Calcaneus fracture

AO/OTA 82

Intra-articular, joint depression

See it in 3D on the real bones, displace and reduce it, with simulated X-ray and CT — free, in your browser.

The talus is driven into the calcaneus like a wedge, breaking the posterior facet of the subtalar joint. The heel widens and shortens; Böhler's angle flattens.

Calcaneus fracture, lateral view. Arrow: flattened calcaneus with loss of Böhler's angle. — James Heilman, MD, CC BY-SA 4.0, via Wikimedia Commons.

Mechanism

Fall from height onto the heels (look for spine and other lower-limb fractures).

Clinical findings

Heel swelling and bruising extending to the sole; blisters; compartment syndrome of the foot.

Imaging

Lateral of the hindfoot: Böhler’s angle (normal 20–40°) and Gissane’s angle.
Axial (Harris) view: width, varus and the sustentaculum.
AP of the foot: calcaneocuboid joint.
CT (axial, coronal and sagittal): mandatory for intra-articular fractures (Sanders classification). Check the spine: same mechanism.

Lateral (Böhler angle normally 20–40°), axial (Harris) and oblique views; CT is mandatory for intra-articular fractures (Sanders classification on coronal cuts).

Classification

Extra-articular: Tuberosity avulsions, anterior process, body without subtalar involvement.
Sanders I–IV: Number of posterior facet fragments on coronal CT (I undisplaced, II two parts, III three, IV comminuted).

Types shown in 3D

Tuberosity avulsion: Extra-articular: the Achilles tendon pulls off the posterosuperior tuberosity. Emergency if the skin is tented: reduce and fix.
Tongue type: Intra-articular (Essex-Lopresti): the secondary line exits through the back of the tuberosity, so the posterior facet stays attached to a "tongue" that tilts up. Can be reduced percutaneously.
Joint depression (Sanders II–III): The posterior facet is a separate fragment driven down into the body: Böhler's angle flattens. Open or sinus-tarsi reduction.
Sanders IV: Comminuted posterior facet (four or more parts). Poor results; consider primary subtalar fusion.

Treatment

Non-operative: Undisplaced or in smokers, diabetics and vascular disease: elevation, early motion, non-weight-bearing 8–10 weeks.
Operative: Displaced intra-articular fractures in suitable patients: sinus tarsi (minimally invasive) or extended lateral approach, restore the facet, height and width. Tuberosity avulsions are emergencies (skin pressure). Sanders IV: consider primary subtalar fusion.

Aftercare

No weight bearing for 8–12 weeks.

Complications

Wound breakdown (extended lateral approach)
Subtalar arthritis
Heel widening, peroneal impingement
Compartment syndrome → claw toes