Calcaneal Fractures

Which calcaneal fracture you are looking at changes everything on this page. The whole account here - Sanders, the extensile approach, the wound-complication problem, the arthrodesis question - is about the intra-articular fracture through the posterior facet. Two others spare that facet and are managed completely differently: the anterior process fracture, usually an avulsion treated non-operatively, and the calcaneal tuberosity fracture, where the threat is skin necrosis from a displaced fragment tenting the posterior heel and the urgency is soft-tissue, not articular. The measurements that screen for a posterior-facet injury on plain film are on Bohler and Gissane angles - and a normal Bohler angle excludes facet depression, not a calcaneal fracture. The complication to look for in the first hours is foot compartment syndrome; the one that arrives years later is subtalar arthritis. The other hindfoot fracture with the same soft-tissue-timing logic is the talus.

Mechanism. Axial loading drives the talus down into the calcaneus - a fall from height, or a dashboard injury in a road collision. The energy is high, the bone is cancellous, and the fragments displace in a predictable pattern around the one part of the calcaneus that does not move.

• Fall from height - 60-70%, over 2 metres
• Motor vehicle accident - 20-25%
• Industrial or crush injury - 10-15%

Who. Working-age men: 75-80% of patients are male, the mean age is 35-45 and the peak 30-50, and most are manual labourers and construction workers.

What the injury costs. These are devastating injuries. 30-40% never return to their previous employment, 40-60% still have pain at two years despite treatment, and in Sanders III-IV fractures 50-70% have subtalar arthritis by two years. Per-patient healthcare cost is substantial in high-income settings, and lost productivity and long-term disability sit on top of it. Outcome turns on the articular injury, the patient's age and occupation, and whether the posterior facet can be reduced anatomically.

The constant fragment. The sustentaculum tali is the medial shelf that supports the talar head, held to the talus by the strong interosseous talocalcaneal ligament and the deltoid ligament complex. It therefore does not displace, and in injury it acts as a hinge: the primary fracture line of Sanders runs lateral to it, and every other fragment displaces relative to it. The operation reverses that - all fragments are reduced to the sustentaculum.

Vessels and nerves in the field. The lateral calcaneal artery, from the peroneal artery, supplies the lateral wall and the skin over it - the skin the extensile lateral approach raises as a flap. It is preserved by dissecting subperiosteally, and gentle handling of the flap reduces the risk of necrosis. Branches of the medial calcaneal artery supply the inferior and medial bone. The sural nerve runs posterolaterally, 1-2cm posterior to the lateral malleolus and straight through the line of that approach, so it is identified and retracted rather than stretched; the medial calcaneal nerves, from the tibial nerve, are at risk from medial pin placement.

Sanders (1993) is the classification that decides treatment and predicts outcome in intra-articular fractures, and it is read from a single slice: the coronal CT cut through the widest part of the posterior facet.

How to apply it. Find the sustentaculum first, the medial and constant fragment. Then count the fracture lines crossing the facet from lateral to medial - A in the lateral third, B in the central third, C in the medial third between the central line and the sustentaculum. The type is the number of articular fragments; the subtype names the lines present, so IIA is the A line alone, IIB the B line, IIC the C line, and IIIABC has all three.

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The older systems. Essex-Lopresti divides fractures by mechanism on the lateral radiograph into tongue-type and joint-depression. It still names what you are looking at, and the displaced tongue-type still changes the urgency of the operation, but it does not otherwise guide treatment.

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History. The mechanism gives you the energy: the height of the fall, or the dashboard strike. The answers that change management are the time since injury and how the swelling has progressed, whether both feet were involved, whether the back hurts, the comorbidities that decide wound healing - diabetes, smoking, peripheral vascular disease - and the occupation, which will shape the treatment choice.

Examination. Look for swelling and ecchymosis laterally and on the sole, a heel that is wider than the other side and has lost its normal contour, and the state of the skin: 5-10% of these fractures are open, and fracture blisters delay surgery. Palpate for tenderness, a step-off in the lateral wall, and compartments that feel firm and tense. Record the dorsalis pedis and posterior tibial pulses, sensation in the tibial, sural and superficial peroneal territories, and whether passive toe dorsiflexion hurts.

Associated injuries. Axial loading from a height drives multiple injuries, so the assessment is systematic:

• Lumbar spine fracture - 10% of patients, 25% when both heels are fractured, most commonly an L1-L2 compression fracture. Image the spine if the fractures are bilateral or the back hurts
• The other calcaneus - bilateral in 10%; examine and image both feet
• Other lower limb fractures - tibial plateau, femoral neck, acetabulum, so examine the whole limb
• Compartment syndrome, which declares itself in the first 48 hours

Radiographs. Each view answers a different question:

• Lateral foot - the Bohler and Gissane angles
• Axial (Harris) view - varus or valgus of the tuberosity, and the width of the heel
• AP and oblique foot - the anterior process and the calcaneocuboid joint

The two angles. Bohler's angle is normally 20-40 degrees, typically 30-35. Flattening to under 20 degrees means the height has collapsed and predicts a poor outcome with non-operative treatment, especially under 10 degrees; an angle under 0 degrees predicts a poor outcome whatever is done. Gissane's critical angle is normally 120-145 degrees and opens up as the posterior facet is depressed. Compare the height and width with the uninjured side: widening means the lateral wall has blown out.

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CT is the study that classifies and plans. Fine-cut (1-2mm) axial, coronal and sagittal reconstructions within 24-48 hours of presentation for every intra-articular fracture, with the coronal slice through the widest posterior facet as the slice that classifies; 3D reconstruction is for surgical planning, not for classification. Read it for the Sanders type and subtype, the number and displacement of the fragments, the posterior facet step-off, lateral wall comminution and widening, the calcaneocuboid joint, and associated anterior process or sustentacular fractures. Use it to judge whether the planned approach is feasible, to template the plate, and to choose the order in which the fragments will be reduced.

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MRI is rarely indicated and adds nothing to a displaced fracture with a positive CT. Its uses are the occult fracture - normal radiograph but a convincing clinical picture - a suspected bifurcate ligament injury, and the stress fracture of overuse in military recruits.

The decision is selective, not routine. The pragmatic UK Heel Fracture Trial found no symptomatic or functional advantage from ORIF at two years in an ordinary population, with markedly more complications and reoperations after surgery. The earlier Canadian trial found the same overall equivalence, but once Workers' Compensation patients were removed it located real benefit in defined subgroups - younger patients, women, light workloads, a moderately reduced Bohler angle, and fractures that could be reduced anatomically. Read together they do not say never operate; they say operate on the patient who stands to gain.

Who gains. A working-age patient (under 60 years) with a Sanders II or III fracture who can comply with non-weight bearing, where the height, width and facet can be restored: the return-to-work rate and physical function are better. Sanders I is already reduced, and Sanders IV is too comminuted for fixation to change the outcome. Add a heavy-labour occupation and an age over 50 to a Sanders IV and the operation to consider is a primary subtalar fusion, not a plate.

Tongue-Type Fractures: A Soft-Tissue Emergency

Most displaced intra-articular calcaneal fractures are operated in a delayed fashion (10-21 days, once the wrinkle test is positive). The important exception is the displaced tongue-type fracture (Essex-Lopresti), which can be a true soft-tissue emergency.

• Why it is urgent: in a tongue-type pattern the secondary fracture line exits posteriorly through the tuberosity, so the superior "tongue" fragment is pulled proximally by the Achilles. The sharp superior edge of this rotating fragment presses against and tents the posterior heel skin from the inside. Unrelieved, this causes pressure ischaemia and full-thickness posterior skin necrosis within hours to a couple of days, converting a closed injury into an open one over the worst possible soft-tissue envelope.
• Recognise it: a displaced tongue-type fracture on the lateral radiograph plus blanching, tenting, or a dusky/indented patch of skin over the posterosuperior heel. This patient is reduced urgently, not at 10-21 days.
• Essex-Lopresti / Westhues percutaneous reduction: with the knee flexed to relax the gastrocsoleus, a large Steinmann pin or Schanz screw is driven into the displaced tongue fragment along its long axis and used as a lever (joystick) to reduce the fragment - and the posterior facet attached to it - back down into position. The reduction is then secured percutaneously (the pin advanced across the fracture and/or supplementary lag screws). This immediately decompresses the threatened skin and can definitively fix simple tongue-type patterns without the extensile dissection.
• If the skin is already compromised, manage as an open injury (debridement, soft-tissue-led plan) rather than proceeding to formal ORIF through devitalised tissue.

The operation. Restore the height, reduce the posterior facet onto the sustentaculum, narrow the heel back to its normal width, and hold all of it with a lateral plate whose key screws reach the sustentaculum. Everything else is soft-tissue discipline.

Pre-operative PlanningPositioningApproachLimited ApproachesReductionFixationClosure

Timing is soft-tissue led. Operate at 10-21 days: long enough for the swelling to resolve and the fracture blisters to epithelialise, and time to stop the smoking and control the glucose. Surgery within 7 days carries a 40-50% wound-complication rate. Past 3 weeks the fragments are uniting in their malunited position and the reduction becomes difficult.

Wrinkle Test

Gently pinch the lateral skin over the fracture site. If it wrinkles, the swelling has resolved enough to operate; if the skin stays tense and shiny, wait. There is no number of days that substitutes for the test - operating on a swollen heel takes the wound-complication rate from 20% to over 40%.

Who breaks down. Smoking is the single greatest risk factor, with a relative risk of 3.7. Diabetes, obesity and unresolved swelling add to it, and together they can turn a 20% wound-complication rate into over 50%. An open fracture is a different problem again, carrying a 40-50% infection rate.

Consent. The wound dominates the conversation: dehiscence and skin necrosis are what this operation risks. Beyond the wound, discuss infection, numbness in the sural territory, metal that becomes prominent and may need removing, the subtalar arthritis that follows the injury rather than the operation - with the 15-25% who come to a fusion within five years - thromboembolism in 2-5%, and pain that persists despite an anatomical reduction.

Pre-operative Checklist

1-2 weeks beforePatient Optimisation

• Smoking cessation (minimum 4 weeks ideal, 2 weeks acceptable)
• Diabetic control (HbA1c under 8%)
• Nutrition optimisation (albumin over 3.5)
• Weight loss if obese (BMI over 35 high risk)

Day beforeImplant Planning

• Review CT to template plate size and screw lengths
• Standard: lateral calcaneal locking plate (7-9 holes)
• Screws: 3.5mm cortical and locking, 35-50mm lengths
• K-wires: 1.6mm and 2.0mm for provisional fixation
• Consider calcium phosphate bone void filler for voids

Day of surgeryEquipment

• C-arm fluoroscopy (confirm positioning before draping)
• Lamina spreaders or Schanz pins for distraction
• Dental picks or curettes for fracture debris removal
• Self-retaining retractors (avoid excessive tension)
• Headlight or surgical loupe magnification

Position. Lateral decubitus with the affected side up, on a well-padded beanbag or inflatable lateral positioner. The down leg has hip and knee flexed with a pillow between the knees, an axillary roll goes under the dependent chest to protect the brachial plexus, and the down arm rests on an arm board without abduction beyond 90 degrees.

Pressure points. Pad the axilla, the dependent shoulder, the dependent lateral chest wall, the dependent iliac crest, the down leg - where the pillow between the knees protects the peroneal nerve - and the down ankle and foot. The up leg needs minimal padding, which leaves it free to be moved.

The operative leg. Hip neutral, knee flexed 30-45 degrees to relax the gastrocnemius, the thigh resting on a padded support or sandbag that holds the flexion, the leg allowed to rotate internally a little for easier access to the lateral wall, and the foot off the table so it hangs free. An assistant can then manipulate the foot - axial traction, varus and valgus correction - while the surgeon works on the fragments. The prone position allows access to both heels but makes reduction harder.

The C-arm. Confirm the images before draping: the lateral view for the Bohler angle and the posterior facet, the axial Harris view for width and varus or valgus. Bring the C-arm from the contralateral side under the table, satisfy yourself the image quality is adequate, and mark its position on the floor with tape.

The incision. An L-shaped lateral incision, and the corner of the L is where the flap's blood supply is at stake. The horizontal limb runs 2cm below the tip of the fibula, from the Achilles tendon posteriorly to the calcaneocuboid joint anteriorly (8-10cm), keeping at least 1cm of skin below the fibular tip to protect the sural nerve. The vertical limb curves gently from the midpoint of the horizontal limb down to plantar skin, avoiding the heel pad, then curves anteriorly towards the base of the fifth metatarsal, ending on non-weight-bearing lateral skin. Sharp angles impair the blood supply and are avoided.

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Surgical Approach

Step 1Superficial Dissection

• Incise skin and subcutaneous tissue in one layer (no undermining)
• Identify the sural nerve at the posterosuperior corner (1-2cm posterior to fibula)
• Protect it with a vessel loop or gentle retraction
• Raise the flap - skin, subcutaneous tissue and fat as a single unit
• Elevate off the peroneal tendons in the avascular plane

Do not create subcutaneous pockets: the flap survives only if it is raised thick and as one layer.

Step 2Deep Dissection

• Identify the peroneal tendons in their sheath posteriorly and retract them posteroinferiorly (the sheath need not be opened)
• Incise periosteum along the superior border of the calcaneus
• Elevate periosteum and remaining soft tissue off the lateral wall as a single sleeve
• Dissect subperiosteally from the calcaneocuboid joint anteriorly to the posterior tuberosity
• Leave periosteum on the bone - it is needed for healing

The exposure is complete when the entire lateral wall lies open, anterior process to posterior tuberosity.

Step 3Fragment Visualisation

• The lateral wall is typically one large blowout fragment
• Distract it laterally and inferiorly with a lamina spreader
• Remove haematoma and small loose fragments, preserving the large ones
• Irrigate the fracture
• Identify the sustentaculum fragment medially, still attached to the talus

The goal of the exposure is a clear view of the posterior facet, because reduction is judged by eye as well as by image.

Sural Nerve Protection

The sural nerve crosses the posterosuperior corner of the incision and is injured in 5-10% of these approaches. Keep the horizontal limb at least 1cm inferior to the fibular tip, find the nerve early at that corner, and retract it gently rather than stretching it. The result of injury is numbness over the lateral foot and heel - a minor disability that generates major dissatisfaction.

The sinus tarsi approach. A short oblique incision over the sinus tarsi, through which the depressed facet fragments are elevated and held. It cuts the wound-complication rate to under 10%, and the trade is exposure: it is limited to Sanders II.

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Percutaneous screw fixation. For suitable patterns the reduction is made and held through percutaneous access with K-wires and cannulated screws, without an open exposure and without raising a flap.

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The sequence. Height first, then the articular surface, then width, with the sustentaculum as the reference throughout because it has not moved.

Reduction Steps - Key Sequence

Step 1Restore Height

• Axial traction on the foot, an assistant pulling on the forefoot
• A lamina spreader between the lateral wall and the sustentaculum, or a Schanz pin in the posterior tuberosity distracted with a universal distractor
• Elevate the depressed posterior facet fragments with a dental pick or elevator
• Restore height towards pre-injury, judged against the CT or the other side

Fluoroscopy check: on the lateral view the Bohler angle should approach 20-30 degrees.

Step 2Reduce the Posterior Facet

• Visualise the fracture lines on the facet and reduce fragments sequentially, starting with the largest (a Sanders IIB is the easiest of them)
• Reduce each one to the sustentaculum, not to its neighbour
• Hold each with a 1.6mm K-wire as it is reduced
• Check congruity by direct vision and by image
• Accept nothing over a 2mm step-off

Fluoroscopy: Broden views (oblique 30-40 degrees) show the posterior facet reduction.

Step 3Restore Width

• Compress the lateral wall fragment medially with large pointed reduction clamps, lateral to medial
• Match the width to the contralateral heel on the axial view
• Do not over-compress: that produces varus

Step 4Provisional Fixation

• 2.0mm K-wires from the lateral wall across the major fracture lines
• Typically 2-3 wires holding the facet fragments to the sustentaculum, plus one from the posterior tuberosity into the body
• Re-check every fluoroscopic view once the wires are in, and re-reduce if a step-off over 2mm remains
• Leave the wires until the plate is on, or the reduction will be lost

Bohler Angle Restoration

The radiographic goal is a Bohler angle of 20-30 degrees, with over 20 degrees the minimum acceptable. Failure to get it above 15 degrees predicts a poor functional outcome.

The plate holds what the wires hold. An anatomically contoured lateral calcaneal locking plate (7-9 holes), low profile to limit prominence, taking both locking and non-locking screws, long enough to span the calcaneocuboid joint to the posterior tuberosity.

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Plating Steps

Step 1Plate Positioning

• The plate sits on the lateral wall cortex, centred on the posterior facet
• Posterior end 5mm from the Achilles insertion, to avoid prominence
• Anterior end at or just past the calcaneocuboid joint
• Superior border just below the level of the subtalar joint
• Hold it with a K-wire or plate-holding forceps and check on image that it will not irritate the peroneal tendons posteriorly

Step 2Screw Sequence

The order prevents loss of the reduction you have just achieved:

1. Posterior tuberosity screw (non-locking) - engages the posterior fragment and compresses it to the plate
2. Anterior screw (non-locking) - engages the calcaneocuboid area and stabilises the plate
3. Sustentaculum screws (locking, 40-50mm) - from lateral, through the plate, across the fracture into the sustentaculum
4. Superior screws (locking, 35-45mm) - engage the superior cortex and support the posterior facet
5. Fill the remaining holes with locking screws as needed

Remove the K-wires once the screws are in, confirming the reduction has held.

Step 3Verification

• Lateral: Bohler angle over 20 degrees, screw position, no screw in the joint
• Axial: width restored, the sustentaculum screws visibly engaging medial bone
• Broden oblique: posterior facet step-off under 2mm
• Stress the fixation gently: there should be no movement at the fracture

If the reduction or the fixation is inadequate, take the screws out and do it again now, not at a second operation.

Sustentaculum Screws - The Key to Fixation

The screws that run from the lateral plate across the fracture into the sustentaculum are the fixation; without purchase in that medial fragment the construct fails. On the axial view the sustentaculum appears as the medial shelf, and the screws - typically 2-3, 40-50mm, locking - should be seen entering it.

The drain. A drain reduces haematoma and tension under the flap and may lower the infection risk, but it is also a portal for infection and a second wound. A small closed suction drain for 24-48 hours is reasonable if there is significant oozing; remove it when the output falls under 30ml per 24 hours.

Closure, layer by layer. There are no deep sutures - the fracture site communicates with the surface - so the dermis is closed with 3-0 absorbable (Monocryl) simple interrupted sutures under as little tension as possible, and the skin with 3-0 or 4-0 nylon or prolene as vertical mattress or simple interrupted stitches 5-8mm apart. The edges should meet without blanching. Avoid a running subcuticular closure: it hides early dehiscence, which is the one complication you want to see the day it starts.

The dressing. Adhesive skin strips (Steri-Strips) over the incision, non-adherent gauze (Xeroform or Adaptic), fluffed gauze padding around the heel, a soft roll (Webril or Soffban) wrap, and a short leg plaster or fibreglass backslab (U-slab). Elevate the leg on pillows immediately. Nothing circumferential and tight, which risks compartment syndrome.

Wound Dehiscence Prevention

Dehiscence is the complication that defines this approach, and the prevention is the whole of this list: operate only on a positive wrinkle test, raise the flap full-thickness with no undermining, handle tissue without crushing it in forceps, keep cautery away from the skin edges, close without tension, and elevate for a minimum of 5 days afterwards. If it dehisces: local wound care, consider negative pressure therapy, and delayed closure or a skin graft if needed.

Calcaneal Malunion: Classification and Salvage

Malunion is the characteristic late consequence of a displaced fracture healed in a deformed position (more common after non-operative care, and after failed/lost ORIF). The deformity is multiplanar and its components drive distinct symptoms:

• Loss of calcaneal height → the talus settles into a more horizontal ("flat-top"/declined) position, causing anterior ankle impingement and loss of ankle dorsiflexion.
• Heel widening with a lateral wall exostosis → subfibular and peroneal impingement (lateral hindfoot pain, peroneal tendon irritation or subluxation).
• Hindfoot malalignment (usually varus, occasionally valgus).
• Post-traumatic subtalar arthritis.

Stephens-Sanders CT classification of calcaneal malunion matches the salvage to the deformity:

• Type I - lateral wall exostosis with subfibular/peroneal impingement, without significant subtalar arthritis → lateral wall exostectomy (± peroneal tenolysis).
• Type II - lateral exostosis plus subtalar arthritis, with acceptable overall alignment → exostectomy plus in-situ subtalar arthrodesis.
• Type III - the above plus hindfoot malalignment and loss of height → exostectomy plus corrective subtalar arthrodesis, using a distraction bone-block (interposition) subtalar arthrodesis to restore lost height, with a calcaneal osteotomy (e.g. Dwyer for fixed varus) to correct alignment.

The distraction bone-block subtalar arthrodesis interposes a tricortical graft in the distracted subtalar joint to restore talar declination - this is what relieves the anterior ankle impingement and recovers dorsiflexion that a simple in-situ fusion leaves behind. The high-risk group for needing this late fusion (presenting Bohler angle under 0 degrees, Sanders IV, heavy-labour Workers'-Compensation males, initial non-operative treatment) is exactly that defined in the Csizy and Buckley data. (See the dedicated subtalar arthrodesis and malunion topics for fusion technique and general malunion principles.)

The bone is cancellous and slow. Non-weight bearing for a minimum of 6 weeks is not negotiable after fixation: weight before then risks losing the reduction and the fixation with it. Partial weight bearing starts at 6 weeks only if the radiograph shows early healing, with the fracture lines beginning to blur, and progression is deliberately slow - aggressive loading brings swelling, pain and secondary displacement. Many patients take 12-16 weeks to reach comfortable full weight bearing, which is worth saying out loud at the first consultation.

What predicts the result. The Sanders type predicts the outcome whatever the treatment. Age, occupation and compensation status then decide what the same hindfoot means to the patient in front of you, and the two measurements the surgeon controls are the step-off and the Bohler angle.

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