No commercial reuse: See rights and reprints htt p:// ww w .bmj .com/pe r miss ion s Subscribe: http ://ww w .bmj.co m/su bsc r ibe BMJ 2014;349:g4483 doi: 10.1136/bmj.g4483 (Published 24 July 2014 P!ge 1 o" 13 #$%$&#' )*e+!,i-e -e+sus oo*e+!,i-e ,+e!,me, "o+ losed dis*l!ed i,+!!+,iul!+ "+!,u+es o" ,he !l!eus: +!domised o,+olled ,+i!l )P$ &''$%% !mi! +i""i *+o"esso+ o" ,+!um! !d o+,ho*!edi su+ge+y i5 P!+sos seio+ +ese!+h "ello i medi!l s,!,is,is $!+, %h! !ssoi!,e *+o"esso+ i s,!,is,is 7u+i uli5o- lii!l +ese!+h "ello 'h!+les u,hiso *+o"esso+ o" lii!l im!gig M!+g!+e, ho+ogood *+o"esso+ o" e*idemiology %!+!h $ !mb *+o"esso+ o" +eh!bili,!,io "o+ ,he eel <+!,u+e +i!l ( e< i-es,ig!,o+s =!+i5 Medi!l %hool !d e*!+,me, o" %,!,is,is i-e+si,y o" =!+i5 !d i-e+si,y os*i,!l o" 'o-e,+y !d =!+i5shi+e % +us, 'o-e,+y &bs,+!, )bje,i-e o i-es,ig!,e he,he+ su+ge+y by o*e +edu,io !d i,e+!l "i>!,io *+o-ides bee"i, om*!+ed i,h oo*e+!,i-e ,+e!,me, "o+ dis*l!ed i,+!!+,iul!+ !l!e!l "+!,u+es. esig P+!gm!,i mul,ie,+e ,o !+m *!+!llel g+ou* !ssesso+ bli ded +!domised o,+olled ,+i!l ( eel <+!,u+e +i!l. %e,,ig 22 ,e+,i!+y +e"e++!l hos*i,!ls i,ed igdom. P!+,ii*!,s 1?1 *!,ie,s i,h !u,e dis*l!ed i,+!!+,iul!+ !l!e!l "+!,u+es +!domly !llo!,ed ,o o*e+!,i-e (@A3 o+ oo*e+!,i-e (@A8 ,+e!,me,. M!i ou,ome me!su+es he *+im!+y ou,ome me!su+e !s *!,ie, +e*o+,ed e++&,5is so+e "o+ *!i !d "u,io (s!le 0100 100 beig ,he bes, *ossible so+e !, ,o ye!+s !",e+ iju+y. %eod!+y ou,omes e+e om*li!,ios; hid"oo, *!i !d "u,io (&me+i! )+,ho*!edi <oo, !d &5le %oie,y so+e; gee+!l he!l,h (%<36; u!li,y o" li"e ($C?; lii!l e>!mi!,io; !l5ig s*eed; !d g!i, symme,+y. &!lysis !s by i,e,io ,o ,+e!,. #esul,s 9?D "ollou* !s !hie-ed "o+ ,he *+im!+y ou,ome (69 i o*e+!,i-e g+ou* !d A4 i oo*e+!,i-e g+ou* !d ! om*le,e se, o" seod!+y ou,omes e+e !-!il!ble "o+ A?D o" *!+,ii*!,s. he+e !s o sigi"i!, di""e+ee i ,he *+im!+y ou,ome (me! e++&,5is so+e 69.8 i o*e+!,i-e g+ou* - 6?.A i oo*e+!,i-e g+ou*; !djus,ed 9?D o"idee i,e+-!l o" di""e+ee EA.1 ,o A.0 o+ i !y o" ,he seod!+y ou,omes be,ee ,+e!,me, g+ou*s. 'om*li!,ios !d +eo*e+!,ios e+e mo+e ommo i ,hose ho +eei-ed o*e+!,i-e !+e (es,im!,ed odds +!,io A.? 9?D o"idee i,e+-!l 2.0 ,o 41.8. 'olusios )*e+!,i-e ,+e!,me, om*!+ed i,h oo*e+!,i-e !+e shoed o sym*,om!,i o+ "u,io!l !d-!,!ge !",e+ ,o ye!+s i *!,ie,s i,h ,y*i!l dis*l!ed i,+!!+,iul!+ "+!,u+es o" ,he !l!eus !d ,he +is5 o" om*li!,ios !s highe+ !",e+ su+ge+y. B!sed o ,hese "idigs o*e+!,i-e ,+e!,me, by o*e +edu,io !d i,e+!l "i>!,io is o, +eommeded "o+ ,hese "+!,u+es. +i!l +egis,+!,io 'u++e, 'o,+olled +i!ls F%#'3A188?41. F,+odu,io Fractures of the calcaneus, or heel bone, make up about 2%of all fractures and are the commonest fracture of the tarsal bones. 1 Some calcaneal fractures are minor injuries, but many are severe, high energy fractures. These more serious injuries usually occur after a fall from a height, often from scaffolding or a ladder, or as a result of a road t raffic incident. n 2!1!, 2"21 people in #ngland, 2 and 1" 2"$ in the nited States, & 'ere admitted to hospital 'it h these serious injuries, typically 'ith an inpatient stay of more than a 'eek. The incidence is even higher in developing countries. $ ( These calcaneal injuries are destructive, 'ith fracture and displacement of the 'hole bone and its joint surfaces) the subtalar joint in particular may be severely disrupted. *ith conservative treatment the fracture fragments usually heal together, but the calcaneus remains deformed, the joint surfaces are incongruous, and the alignment of the leg through the ankle to the heel is lost. Severe, painful osteoarthritis of the subtalar joint often follo's. +ecovery is prolonged, typically taking t'o years. #ven then, most patients have a painful, stiff, deformed foot, and are unable to 'ear a normal shoe) 'alking is painful and many need the assistance of a 'alking stick. These poor outcomes are especially problematic for the typical patient 'ho is a labourer or outdoor 'orker, as they are unable to resume their occupation. This affect on 'orking life 'as recognised as early as 1-1 /0rdinarily speaking, the man 'ho breaks his heel bone is done, so far as his industrial future is concerned. " Corresponden ce to: D Griffin Division of Health Sciences !arwic" #edical School $niversit% of !arwic" Coventr% C&' ()* $+ damian. g r if fi n, w ar wi c ".ac. u" #ese!+h