shoes.

According to the authors, this technique is effective in relieving pressure from already compromised soft tissues, facilitating wound surveillance/dressing changes, and providing immobilization adequate to promote fracture healing.

The authors of Scientific Poster P0980, “A Novel Casting Technique for Tongue Type Calcaneus Fractures with Soft Tissue Compromise” are Sara E. Heintzman, MD; Erik A. Lund, MD; James W. Bubla; and Paul S. Whiting, MD. This technique was recently published in Foot & Ankle Orthopaedics.


  1. Heintzman SE, Lund EA, Bubla JW, Whiting PS. A novel casting technique for tongue-type calcaneus fractures with soft tissue compromise. Foot & Ankle Orthopaedics. 2017; 2(4):1-6.