• The patient is positioned in a lateral decubitus position
• Safe support is needed so that the table can be tilted for fluoroscopy or for an additional reduction maneuver
• The landmarks for incision are the distal fibula, the anterior process of the calcaneus, the calcaneocuboid joint and the base of the 5th metatarsal
• A large L-shaped (right side) or J-shaped (left side) surgical incision is made beginning approximately 4 cm above the tip of the lateral malleolus, midway between the posterior border of the fibula and the Achilles tendon
• The lateral incision allows direct access and easier reduction of the displaced lateral fragment, compared to medial approach
• The incision begins proximally, curves below the sural nerve, and then moves upward to the calcaneocuboid joint
• It is imperative to avoid harming the sural nerve and prevent skin flap difficulties

• The incision is made down to the bone in order to make a cutaneous - subcutaneous flap that includes the peroneal tendons. The flap is developed anteriorly to expose the posterior subtalar joint.

• The flap is elevated, along with the sural nerve and peroneal tendons
• Pins are then inserted and bent to hold the flap and the soft tissues
• The subtalar joint is opened and the fractures of the lateral calcaneal wall are dissected, in order to expose the fractured and depressed articular fragments
• The reduction maneuver usually begins at the posterior articular surface and proceeds to the Gissane angle and to the body of the calcaneus
• However, if varus tilt of the calcaneus prevents anatomic reduction of the posterior facet, the alignment of the body may need to be corrected prior to the reduction of the joint surface

• The fractured lateral wall of the calcaneus is gently opened, leaving the fracture fragments within their periosteal envelope
• The fragments are elevated, the articular surface is reduced, and fixation is made using temporary Kirschner wires
• Most of the time, the posterior facet is first restored, with the medial facet in relation to the sustentaculum tali, the anterior facet and at last the posterior tuberosity.
• These steps should enable the surgeon to restore the length and width of the calcaneus

Three areas of dense cortical bone will hold fixation well:

• distal portion of the calcaneus (near
  the calcaneocuboid joint),
• below the angles of Gissane(below
  the posterior facet),
• the tuberosity

A triangle of soft cortical bone in the middle portion of the calcaneus is a neutral triangle that will not hold a screw well.