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.
|||Adams MR,Koury KL,Mistry JB,Braaksma W,Hwang JS,Firoozabadi R, Plantar Medial Avulsion Fragment Associated With Tongue-Type Calcaneus Fractures. Foot [PubMed PMID: 30841752]|
|||Bibbo C,Siddiqui N,Fink J,Powers J,Ehrlich DA,Kovach SJ, Wound Coverage Options for Soft Tissue Defects Following Calcaneal Fracture Management (Operative/Surgical). Clinics in podiatric medicine and surgery. 2019 Apr; [PubMed PMID: 30784540]|
|||Cottom JM,Douthett SM,McConnell KK, Intraoperative Reduction Techniques for Surgical Management of Displaced Intra-Articular Calcaneal Fractures. Clinics in podiatric medicine and surgery. 2019 Apr; [PubMed PMID: 30784536]|
|||Hordyk PJ,Fuerbringer BA,Roukis TS, Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures. Clinics in podiatric medicine and surgery. 2019 Apr; [PubMed PMID: 30784528]|
|||Schepers T, Sinus Tarsi Approach with Screws-Only Fixation for Displaced Intra-Articular Calcaneal Fractures. Clinics in podiatric medicine and surgery. 2019 Apr; [PubMed PMID: 30784532]|
|||Herrera-Pérez M,Oller-Boix A,Valderrabano V,González-Casamayor S,Gutiérrez-Morales MJ,Guerra-Ferraz A,País-Brito JL, [Calcaneal fractures: controversies and consensus]. Acta ortopedica mexicana. 2018 May-Jun; [PubMed PMID: 30521710]|
|||Diacon AL,Kimmel LA,Hau RC,Gabbe BJ,Edwards ER, Outcomes of midfoot and hindfoot fractures in multitrauma patients. Injury. 2019 Feb; [PubMed PMID: 30448328]|
|||Jiménez-Almonte JH,King JD,Luo TD,Aneja A,Moghadamian E, Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. Clinical orthopaedics and related research. 2019 Feb; [PubMed PMID: 30664605]|
|||Shih JT,Kuo CL,Yeh TT,Shen HC,Pan RY,Wu CC, Modified Essex-Lopresti procedure with percutaneous calcaneoplasty for comminuted intra-articular calcaneal fractures: a retrospective case analysis. BMC musculoskeletal disorders. 2018 Mar 9; [PubMed PMID: 29523122]|
|||Spierings KE,Min M,Nooijen LE,Swords MP,Schepers T, Managing the open calcaneal fracture: A systematic review. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons. 2018 Nov 5; [PubMed PMID: 30467055]|
|||Zhang Z,Wang Z,Zhang Y,Qiu X,Chen Y, Risk factors for increased postoperative drainage of calcaneal fractures after open reduction and internal fixation: An observational study. Medicine. 2018 Aug; [PubMed PMID: 30095652]|
|||Albin SR,Koppenhaver SL,Marcus R,Dibble L,Cornwall M,Fritz JM, Short-Term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial. The Journal of orthopaedic and sports physical therapy. 2019 Feb 13; [PubMed PMID: 30759357]|
|||Toro G,Langella F,Gison M,Toro G,Moretti A,Toro A,Iolascon G, Stentoplasty of calcaneal fractures: Surgical technique and early outcomes. Injury. 2019 Feb 2; [PubMed PMID: 30739765]|
|||Buckley RE,Tough S, Displaced intra-articular calcaneal fractures. The Journal of the American Academy of Orthopaedic Surgeons. 2004 May-Jun; [PubMed PMID: 15161170]|
|||Aldridge JM 3rd,Easley M,Nunley JA, Open calcaneal fractures: results of operative treatment. Journal of orthopaedic trauma. 2004 Jan; [PubMed PMID: 14676550]|
|||Siebert CH,Hansen M,Wolter D, Follow-up evaluation of open intra-articular fractures of the calcaneus. Archives of orthopaedic and trauma surgery. 1998; [PubMed PMID: 9801778]|
|||Eastwood DM,Langkamer VG,Atkins RM, Intra-articular fractures of the calcaneum. Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. The Journal of bone and joint surgery. British volume. 1993 Mar; [PubMed PMID: 8444935]|
|||Benirschke SK,Sangeorzan BJ, Extensive intraarticular fractures of the foot. Surgical management of calcaneal fractures. Clinical orthopaedics and related research. 1993 Jul; [PubMed PMID: 8519099]|
|||Sanders R,Vaupel ZM,Erdogan M,Downes K, Operative treatment of displaced intraarticular calcaneal fractures: long-term (10-20 Years) results in 108 fractures using a prognostic CT classification. Journal of orthopaedic trauma. 2014 Oct; [PubMed PMID: 25243849]|