The document provides detailed information on calcaneal fractures, including epidemiology, classification systems, imaging, treatment approaches, and complications. Some key points: - Intra-articular fractures account for approximately 75% of calcaneal fractures. - Sanders classification is most commonly used, dividing fractures into 8 types based on number of fragments and location of fracture lines seen on CT scan. - Goals of treatment are to restore calcaneal height, width, and alignment as well as achieve anatomic reduction of joints. Treatment may include closed reduction, ORIF, external fixation, or arthrodesis. - Common complications include wound healing issues, post-traumatic arthritis, nerve damage, and mal

1. AJM Sheet: Calcaneal
Fractures

2. AJM Sheet:
The standard trauma work-up again
applies with primary and secondary
surveys. The following describes
unique subjective findings,
objective findings, diagnostic
classifications and treatment
considerations.

3. SUBJECTIVE
Demographics:
• Men > Women: Age range generally 30-60
• Account for ~2% of all fractures: 2-10% are
bilateral
10% associated with vertebral fracture (most
commonly L1)
1% associated with pelvic fracture and
urethral trauma.

4. Common
mechanisms of
injury
Direct axial load
Vertical shear force/fall from height
MVC
Gastroc contraction
Stress fracture
Ballistics
Iatrogenic surgical fracture

5. OBJECTIVE
Physical Exam:
Pain with palpation to heel
Short, wide heel
Mondor’s Sign: Characteristic ecchymosis extending
into plantar medial foot
Hoffa’s sign: Less taut Achilles tendon on involved
side
Inability to bear weight
Must rule out compartment syndrome

6. IMAGING
Plain film Imaging: demonstrate loss of calc.
height/width
• Calcaneal Axial View: Demonstrates lateral
widening and varus orientation

7. IMAGING
• Bohler’s Angle: Normally 25-40 degrees.
[Decreased with fracture]
• Critical Angle of Gissane: Normally 125-140
degrees [Increased with fracture]

8. Broden’s View: Internally rotated oblique
views to view the middle and posterior facets
Isherwood Views: 3 oblique views to view all
facets.
IMAGING

9. Isherwood Views:
3 oblique views to view all facets:
• Medial Oblique
• Visualizes anterior face
• Medial Oblique axial
• Visualizes middle facet
• Lateral Oblique axial
• Visualizes posterior face
IMAGING

10. IMAGING
CT Scan:
Gold standard for evaluation and
surgical planning
The coronal view forms the basis of
the Sanders

11. Calcaneal
Fracture
classifications and
descriptions
1. Sanders Classification
2. Rowe Classification of calcaneal fractures
3. Essex-Lopresti Classification
4. Zwipp Classification

12. Sanders
Classification
Type “number” describes the # fragments formed
with fracture
A, B and C represent the location of fracture lines
A– Lateral
B – Center
C— Medial
Associated readings:
[Koval KJ, Sanders R. The radiographic evaluation of calcaneal fractures.
CORR. 1993 May; 290: 41-6.]
[Sanders R. Displaced intra-articular fractures of the calcaneus. JBJS-Am.
2000 Feb; 82(2): 225-50.]

16. Essex-Lopresti
Classification
Extra-articular (~25%)
Intra-articular (~75%)
• Tongue-type
• Joint depression
• fractures
Both intra-articular fractures
Have the same primary force, but different secondary
exit points.
[Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis.
Br J Surg 1952; 39: 395-419.]

17. Zwipp Classification
Assigns 2-12 points based
on:
• Number of fragments
• Number of involved
joints
• Open fracture or high
soft tissue injury
• Highly comminuted
nature, or associated
talar, cuboid, navicular
fractures [Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies and
recent developments. Injury 2004; 35(5): 443-61.]

18. Treatment of
calcaneal
fractures
Goals of therapy are to:
• Restore calcaneal height
• Decrease calcaneal body widening (reduce
lateral wall blow-out)
• Take calcaneus out of varus
• Articular reduction.

19. AJM Sheet:
Appreciate the debate in the literature
between cast immobilization vs.
percutaneous reduction vs. ORIF vs.
primary arthrodesis. Possible use of
delta frame to allow for closed reduction
and balancing of soft tissue swelling pre-
operatively.
[Barei DP, et al. Fractures of the calcaneus. Orthop Clin North Am. 2002 Jan;
33(1): 263-85.]
Review the lateral extensile surgical approach
[Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot. Surgical
management of calcaneal fractures. CORR. 1993 Jul; 292: 128-134.]

20. AJM Sheet:

21. COMPLICATIONS
• Wound healing,
• Arthritis,
• Lateral ankle impingement,
• Malunion,
• Non-union, etc.
[Benirschke SK, Kramer PA. Wound healing complication in closed and open calc fractures. J
Orthop Trauma. 2004; 18(1): 1-6.]
[Cavadas PC, Landin L. Management of soft-tissue complications of the lateral approach for
calcaneal fractures. Plast Reconstr Surg. 2007; 120(2): 459-466.]

22. QUESTIONS AND ANSWERS

23. How often do
intra-articular
fractures occur?
• Approximately 75% are intra-articular

24. What three factors
determine the
pattern of
comminution and
location of the
fracture lines?
Position of the foot at impact
Force at impact
Bone quality

25. Describe the
Rowe
classification.
• Ia: plantar tuberosity fracture
• Ib: sustentaculum tali fracture
• Ic: anterior process fracture
• IIa: fracture of the posterior aspect of the
calcaneus not involving the Achilles tendon;
‘beak fracture’
IIb: avulsion fracture of the posterior aspect
of the calcaneus
• III: fracture of the body without STJ
involvement
• IV: fracture of the body with STJ involvement
• V: comminution of the body of the calcaneus

26. Describe the
Essex-Lopresti
classification?
Intra-articular fracture classification only
• Tongue type fracture: primary fracture line
runs superior to inferior and secondary
fracture line exits from the posterior aspect
of the calcaneus.
• Joint depression: primary fracture line runs
superior to inferior with a second fracture
line surrounding the STJ (posterior facet)

27. Describe
Sanders
classification.
I: All non displaced articular fractures
irrespective of the fracture lines
II: Two part fracture of the posterior
facet
III: Three part fracture of the posterior
facet with central joint depression
IV: Four part articular fracture; often
more pieces and highly comminuted

28. How many
stages are in the
Sander’s
classification
(including
subtypes)?
Eight (I, IIA, IIB, IIC, IIIAB, IIIAC, IIIAB,
IIIAC, IV)

29. On which imaging
modality is the
Sanders
classification
based and what
slice is used?
CT imaging
Based on the widest section of the
sustentaculum tali in 3 mm coronal slices

30. In the Sander’s
line
classification, is
line A medial or
lateral?
Lateral

31. The ecchymosis
seen in calcaneal
fractures is known
as what?
Mondour’s sign; this usually occurs
plantarly but can also occur distal to
both malleoli

32. Where are fracture
blisters most
commonly located
in calcaneal
fractures?
The medial side because during the
fracture there is predominantly
shearing and stretching of the soft
tissues on the medial side of the
foot.

33. What two
important angles
are associated
with calcaneal
fractures?
Bohler’s angle: Normally 20 – 40 degrees;
decreases with depression of the posterior STJ
Gissane’s angle: Normally 120 – 140 degrees;
will increase with the depression of the joint

34. What plain film
views would you
order and what
would you see on
each?
Lateral foot: see joint depression; evaluate
the two angles in the question above; check
for loss of height of the posterior STJ
AP foot: to evaluate all other foot bones for
additional fractures/pathology
Harris-Beath and/or Broden view: to evaluate
the posterior facet of the STJ
Lateral oblique: anterior process of the
calcaneus to check for CC joint involvement

35. What is a
Broden’s view
and how is it
taken? (Broden
projection I)
A way to evaluate the posterior STJ on plain
films.
Patient is supine with cassette under the foot;
leg is internally rotated 30 – 40 degrees.
X-ray beam is centered over the malleoli and
four consecutive projections are made with
the tube angled at 40, 30, 20 and 10 degrees
toward the head of the patient.

36. What are the
fragments
usually seen in
calcaneal
fractures?
• Superomedial fragment (Constant or
sustentacular fragment)
• Posterior facet fragment
(superolateral, semilunar or comet
fragment)
• Tuberosity fragment (main fragment)
• Anterior process fragment Anterior STJ
fragment
• The three important fragments that
must be reduced.

37. What are the
goals of ORIF
with calcaneal
fractures?
1. Restoration of length, width and
height of the calcaneus
2. Anatomic reduction of all involved
joint surfaces
3. Restitution of function by stable
osteosynthesis without joint trans-
fixation.

38. PEARL
• In July 2000 in the Journal of Orthopedic
Trauma there was a report of using
injectable bone cement for augmentation of
ORIF of calcaneal fractures. The authors
report using an injectable cement in the area
of the neutral triangle under the posterior
facet. This will allow for good resistance
from compression that ORIF alone can’t give.
At the end of their study, they were having
patients fully weight bear at 3 weeks post
op. This is about 10 weeks earlier than some
authors report. This could potentially be a
great tool for augmentation or internal
fixation in these fractures.

39. What are the
four ways to
treat calcaneal
fractures?
•Non-operative
•ORIF
•Ex-fix
•Primary STJ arthrodesis

40. What else should
be evaluated
when dealing
with calcaneal
fractures?
1. Proximal injuries (lower
back, spine, neck and head)
2. Bladder rupture

41. Which
vertebrae are
most commonly
injured?
L1, L2
• Wong (1966) found that 11% of males
with calcaneal fractures also had
vertebral
• Compression fractures

42. What is the
‘wrinkle test’?
A way to evaluate if the soft tissue
swelling has reduced enough for
surgical intervention
Dorsiflex and evert the foot and the
skin on the lateral side of the foot
will wrinkle

43. What are the
locations for the
incisions of ORIF
and the
advantages of
each?
• Lateral extensile, Modified Ollier
• Easy visualization of posterior facet and
calcaneocuboid joint
• Avoids neurovascular bundle
• Medial
• Initially popularized by McReynolds
• Easy reduction of the sustentacular fragment
• Seligson’s lateral extensile
Described by Giouild (F&A, 1984)
Some authors use both approaches so each
fragment can be adequately visualized Many
authors also use the lateral approach for which
there are many variations.

44. When should
primary
arthrodesis be
done?
In a highly comminuted intra
articular fracture (i.e. Sander’s type
IV)

45. Name ten
complications of
treatment of
calcaneal
fractures.
1. Nerve damage
2. Post traumatic arthritis
3. RSD
4. Compartment syndrome
5. Nerve entrapment
6. Wound dehiscence (with or without
calcaneal osteomyelitis)
7. Malposition after fixation

46. Name ten
complications
of treatment of
calcaneal
fractures.
8. Calcaneal malunion
Classified by Stephens and Sanders
Type I: large lateral exostosis with or without
extremely lateral arthrosis of the STJ
Type II: a lateral exostosis combined with major
arthrosis across the width of the STJ
Type III: a lateral exostosis, severe arthrosis of the
STJ and malunion of the calcaneal body with the
hindfoot in varus or valgus angulation
9. Peroneal tendonitis/subluxation
10. Heel pad pain, Damage to the fatty plantar heel
pad

47. What is the most
frequent post-op
complication with
ORIF of calcaneal
fractures?
• Wound dehiscence (cited numerous
places in the literature)

48. NOTE
There seems to be a large discrepancy in
outcomes following treatment of intra-
articular calcaneal fractures. This is seen
between those injuries suffered while at work
and those that are not. Since this injury
frequently occurs in the working population, it
is difficult not to include these subjects in
studies. Recently, there have been reports
alluding to this idea so hopefully in the future
we will see studies on injuries that are not
sustained at work.