OBJECTIVE: To summarize the clinical treatment experience of severe open heel fractures. METHODS: From July 2006 to April 2009, 28 patients with severe open heel fractures were treated, and the related clinical treatment experience was summarized. Among them, 21 cases were male and 7 cases were female. The ages ranged from 16 to 55 years. There were 26 cases of car accident injury and 2 cases of fall injury; 22 cases of unilateral open skin injury and 6 cases of bilateral open injury; 18 cases of fresh trauma and 10 cases of delayed trauma with different degrees of tissue necrosis, including 3 cases with purulent secretion. 20 cases were repaired by internal fixation with clear fracture repositioning, and 8 cases were repaired by flap grafting at the same time of internal fixation with clear fracture repositioning, including 5 cases of free flap with anastomosis of blood vessels. The flap repair was performed in 8 patients at the same time as the fracture reduction and internal fixation. Results: All tissue flap grafts were viable and the wounds healed in 25 cases without secondary infection; 3 cases were repaired with partial open tissue flap grafts and the wounds were completely closed 3-5 weeks after surgery. No delayed infection occurred in all cases. Discussion: The heel bone is located in the lower posterior part of the foot, and its metatarsal side has a thick heel fat pad, while its medial and lateral and posterior soft tissues are thin, and trauma to the heel bone can easily cause open fractures of the heel bone and also skin defects. Open fractures of the heel bone are mostly caused by strong violence, and can also be caused by machine strangulation. The fracture is comminuted, the subtalar articular surface collapses, and a large bone defect cavity remains after the fracture is repositioned. Small skin defects can be repaired by low-tension sutures or skin grafting, while large skin defects often require flap repair. Clinical healing of fresh wounds can be achieved in one stage with thorough debridement and drainage, and none of the cases in this group had delayed infection. A flap graft can also be used to heal a non-dischargeable skin defect, but the wound should be closely monitored and some sutures should be removed once redness and swelling of the suture is detected to facilitate timely drainage and avoid infection. Delayed wounds with infection or tissue necrosis should be repaired with flap grafting after thorough debridement, but drainage wounds are routinely left in the area of easy drainage and cleaned and changed daily after surgery, to be closed by themselves after filling with granulation tissue. Patients with deferred surgery can still apply the heel dissection plate for fracture fixation, and open wounds that have been fixed with the heel dissection plate need to be repaired with a flap graft, while the plate is not necessarily removed.