Calcaneal fracture

Last revised by Dr Calum Worsley on 08 Feb 2022

Calcaneal fractures are the most common tarsal fracture and can occur in a variety of settings.

The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3.

Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8:

  1. extra-articular: 25-30%
  2. intra-articular: 70-75%
    • intra-articular body fracture

The calcaneus is also a common site of stress fractures, occurring in the posterosuperior aspect.

Another method of classification is as 

  • type A fractures: the anterior process of the calcaneus is fractured
  • type B: fracture of the mid calcaneus, trochlear process, and sustentaculum tali
  • type C: fracture of the posterior tuberosity

Calcaneal fractures are best assessed with a calcaneal series of radiographs, though are often identified on a lateral ankle radiograph if the presentation does not lead the requesting of calcaneal views specifically. The Böhler and Gissane angles are used to assess the severity of calcaneal fractures, and their postoperative appearance is correlated with functional outcomes 12.

CT is the modality of choice to evaluate calcaneal fracture. It can show the extent and extra- or intra-articular components of the fracture and hematoma along the sole of the foot (Mondor sign). Intra-articular fractures are often classified using the Sander classification system, which is one of the only systems that correlate well with patient outcome.

If bilateral calcaneal fractures are seen, then the spine should also be evaluated for fracture as the mechanism of injury is often a large load to the axial skeleton, such as a fall from height.

If an intra-articular calcaneal fracture is seen, the images should be scrutinized for a lateral malleolar fleck sign (ankle), which raises the likelihood of peroneal tendon instability 10.

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Cases and figures

  • Case 1: intra-articular fracture
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  • Case 2: extra-articular fracture
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  • Case 3: tuberosity avulsion fracture
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  • Case 4: anterior process fracture
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  • Case 5: axial projection
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  • Case 6: body fracture (MRI)
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  • Case 7: stress
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  • Case 8: calcaneal anterior process fracture
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  • Case 9: extra-articular calcaneal fracture
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  • Case 10: anterior process fracture
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  • Case 11: intra-articular
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  • Case 12: anterior calcaneal process fracture
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  • Case 13: comminuted fracture
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  • Case 14: anterior process
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  • Case 15
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