Fractures of the calcaneus (heel bone) are the most common tarsal bone fracture. Most
calcaneal fractures occur as the result of a fall from a height greater than 14
feet. Calcaneal fractures are common among roofers and rock
climbers. The second most common contributing cause to these traumatic
fractures are automobile accidents. Calcaneal fractures are most commonly
found in males age 30-50 y/o.
Calcaneal fractures have a track record of being
difficult to treat and have frustrated doctors for years. The calcaneus is much
like an egg; an outer firm shell and soft on the inside. As a result, the
calcaneus often shatters when broken. Calcaneal repair not only requires
re-apposition of multiple fracture patterns, but also requires restoration of
the subtalar joint. The subtalar joint is the interface between the calcaneus
and talus and is a primary load bearing joint of the foot. In some cases, the
calcaneal-cuboid joint may also be affected by an extensive fracture pattern.
Three classifications are used to describe calcaneal fractures. The
Essex-Lopresti classification describes subtalar joint depression fractures
(very severe fractures) in a bit more detail than the more commonly used Rowe
classification. A third, and newer classification proposed by Sanders in 1993
uses CT scanning to determine the stage of calcaneal fracture. Plain x-rays and CT scans are often used to determine the
extent and classification of calcaneal fractures.
The Essex-Lopresti Classification Of
Type A - Tongue type
Type B - Joint depression type
The Rowe Classification Of Calcaneal
Type 1a - Tuberosity fracture medial or
Type 1b - Fracture of the sustentaculum tali
Type 1c - Fracture of the anterior process of the calcaneus
Type 2A - Beak fracture of the posterior calcaneus
Type 2b - Avulsion fracture involving the insertion of the tendo-Achillles
Type 3 - Oblique fracture not involving the subtalar joint
Type 4 - Body fracture involving the subtalar joint
Type 5 - Body fracture with
subtalar joint depression and comminution
The Sanders Classification Of Calcaneal Fractures
Type I fractures are nondisplaced.
Type II are two-part or split fractures
Type III are three-part or split depression fractures.
Type IV were four-part or highly comminuted articular fractures.
Stress fractures of the calcaneus
Stress fractures of the calcaneus are
the result of a sudden abrupt injury but can occur without a history
The most common injury seen our practice is a fall from a height of more than 6
feet. A stress fracture of the calcaneus is a condition that
is often overlooked as a differential diagnosis of heel
pain. Plantar fasciitis (also called heel spur syndrome) is so
common that most health care providers will defer to plantar fasciitis as a
primary diagnosis when evaluating heel pain. A good patient history, and
particularly one that notes the onset and character of the pain, is very
important when differentiating between plantar fasciitis and calcaneal stress
The diagnosis of calcaneal stress fractures can
be difficult at times. Stress fractures, regardless of where they occur in
the body, are different than what we would tend to think of when we discuss
fractures. The appearance of a stress fracture on x-ray is not always
evident. Quite often, the only x-ray findings that we'll see are those
signs that show up towards the end of the healing process, sometimes as long as
several months after the onset of the injury. We don't actually visualize the
fracture, but rather we see the calcification that occurs in the late phases of
the healing process. Should the symptoms of heel pain not respond to
treatment for plantar fasciitis, or initial clinical findings seem suggestive of
a stress fracture, there are several tools that can be used to help
differentiate between calcaneal stress fractures and each of the other common
conditions considered in treating heel pain. These tools include plain x-ray,
bone scans, CT scanning and MRI.
Plain x-rays may be able to visualize a calcaneal stress fracture, but
quite often due to the lack of disruption of the bone, plain films lack
the ability to 'see' the fracture. As fractures heal, many times the
healing process can be seen on plain x-ray films. The healing process will
increase the amount of calcium surrounding the fracture. This increase in
calcium is called bone callus. The formation of bone callus typically takes about 4-6 weeks to see on plain x-ray, therefore,
periodic follow-up x-rays may aid in diagnosing a stress fracture of the
heel. Additional finding may include radiolucency (darkening) of the x-ray
in the early stages of fracture repair.
A three phase technetium bone scan can help
differentiate the location and degree of inflammation in the calcaneus thereby
helping to diagnose a calcaneal stress fracture.
Bone scans are tests that utilize a radioactive nucleotide injected into the patient
to identify areas of inflammation. A
scan is taken of the injured area three times over the course of three
hours. Each of the scans show a different degree of inflammation based upon
the increased blood flow to the inflamed area. In the case of a calcaneal
fracture, a bone scan can help in many ways. First, the scan will locate
the area of the fracture based upon the inflammation seen in fracture
healing. Second, the bone scan will help to differentiate between many
other potential problems of the heel such as plantar fasciitis. And
lastly, a scan can help to determine the acuteness of the injury. For
instance, we may see a questionable area on an x-ray but we will not be able to
tell whether the suspected injury is old or new. The bone scan will help
us in that a new injury will 'light up' on the scan due to its' current
inflammation. An old injury on the other hand will not 'light up' on the
scan due to its' lack of current inflammation.
CT (computerized tomography) scanning is a test that performs
a series of x-ray slices or cuts through the calcaneus. Computer
software organizes these images in a way so that we can see a series or
progression of change through the heel. CT scanning is particularly
useful for defining contrast. Although not considered the best testing
modality for calcaneal stress fractures (Sanders Stage I), CT scanning is
the best tool for displaced calcaneal fractures (Sanders stage II-IV)
MRI's are also helpful in differentiating
calcaneal fractures from plantar fasciitis. MRI's can identify small areas
of bone edema suggestive of a fracture. Often, due to the cost of an MRI,
insurance companies will request a bone scan of the heel prior to approving
a more costly MRI.
Treatment of calcaneal fractures
Non-displaced calcaneal fractures (Sanders Stage I) require a
period of rest and partial to complete immobilization. Treatment options
include hard casts or removable
The duration of symptoms and time necessary for adequate healing varies with the
age, nature of the fracture and general health status of the fracture. It
is not unusual to find calcaneal fractures that are symptomatic up to 4-6 months
As previously mentioned, displaced calcaneal fractures (Sanders
Stage II-IV) can
be very difficult to manage. Closed
reduction (manipulation of the fracture under anesthetic without surgery) can be successful in treating calcaneal fractures. The success
of closed reduction depends upon the stage of calcaneal fracture. Open
reduction, often called ORIF or open reduction with internal fixation, is what
doctors use when closed reduction fails to reduce the fracture. Open
reduction is not guaranteed to produce more successful outcomes compared to
The decision when to perform ORIF for calcaneal fractures varies.
Some doctors prefer to act as soon after the injury as possible, while others
prefer to wait 1-2 weeks following the injury using a
to allow for the initial phase of inflammation to subside. Follow-up
post reduction (whether close or open) varies but will include a period of
non-weight bearing, splinting or casting to allow for fracture healing.
In severe cases of joint depression fractures
(Sanders Stage 3 and 4) additional surgery may be required to fuse the subtalar
joint. If the subtalar joint is significantly damaged
in the injury, fusion of the subtalar joint is the only solution. Most doctors will
stage these procedures, performing a subtalar fusion long after the immediate
trauma of the injury. In severe cases of subtalar joint disruption where
degenerative arthritis is inevitable, subtalar joint fusion may be advocated
during ORIF of the calcaneal fracture.
The photos below show ORIF (open reduction with internal fixation)
of a Sanders stage 4 fracture. Images 1 and 2 show the approach to the
calcaneus, isolating the sural nerve in the lateral heel. Image 3 shows
dissection of the subtalar joint. Image 4 shows the calcaneal cuboid
joint. Images 5 and 6 show reduction of the fracture and partial fixation.
Images 7 and 8 show closure and drain placement prior to placement in a
Calcaneus - the bone of the heel.
Calcaneo-cuboid joint - joint found between the calcaneus and cuboid bones.
ORIF - open reduction with internal fixation.
Subtalar Joint - (STJ) the joint between the two
major bones of the rearfoot, the talus and calcaneus. The STJ is a common
site of residual arthritis following calcaneal fractures.
Technetium - a radioactive substance that is attracted to area of inflammation.
Used as the active substance in bone scans.
The calcaneus is surrounded by a very firm
outer surface of cortical bone. The inside of the calcaneus is soft and spongy
consisting of softer cancellous bone. This architecture is much like an
egg; hard on the outside and very soft in the center. And just like an
egg, the calcaneus is very susceptible the crush injuries.
The calcaneus is
an unusually shaped bone with numerous surfaces making up the support for the
subtalar joint and the calcaneal cuboid joint. Numerous tubercles project
from the calcaneus enabling the attachment of ligaments, retinaculum, fascia and
The dorsal, or top surface of the calcaneus is covered with an
articular surface that makes up the calcaneal side of the subtalar joint. The
cortical bone supporting the subtalar joint is quite thick and accustom to
repetitive load. The subtalar joint actually consists of three separate
joint surfaces; the anterior, middle and posterior facets. The anterior
and middle facets are the two smaller facets of the subtalar joint. The
anterior and middle facets are separated from the posterior facet by the sulcus
calcanei. The posterior facet of the subtalar joint is the largest of each
of the facets. The posterior facet slopes obliquely up and away from the
Radiographic anatomy of the calcaneus includes a number of
important findings that are used to evaluate calcaneal fractures. The
subtalar joint facets create an angle that is used to determine the extent of
joint depression fractures. This angle is called The Angle of Gissane, or
The Crucial Angle of Gissane. The normal measurement of this angle is
120-145 degrees. An increase in The Crucial Angle indicates a joint
depression fracture of the calcaneus.
Immediately below The Angle of Gissane is a radiolucent area of
the calcaneus called the neutral angle. The neutral angle is a divergence
of trabecula away for the subtalar joint. The neutral angle is considered
the weakest aspect of the calcaneus and is very susceptible to fracture when
axial load is applied from the talus.
An important anatomical consideration in calcaneal fractures is
the soft tissue envelop that is present surrounding the heel. This soft
tissue envelop consists of tendons that traverse the calcaneus and an extensive
series of ligaments on the medial, lateral and plantar sides of the
calcaneus. A number of muscles attach to the plantar, or bottom of the
calcaneus that also act to maintain the basic structure of the calcaneus during
and following injuries. In the event of a calcaneal fracture, the soft
tissue envelop encloses the fracture. Compound fractures of the calcaneus
are rare due to the presence of this soft tissue envelop.
The biomechanics of calcaneal fractures are
determined based upon three factors. Those factors include (1) the position of
the foot at the time of injury (2) the direction in which force is applied to
the calcaneus at the time of injury and (3) the ability of the calcaneus to
withstand force. The combination and extent of axial load and shear force is
what defines each calcaneal fracture.
The majority of calcaneal
fractures occur as the result of a fall from a height. When the heel strikes the
ground, the mass of the body continues to drive force down towards the ground,
and in many instance, through the calcaneus. This force is called axial
force or axial load. The primary fracture line, or most significant
location of the break in the calcaneus, is defined by axial load.
If the heel is inverted (soles facing each other) or everted (soles away from
each other) at the time of injury, then axial force cannot be driven directly to
the ground. This deviation of axial force creates a second load called
shear force or shear load. Shear load will force the load to deviate from
the primary fracture line and creates a series of secondary fracture lines.
Calcaneal stress fractures may follow fracture patterns as defined by our
classifications, or may deviate based upon the cause of the injury. Stress
fractures are common in sports like soccer and basketball, particularly in
athletes who are beginning training. This particular type of calcaneal
stress fracture is due to excessive repetitive loading. Calcaneal stress
fractures can also be due to a single traumatic event such as a fall or
Calcaneal fractures come in all shapes and sizes. Some are quite
obvious and severe while others are less obvious and more difficult to diagnose. The
symptoms of a calcaneal fracture following a fall include (1) inability to bear
weight on the heel (2) swelling of the heel and (3) bruising of the heel and
ankle. Pain is usually severe enough to warrant a visit to your local
emergency room for care.
Calcaneal stress fractures on the other hand, are much different in their
presentation. Patients who have sustained a calcaneal stress fracture may
or may not remember an incident of trauma. Calcaneal stress fracture pain begins
with initial weight bearing and continues throughout the day. Pain is
described as dull achy pain. Pain is usually present with compression of
the medial and lateral walls of the heel. Bruising may or may not be
present in a calcaneal stress fracture. Continued pain usually motivates a patient to visit their doctor
where x-rays are taken. X-rays for calcaneal stress fractures are often
inconclusive. As symptoms persist, an MRI is used to identify what
radiologists call bone edema, or swelling within the bone. Bone edema is
the marker that pinpoints a calcaneal stress fracture. Symptoms of
calcaneal stress fractures may persist for 6 months or more.
Symptoms of a traumatic calcaneal fracture (Sanders Stage II-IV) following a fall
or other injury are quite
obvious. Therefore calcaneal fractures that are the result of a fall have
no differential diagnosis knowing that the injury was directly related to a
The differential diagnosis of calcaneal stress fractures
Baxter's nerve entrapment
- an entrapment of
the recurrent branch of the posterior tibial nerve.
Gout - deposition of monosodium urate
Heel spur syndrome - see plantar fasciitis.
Plantar fasciitis - a common condition of the
heel that results in pulling by the plantar fascia and a tearing pain at the
attachment of the fascia on the bottom of the heel. Pain is severe with
the first few steps out of bed in the morning or after a brief period of rest.
Retrocalcaneal bursitis (Albert's Disease) - this is the formation and inflammation
of a bursa at the back of the heel
between the heel bone and Achilles tendon.
Sero-negative arthropathies such as Reiter's Syndrome.
Sever's Disease - and inflammatory condition typically found in young over weight
boys age 10 to 15 years old.
Tarsal Tunnel Syndrome - also known as posterior tibial nerve neuralgia.
Tarsal Tunnel Syndrome (TTS) characteristically has pain that does not decrease with rest.
Also, TTS often presents with numbness or 'tingling' of the toes.
Products Recommended for Calcaneal Fractures:
This article was written by Jeffrey A. Oster, DPM and last updated
Rowe CR, Sakellarides HT, Freeman PA, et al. Fractures of the os calcis: long
term follow-up study of 146 patients. JAMA 1963;184:920-923.
Hermann OJ. conservative therapy for fractures of the os calcis. J Bone Joint
Parker JC. Injuries of the hindfoot. Clin Orthop 1977; (122):28-36.
Palmer I. The mechanism and treatment of fractures of the calcaneus: open
reduction with the use of cancellous grafts. J Bone Joint surg
Thordarson DB, Krieger LE: Operative vs. nonoperative treatment of
intra-articular fractures of the calcaneus: a prospective randomized trial.
Foot Ankle Int 17:2-9, 1996.
R. Sanders. Intra-articular fractures of the calcaneus: Present state of the
art. J. Orthop. Trauma. Vol 6. 1992. p 252-265.
Sanders R, Fortin P, DiPasquale A, et. al.: Operative treatment in 120 displaced
intr-articular calcaneal fractures. Results using a prognostic computed
tomographic scan classification. Clin Orthop Rel Res 290:87-95.
Giachino AA, Uhthoff HK. Intra-articular fractures of the calcaneus. JBJS Vol
71-A. 1989. p 784-786.
Prasartritha T, Sethavanitch C: Three-dimensional and two-dimensional
computerized tomographic demonstration of calcaneus fractures. Foot Ankle Int.
Sceppers T, et al: Calcaneal fracture Classification: A Comparative Study. J
Foot Ankle Surg 48:2 2009. p 156-162
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