Calcaneal fractures


The calcaneus, known as the heel bone, is the largest of the tarsal bones and articulates with the cuboid bone anteriorly and the talus bone superiorly.

It transmits the majority of the body’s weight from the talus bone to the ground.

These fractures usually result from a high-energy load to the foot.

Such fractures require great force, they are often accompanied by other serious injuries;

Refers to a break of the calcaneus or heel bone.

Uncommon injuries, and they account for only 1 to 2% of all fractures.

If not treated promptly, they can result in long-term disability.

Symptoms include pain, bruising, trouble walking, and deformity of the heel.

It may be associated with breaks of the hip or back.

Accounts for about 2% of bone fractures.

Account for 60% of fractures of the mid foot bones.

Typically occurs when a person lands on their feet following a fall from a height or during a motor vehicle collision.

Additional, can occur with muscular stress where the resulting forces can lead to the trauma of fracture.

They are often attributed to shearing stress, with compressive forces combined with a rotary direction

Diagnosis is suspected based on history and symptoms, confirmed by X-rays or CT scaning.

X-rays include axial and lateral views should be taken.

Up to 10% of these fractures are missed at initial presentation.

Calcaneal fractures that remain normally aligned may be treated by casting without weight bearing for around eights weeks.

If the calcaneal bones are not properly aligned surgery is generally required to return the bones to their normal position with better outcomes.

Surgery may be delayed a few days, unless the skin is not intact.

Undisplaced fractures may heal in around three months.

More significant calcaneal fractures can take two years to heal.

Arthritis and decreased range of motion of the foot may remain after such fractures.

The most common symptom of a calcaneal fracture is pain over the heel area.

This pain is increased when the heel is palpated or squeezed.

Other symptoms of calcaneal fracture include: inability to bear weigh, limited mobility of the foot, and limping.

Swelling, redness, and hematoma may occur.

The area around the heel and the hindfoot is usually tender and swollen.

A hematoma extending to the sole of the foot is pathognomonic for calcaneal fracture.

Such a hematoma is called Mondor Sign.

Clinically the heel may become widened with associated edema due to displacement of lateral calcaneal border.

Osteoporosis and diabetes can lead to a calcaneal fracture.

The risk of muscular stress fractures can be reduced through stretching and weight-bearing exercise, such as strength training.

Minimalist footwear and running barefoot can lead to a variety of stress fractures including that of the calcaneus.

A greater bone density indicated less risk for fractures in the calcaneus.

The diabetic population is more susceptible to the risks of fracture, healing complications and infection

The initial assessment of a calcaneal fracture is conventional radiography, with axial, anteroposterior, oblique, and views with dorsiflexion and internal rotation of the foot.

Conventional radiography is limited for visualization of calcaneal anatomy, especially at the subtalar joint, and CT scan is currently the imaging study of choice for evaluating calcaneal injury and classification of calcaneal fractures.

They are categorized as intra-articular or extra-articular on the basis of subtalar joint involvement.

Intra-articular fractures are more common and involve the posterior talar articular facet of the calcaneus.

The Sanders classification describes these fractures into four types based on the location of the fracture at the posterior articular surface.

Extra-articular fractures are less common and may be located anywhere outside the subtalar joint, and are categorized depending on whether the involvement of the calcaneus is anterior (Type A), middle (Type B) or posterior (Type C).

The Angle of Gissane, is the angle formed by the downward and upward slopes of the calcaneal superior surface, and on a lateral radiograph, an angle of Gissane > 130° suggests fracture of the posterior subtalar joint surface.

Bohler’s angle, is another normal anatomic landmark seen in lateral radiograph formed by the intersection of 1) a line from the highest point of the posterior articular facet to the highest point of the posterior tuberosity, and 2) a line from the former to the highest point on the anterior articular facet. Bohler’s angle is normally 25° to 40°.

A decreased Bohler’s angle is indicative of a calcaneal fracture.

There are 4 types of intra-articular fractures classified by the Sanders classification system.

Type I fractures are non-displaced fractures with a displacement of < 2 mm.

Type II fractures consist of a single intra-articular fracture that divides the calcaneus into 2 pieces:

Type IIA: fracture occurs on lateral aspect of calcaneus

Type IIB: fracture occurs on central aspect of calcaneus.


Type IIC: fracture occurs on medial aspect of calcaneus.

Type III fractures consist of two intra-articular fractures that divide the calcaneus into 3 articular pieces.

Type IIIAB: two fracture lines are present, one lateral and one central.

Type IIIAC: two fracture lines are present, one lateral and one medial.

Type IIIBC: two fracture lines are present, one central and one medial.

Type IV fractures consist of fractures with more than three intra-articular fractures.

Extra-articular fractures include fractures that do not involve the posterior facet of the subtalar joint.

Type A involve the anterior calcaneus.

Type B involve the middle calcaneus including the sustentaculum tali, trochlear process and lateral process.

Type C involve the posterior calcaneus, the posterior tuberosity and medial tubercle.

Non-surgical treatment is for extra-articular fractures and Sanders Type I intra-articular fractures, if the calcaneal weight-bearing surface and foot function are not compromised and include closed reduction with or without casting, or casting alone, no weight-bearing for a few weeks followed by range-of-motion exercises and progressive weight bearing for a period of 2–3 months.

A displaced intra-articular fractures requires surgical intervention, before bone consolidation, which is within 3 weeks of fracture.

Conservative surgery consists of closed reduction with percutaneous fixation.

Closed reduction with percutaneous fixation is associated with less wound complications, better soft tissue healing and decreased intraoperative time.

Closed reduction has an increased risk of inadequate calcaneal bone fixation, compared to open procedures.

Open reduction with internal fixation (ORIF) is usually the pref2242ed surgical approach when dealing with displaced intra-articular fractures.

Rehabilitation depends on whether surgery was required or not.

The first phase of the rehabilitation after surgery includes foot elevation and icing for the first 2 days after the operation.

Subsequently, no weight should be applied to the affected foot to getting around.

If no operation was required, the foot undergoes frequent range of motion exercises.

Exercises for the range of motion phase can include eversion, inversion, flexion and extension of the ankle to create a circular foot motion.

In the final phases of rehab, stepping forward, back, side-stepping, and leg stand are employed.

Between 13 weeks to a year is allowed to resume normal activities.

Concomitant injuries should be evaluated, as vertebral compression fractures occur in approximately 10% of these patients.

Tibial, knee, femur, hip, and head injuries should be ruled out by means of history and physical exam.

Treatment requires casting and sometimes surgery.

Stress fractures may occur in the calcaneus, particularly in athletes.

Up to 10% of patients of patients with a calcaneal fracture develop on acute compartment syndrome.

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