Calcaneus fractures are rare but potentially debilitating injuries. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. The hindfoot articulates with the tibia and fibula creating the ankle joint. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal/plantar flexion. Calcaneal anatomy is demonstrated in Figure 1. Historically a burst fracture of the calcaneus was coined a "Lovers Fracture" as the injury would occur as a suitor would jump off a lovers balcony to avoid detection. 
Calcaneal fractures most commonly occur during high energy events leading to axial loading of the bone but can occur with any injury to the foot and ankle.  Falls from height and automobile accidents are the predominant mechanisms of injury, although jumping onto hard surfaces, blunt or penetrating trauma and twisting/shearing events may also cause injury. Most of the injuries cause the bone to flatten, widen, and shorten. Stress fractures may occur with over use or repetitive use, such as running.
The epidemiology of tarsal fractures is as follows:
Falls from height directly translates energy into the calcaneus on impact as the heel strikes a surface crushing the calcaneus against the talus. The talus acting as a wedge causes depression and widening of the calcaneal body. Similarly, a foot depressed against an accelerator, brake or floor board translates a large amount of force through the calcaneus during high-speed automobile accidents. Fracture patterns are similar in either mechanism. Gunshot wounds and other ballistic injuries cause a more diffuse nonpredictable fracture pattern but remain uncommon. Avulsion fractures require a large amount of twisting or shearing force due to the strength of the ligamentous and tendinous attachments to the calcaneus. The tibial artery and nerve run along the medial aspect of the calcaneal body and are thought to be shielded by the sustenaculum tali thus neurovascular injuries are uncommon with calcaneal fractures.
A traumatic event will almost invariably precede the presentation of calcaneal injury.
Evaluation of a potential calcaneus fracture should include the following:
There are two main classification systems of extraarticular fractures.
Sanders Classification: Based on reconstituted CT findings.
Emergent treatment includes:
Open fractures require more urgent surgical treatment and wound care.
Closed fracture reduction can be delayed.
Due to the severe nature and the force required to sustain calcaneal fractures concomitant injuries must be considered. Studies have shown greater than 70% of patients with calcaneus fractures have additional injuries.
Calcaneus fractures have enormous morbidity and are often associated with many other injuries. Thus, the condition is best managed by an interprofessional team that includes a trauma surgeon, emergency department physician, orthopedic nurses, orthopedic surgeon, internist, physiotherapist, and a surgeon. All open wounds need immediate surgery. After surgery complications are common and may include compartment syndrome, osteomyelitis, wound infection malunion and subtalar arthritis. Non displaced fractures are managed conservatively.
Overall the outlook for patients with calcaneus fractures is guarded. Those with an isolated fracture do recover with time but those with a concomitant injury to the pelvis, spine, neck or head often require prolonged rehabilitation and still have residual physical deficits.
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