Calcaneal Fracture
Classification systems
- Intra-articular versus extra-articular
Mechanism
Axial loading from a fall from height or a motor vehicle footwell injury drives the talus into the calcaneus, splitting the posterior facet and widening and shortening the heel. Because the mechanism is axial, always examine the spine and the contralateral limb — associated vertebral and lower limb injuries are common.
Age considerations
- Paediatric
- Uncommon; more often extra-articular with better remodelling and a generally good prognosis on non-operative treatment. High-energy paediatric cases still warrant a spine assessment.
- Young adult
- The typical patient, often a manual worker. Restoring heel height, width and the posterior facet may improve function, but wound complications are frequent and the decision must weigh smoking, diabetes and the soft tissue envelope.
- Elderly
- Non-operative treatment predominates; surgical wound risk in poor skin usually outweighs radiographic gain, and the goal is a shoeable, painless heel rather than a perfect radiograph.
Management options
Non-operative treatmentshowhide
Indication
Extra-articular and minimally displaced intra-articular fractures, and displaced fractures in smokers, diabetics, patients with peripheral vascular disease or a compromised soft tissue envelope.
Implant design notes
No implant. Elevation, a well-padded splint or removable boot, early motion of the ankle and subtalar joint once swelling permits, and delayed weight bearing.
Approach
Non-operative with intensive swelling control.
Steps overview
- Examine the whole spine and both lower limbs given the axial mechanism
- Assess the soft tissue envelope, blister formation and any medial wound
- Elevate strictly and apply a well-padded compressive dressing and splint
- Begin early ankle and, when tolerated, gentle subtalar motion
- Keep non-weight bearing for around six to ten weeks depending on pattern
- Rehabilitate with attention to hindfoot alignment and shoe fitting; counsel on a long recovery
Notes
Warn about persistent heel widening, difficulty with shoe fit and subtalar stiffness. Late subtalar arthritis may require fusion.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Open reduction and internal fixationshowhide
Indication
Displaced intra-articular fractures with a reconstructable posterior facet in a patient with a healthy soft tissue envelope and no major wound risk factors, and displaced tongue-type fractures threatening the posterior skin.
Implant design notes
Low-profile calcaneal plate, or screws alone in a minimally invasive technique, restoring heel height, length, width and the posterior facet. Locking plates help in cancellous comminution. Sinus tarsi or minimally invasive approaches trade some exposure for a markedly lower wound complication rate compared with the extended lateral approach.
Approach
Sinus tarsi approach or a minimally invasive percutaneous technique in most modern practice; extended lateral approach where wide exposure is essential, raising a full-thickness flap protecting the peroneal tendons and sural nerve.
Steps overview
- Delay surgery until swelling settles and the wrinkle sign appears — never operate through blistered oedematous skin
- Obtain cross-sectional imaging to define the posterior facet fragments and plan
- Position laterally with the limb free and image intensifier available
- Expose through the chosen approach, protecting the sural nerve and peroneal tendons
- Reduce the constant medial fragment first, then restore the posterior facet against the talus under direct vision
- Correct heel height, length and varus, holding with wires; place a screw from the tuberosity into the sustentaculum
- Apply the plate or definitive screws and confirm reduction on axial and lateral views
- Close meticulously in layers without tension and elevate; delay weight bearing
Notes
Wound breakdown and deep infection after the extended lateral approach are the feared complications, particularly in smokers and diabetics. A displaced tongue-type fracture tenting the posterior skin is an urgent reduction to prevent skin necrosis.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Viva pearls
- Because the mechanism is axial, always examine the spine and the opposite heel — associated injuries are the classic omission.
- Böhler's angle and the crucial angle of Gissane are the two measurements to quote from the lateral radiograph.
- The soft tissue envelope, smoking and diabetes drive the operative decision far more than the classification grade.
- A displaced tongue-type fracture tenting the posterior skin is a surgical urgency — the skin will necrose.
- The constant medial fragment attached to the sustentaculum is the reduction key.
- Warn every patient about heel widening, subtalar stiffness and a recovery measured in many months.
Sources for further reading
- Rockwood and Green's Fractures in Adults — calcaneus
- Standard operative orthopaedics textbook — fractures of the hindfoot
- Apley and Solomon's System of Orthopaedics and Trauma — injuries of the foot
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Resident-authored study summary in original wording, not reproduced from copyrighted source text.