Calcaneal 1

Modern Study Review (AI-Generated)

High-Yield Summary

Calcaneal fractures are complex injuries predominantly caused by high-energy axial loading, often resulting in intra-articular involvement of the subtalar joint. These fractures carry significant morbidity due to their impact on foot biomechanics and function, making accurate diagnosis and appropriate treatment critical. Modern management balances operative fixation for displaced intra-articular fractures with non-operative care for select extra-articular or minimally displaced injuries, aiming to restore pain-free function and prevent long-term disability.

Key Diagnostic Findings

Anatomy

• Calcaneus: Largest tarsal bone, critical for weight-bearing and gait.
• Plantar Surface: Medial and lateral processes serve as attachment points for the plantar fascia and intrinsic foot muscles.
• Dorsal Surface: Contains three facets forming the subtalar joint:
• Posterior facet: Convex, primary weight-bearing surface of the subtalar joint.
• Middle facet: Concave, located on sustentaculum tali.
• Anterior facet: Concave, continuous with middle facet.
• Interosseous ligament lies between middle and posterior facets.
• Bohler’s angle: Formed by lines from the highest points of the anterior process, posterior process, and tuberosity; decreased angle suggests fracture displacement.

Clinical Presentation

• Intra-articular fractures: Severe heel pain, swelling, bruising, inability to bear weight.
• Extra-articular fractures: Localized pain depending on fragment involved (e.g., anterior process pain anterior/inferior to anterior talofibular ligament).
• Sustentaculum tali fractures: Pain exacerbated by passive great toe extension (FHL tension).
• Tuberosity fractures: May present with Achilles tendon avulsion symptoms.

Imaging

• Standard views: AP, lateral, and axial calcaneal radiographs.
• Special views:
• Broden’s view (medial oblique with varying cephalad angles) to visualize posterior facet.
• Lateral oblique view (foot externally rotated 60°, 10° cephalad beam) for posterior facet assessment.
• CT scan: Gold standard for detailed evaluation of intra-articular fracture patterns and surgical planning.

Classification Systems

Current Gold Standard Treatment

Non-Operative Indications and Treatment

• Minimally displaced intra-articular fractures (Sanders Type I).
• Extra-articular fractures without significant displacement or mechanical compromise.
• Body fractures sparing the subtalar joint with preserved Bohler’s angle and no heel widening.
• Treatment includes immobilization (cast or boot), non-weight bearing initially, followed by gradual mobilization.

Operative Indications and Treatment

• Displaced intra-articular fractures with >2 mm step-off or incongruity, especially Sanders Types II-IV.
• Significant loss of Bohler’s angle (>10° reduction) indicating mechanical disadvantage.
• Heel widening causing shoe wear difficulties or soft tissue compromise.
• Displaced tuberosity fractures with Achilles tendon avulsion.
• Surgical options:
• Open reduction and internal fixation (ORIF) via extensile lateral approach or minimally invasive techniques.
• Percutaneous fixation in select cases.
• Fixation methods include plates, screws, and tension bands.
• Timing: Surgery ideally performed after soft tissue swelling subsides (typically 7-14 days).

Modern Complications & Outcomes

Complications

Outcomes

• Functional outcomes correlate strongly with quality of articular reduction and restoration of Bohler’s angle.
• Non-operative treatment may yield acceptable results in non-displaced fractures but often with residual stiffness.
• ORIF improves subtalar joint congruity and function but carries higher risk of wound complications.
• Long-term follow-up essential to monitor for arthritis and functional decline.

Classic Clinical Notes

Calcaneal 1

Calcaneal Fractures

Reference: Heckmann, James, in Rockwood and Green, 1996, Chapter 32

Main Message

• These are devastating injuries.
• The jury is out with regards to the treatment.
• Probably, there are some that are better fixed, particularly by those who are good at them, and some that are better left alone.
• One hopes that Buckley’s study will delineate some of that…

Points of Interest

Anatomy

• Plantar Surface – medial and lateral processes – for attachment of the plantar fascia and intrinsic foot muscles.
• Dorsal Surface – posterior, middle, anterior facets
• Posterior facet – convex; makes up most of the subtalar joint
• Middle facet – concave; situated on the sustentaculum tali
• Anterior facet – concave; confluent with the middle facet
• The calcaneal groove and interosseous ligament lies between the middle and posterior facets.
• Bohler’s angle: the complement of the angle formed by a line drawn from the highest point of the anterior process to the highest part of the posterior process, and a line drawn from this point to the highest part of the tuberosity.
• Most fractures are intra-articular – caused by axial loading. But there are many that are caused by twisting injuries – these are usually extra-articular.

Radiographs

• AP and lateral views are good
• Axial view of the calcaneus shows the width
• Broden’s view (a medial oblique view) – internally rotate the foot 45°, then shoot at 40, 30, 20, 10 degrees cephalad to get the right AP projection of the posterior facet
• Lateral oblique view – externally rotate the foot 60° and shoot 10° cephalad to get a good lateral of the posterior facet.

Extra-Articular Fractures

Intra-Articular Fractures

• Primary fracture line runs obliquely from plantarmedial to dorsolateral, creating an anteromedial (sustentacular) fragment and a posterolateral (tuberosity) fragment.
• The sustentacular fragment is rarely comminuted, being attached to the talus by the strong deltoid and interosseous talocalcaneal ligaments.
• The tuberosity fragment is the one that gets “shmucked.”
• This primary fracture line is created in this fashion because the talus sits… (text incomplete)

Last Updated on January 25, 2026 by orthonet