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Calcaneus Fracture

From WikiSM
(Redirected from Calcaneus Stress Fracture)

Other Names

  • Calcaneus Fracture
  • Calc fracture
  • Displaced, intraarticular calcaneal fractures (DIACF)
  • Lovers Fracture
  • Don Juan Fracture
  • Calcaneal stress fractures
  • Calcaneal Fracture
  • Fracture of the Calcaneus
  • Heel Bone Fracture
  • Calcaneus Bone Fracture

Background

  • This page refers to fractures of the Calcaneus including both acute and stress fractures

History

  • Described by Hippocrates (need citation)

Epidemiology

  • Accounts for 1-2% of all fractures (need citation)
  • Calcaneus fractures account for 50-60% of tarsal bone fractures, 75% of all foot fractures (need citation)
  • 10 - 17% open fractures (need citation)
  • 75% are intra-articular (need citation)
  • Location
    • Peak incidence of calcaneal tuberosity fractures is women in their 70s (need citation)

Introduction

The Achilles tendon as a deforming force: the Achilles tendon pulls the calcaneal fragment proximal and impinges on the posterior skin of the hindfoot. This type of deformation is seen in tongue-type fractures as well as calcaneal avulsion fractures.[1]

General

  • Intra-articular extension common (60-75%)
  • Average patient is male, age 30-60

Intra-articular (75%)

  • Typically a high energy mechanism involving an axial load through the heel
  • Examples include fall from height, motor vehicle crash
  • Less commonly jumping onto hard surfaces, blunt or penetrating trauma, twisting/shearing events
  • Commonly results in superolateral fragment and superomedial "constant fragment"
  • Due to Talus acting as a wedge compressing the calcaneus

Extra-articular (25%)

  • Calcaneal tuberosity fracture from the Achilles Tendon
    • Associated with poor bone quality/osteoporosis
    • Mechanism: violent contraction of the calf muscles with forced dorsiflexion
    • Mechanism: strong concentric contaction of the triceps surae with knee in full extension
  • Anterior process
    • Usually a twisting mechanism
    • Avulsion injury to the bifurcate ligament
  • Avulsion of the sustentaculum tali

Calcaneal Stress Fractures

Associated Conditions

Anatomy of the Calcaneus

  • Along with Talus, forms the hindfoot which articulates with Tibia, Fibula to form Ankle Joint
  • Transfers most of the body weight from the limb to the ground

Risk Factors

Differential Diagnosis

Differential Diagnosis Ankle Pain

Clinical Features

Clinical picture of a calcaneus fracture with a fracture blister
Calcaneal Squeeze Test

History

  • Patients should be able to describe a clear mechanism
    • Commonly a fall from height, motor vehicle collision
  • Patients will endorse pain, swelling, inability to bear weight
  • Deformity, open fracture may or may not be present
  • History of significant trauma

Physical Exam: Physical Exam Foot And Ankle

  • On inspection, look for
    • Bruising, swelling at heel or plantar arch
    • Shortened, widened heel
    • Must look for breaks in the skin, skin blistering
  • Point tenderness along bone
  • Inability to bear weight
  • Achilles tendon may be retracted in avulsion fracture
    • Plantarflexion may be lost
  • Confirm compartments are soft
  • Loss of plantarflexion strength

Special Tests

Evaluation

  • Nondisplaced fracture of calcaneus
    Nondisplaced fracture of calcaneus
  • CT of comminuted intra-articular calcaneal fracture
    CT of comminuted intra-articular calcaneal fracture
  • How to calculate Bohler's Angle
    How to calculate Bohler's Angle

Radiographs

Measuring Bohler's Angle
Illustration on Critical Angle of Gissane[2]
  • Standard Radiographs Ankle
    • Initial imaging modality of choice
    • Note: normal Bohler's Angle, Angle of Gissane do not exclude calcaneus fracture
  • Harris View
    • Evaluates calcaneus in axial orientation
    • Visualizes tuberosity fragment widening, shortening, and varus positioning
    • Position: maximal dorsiflexion, x-ray beam at 45°
  • Broden View
    • Evaluates posterior facet
    • Indication: intraoperative reduction of posterior facet
    • Technique: ankle in neutral dorsiflexion, ~45° internal rotation, x-rays at 40, 30, 20, and 10° cranial from neutral
  • Bohlers Angle
    • With fracture of posterior facet, may be depressed (<20°)
    • Angle between two lines drawn on lateral radiograph (normal between 20-40°)
    • First line is the highest point on tuberosity and the highest point of the posterior facet
    • Second line is highest point on the anterior process and highest point on the posterior facet
  • Critical Angle of Gissane
    • Angle between two lines drawn on lateral plain film (normal between 130-145°)
    • Line 1: anterior downward slope of the calcaneus
    • Line 2: superior upward slope
    • Abnormal angle suggests collapse of posterior facet
  • Other findings
    • Double density sign: partial separation of sustentaculum tali suggesting subtalar incongruity
    • Calcaneal shortening
    • Varus tuberosity deformity

CT

  • Gold standard for calcaneal fractures
  • Indications
    • Pre-operative planning
    • Classification of severity
    • Where index of suspicion is high and initial radiographs are negative
  • Mondor's Sign
    • Hematoma that extends along the sole, considered pathognomic for calcaneal fracture

MRI

  • Indications
    • Suspected calcneal stress fracture

Classification

Sanders Classification of Calcaneus Fractures

  • Fracture patterns based on number of fracture lines through the posterior facet (as seen on CT)
    • Type I: non-displaced, irrespective of fracture lines
    • Type II: 1 fracture line with 2 part fracture
    • Type III: 3 parts with centrally depressed articular fragment
    • Type IV: highly comminuted consisting of 4 articular segments
  • Fracture lines are described as A through C with A representing lateral lines, B middle, C medial fracture lines adjacent to sustentaculum tali

Essex-Lopresti Classification

  • Depression type
    • Single vertical fracture line through the angle of Gissane
    • This separates the anterior and posterior portions of the calcaneus.
  • Tongue type
    • Single vertical fracture line as a depression type
    • Second horizontal fracture line running posteriorly, creating a superior posterior fragment
    • Tuberosity fragment may then rotate superiorly.

Beavis Classification

  • Based on calcaneal tuberosity fracture pattern
  • Type 1 (Sleeve fracture): small shell of cortical bone avulses from the tuberosity
  • Type 2 (Beak fracture): oblique fracture line runs posteriorly from most superior portion of the posterior facet
  • Type 3 (Infrabursal fracture): from the middle of the tuberosity

Management

Acutely, plae the patient in a Posterior Short Leg Splint
Post operative lateral radiograph

Acute

  • Inital management often ATLS protocol given high energy nature of injuries
  • After life-threatening injuries ruled out, complete neurovascular exam of the lower extremity
  • Aggressive wound care, antibiotics for open fractures
  • Analgesia
  • Immobilization and bulky splint/dressing
  • Non-weight bearing status

Nonoperative

  • Indications
    • Sanders type I
    • Calcaneal stress fracture
    • Small extra-articular fracture (<1 cm) with intact Achilles tendon and <2 mm displacement
    • Normal Bohler's Angle
    • Minimally displaced tuberosity fractures (< 1cm) in elderly folks with reduction function/ physical capacity
    • Poor surgical candidates
  • Immobilization
    • Initially in fiberglass or plaster splint with neutral ankle
    • Conversion to Short Leg Cast with neutral ankle after swelling has subsided
  • Non-weight bearing for 10-12 weeks, until fracture union confirmed on x-ray
    • Stress fractures can likely maintain NWB status for around 6 weeks

Operative

  • Indications
    • Open fractures or fracture dislocation
    • Displaced tongue-type fractures at risk for tissue breakdown
    • Displaced (>2mm) intra-articular fractures
    • Joint depression with articular comminution or anterior process involvement
    • Bohler's angle of <5 degrees on initial presentation
    • Anterior process fractures with >25% of the calcaneocuboid articulation involved
    • Calcaneal body fractures with significant
      • Varus /valgus malalignment
      • Lateral impingement
      • Loss of calcaneal height
      • Significant translation of the posterior tuberosity.
    • Surgical fixation may be delayed in cases of concurrent life-threatening injuries, edema, poor tissue envelopes, and others
  • Technique
    • Closed reduction with percutaneous pinning
    • Open reduction, internal fixation
    • Primary subtalar arthrodesis

Rehabilitation and Return to Play

Early rehab for calcaneus fractures
Late rehab for calcaneus fractures

Phase 1: Acute / Protective Phase (Weeks 0–2)[3]

  • Goals
    • Control pain and edema
    • Promote wound healing (if postoperative)
    • Prevent deconditioning
  • Interventions
    • Non-weight-bearing (NWB) with crutches or knee scooter
    • Elevate limb above heart level
    • Cryotherapy for swelling control
    • Gentle active toe flexion and extension exercises
    • Upper body and contralateral limb conditioning: stationary arm ergometer, seated resistance training
  • Postoperative Considerations (ORIF)
    • Begin early range-of-motion exercises as tolerated (often postoperative day 3)
    • Ankle pumps
    • Gentle subtalar motion in a removable splint
    • Early rehabilitation has demonstrated good functional outcomes without loss of Böhler angle correction

Phase 2: Early Mobilization Phase (Weeks 2–6)[4]

  • Goals
    • Restore ankle and subtalar range of motion
    • Continue edema management
    • Maintain cardiovascular fitness and strength
  • Interventions
    • Continue non-weight-bearing (NWB) or forefoot touch-down weight-bearing per surgeon protocol
    • Consider partial weight-bearing at 4–6 weeks for undisplaced extra-articular fractures
    • Active and active-assisted ROM exercises: dorsiflexion/plantarflexion, Inversion/eversion, Foot alphabet exercises, ROM
    • Gentle talocrural and subtalar joint mobilization as tolerated
    • Scar mobilization once the surgical wound is healed
    • Pool-based therapy after complete wound healing: deep-water running, non-weight-bearing aquatic exercises
    • Continue upper body and core strengthening exercises

Phase 3: Progressive Weight-Bearing Phase (Weeks 6–12)[5]

  • Goals
    • Restore full weight-bearing
    • Normalize gait mechanics
    • Begin lower extremity strengthening
  • Interventions
    • Progress from partial to full weight-bearing based on radiographic healing and clinical tolerance
    • Gait training with emphasis on heel-to-toe mechanics
    • Transition from CAM boot to supportive footwear with heel pad or orthotic as appropriate
    • Progressive strengthening: gastrocnemius and soleus, tibialis anterior, tibialis posterior, peroneal muscles
    • Cardiovascular conditioning: stationary cycling, pool walking and running
    • Proprioceptive and balance training: single-leg stance on stable surfaces, progression to foam pads and wobble boards
    • Continue joint mobilization and balance exercises to improve range of motion, pain, and strength recovery

Phase 4: Advanced Strengthening & Functional Phase (Weeks 12–20)[6]

  • Goals
    • Restore full range of motion
    • Restore strength and endurance
    • Improve neuromuscular control
    • Prepare for sport-specific activity
  • Advanced strengthening:
    • Bilateral progressing to unilateral heel raises
    • Goal of 25 single-leg heel raises
    • Resisted inversion and eversion with resistance bands
    • Intrinsic foot strengthening (towel curls, marble pickups)
  • Advanced balance and proprioception training:
    • Single-leg stance on BOSU or wobble board
    • Perturbation training
    • Eyes-closed balance drills
  • Running progression:
    • Walking to jogging progression as tolerated
    • Walk-jog interval program (e.g., 1 minute jog / 4 minutes walk)
    • Gradual progression over 4–6 weeks
  • Cross-training:
    • Pool running
    • Antigravity treadmill running
  • Plyometric training (late phase):
    • Bilateral hopping
    • Single-leg hopping
    • Box step-downs
  • Begin sport-specific movement and functional training as tolerated

Phase 5: Return-to-Sport Phase (Weeks 20–24+)

  • Goals: Sport-specific skill restoration, full clearance[7]
  • Sport-specific agility drills: cutting, lateral shuffles, figure-8 running, sport-specific footwork
  • Progressive plyometrics: depth jumps, bounding, sport-specific jumping/landing.
  • Full-speed running, sprinting, and change-of-direction drills.
  • In a reported case of a triathlon athlete with calcaneal stress fracture, sports activity began at week 12 with all restrictions eliminated by week 24

Prognosis and Complications

Acute Compartment Syndrome is seen in about 10% of calcaneus fractures[8]
Radiograph of the right foot showing a displaced fracture of the calcaneum with irregular and sclerosed fracture margins in a 22 year old with neuropathic arthropathy[9]

Prognosis

  • Overall
    • Prognosis is poor with up to 40% of patients having complications (need citation)
  • Displaced, intraarticular calcaneal fractures (DIACF)
    • Nonoperative vs operative management is controversial
    • Several prospective-randomized controlled trials (RCT's) have failed to show a significant overall superiority of either treatment[10][11]
    • One small study showed better outcomes with ORIF[12]
  • Sanders classification
    • Type III fractures were 4 times more likely to need a fusion than type II fractures at minimum of 10 year follow up[13]
  • Predictors of better outcome[14]
    • Women
    • Younger Adults
    • Light workload occupation
    • Not receiving workers compensation
    • Higher initial Bohler's angle

Complications

See Also

Internal

External

References

  1. ↑ Williams MD, Cayla, et al. "Calcaneus Fractures: A Possible Musculoskeletal Emergency." (2017).
  2. ↑ Case courtesy of Leonardo Lustosa, Radiopaedia.org, rID: 225249
  3. ↑ Park, Eun Soo, et al. "Calcaneal fracture: results of earlier rehabilitation after open reduction and internal fixation." Archives of Orthopaedic and Trauma Surgery 141.6 (2021): 929-936.
  4. ↑ Eladl, Hadaya Mosaad, et al. "Efficacy of adding mobilization and balance exercises to a home-based exercise program in patients with ankle disability: a randomized controlled trial." Frontiers in Medicine 12 (2025): 1512587.
  5. ↑ De Boer, A. Siebe, et al. "The effect of time to post-operative weightbearing on functional and clinical outcomes in adults with a displaced intra-articular calcaneal fracture; A systematic review and pooled analysis." Injury 49.4 (2018): 743-752.
  6. ↑ Lanzetti, Riccardo Maria, et al. "The role of diabetes mellitus and BMI in the surgical treatment of ankle fractures." Diabetes/Metabolism Research and Reviews 34.2 (2018): e2954.
  7. ↑ Serrano, Simão, Pedro Figueiredo, and João Páscoa Pinheiro. "Fatigue fracture of the calcaneus: from early diagnosis to treatment: a case report of a triathlon athlete." American Journal of Physical Medicine & Rehabilitation 95.6 (2016): e79-e83.
  8. ↑ Pechar, Joanne, and M. Melanie Lyons. "Acute compartment syndrome of the lower leg: a review." The Journal for Nurse Practitioners 12.4 (2016): 265-270.
  9. ↑ Goyal, Rakesh, et al. "Minimally Invasive Treatment for Nonunion in an Unusual Pattern of Neuropathic Calcaneal Fracture: A Case Report." Cureus 14.1 (2022).
  10. ↑ Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, et al. Operative compared with nonoperative treatment of displaced intraarticular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002;84-A:1733–44.
  11. ↑ Agren PH, Wretenberg P, Sayed-Noor AS. Operative versus nonoperative treatment of displaced intraarticular calcaneal fractures: A prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2013;95:1351–7.
  12. ↑ Thordarson DB, Krieger LE. Operative vs. nonoperative treatment of intraarticular fractures of the calcaneus: A prospective randomized trial. Foot Ankle Int. 1996;17:2–9
  13. ↑ 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. J Orthop Trauma. 2014 Oct;28(10):551-63.
  14. ↑ Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. 2002 Oct;84(10):1733-44.
  15. ↑ Hsu AR,Anderson RB,Cohen BE, Advances in Surgical Management of Intra-articular Calcaneus Fractures. The Journal of the American Academy of Orthopaedic Surgeons. 2015 Jul
  16. ↑ Csizy M, Buckley R, Tough S, Leighton R, Smith J, McCormack R, Pate G, Petrie D, Galpin R. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Orthop Trauma. 2003 Feb;17(2):106-12.
Created by:
Parker.young on 17 December 2020 20:46:45
Authors:
Last edited:
8 June 2026 00:06:04
Categories:
Lower Extremity | Trauma | Leg | Ankle | Fractures | Acute | Overuse | Featured
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