The calcaneus is the most commonly fractured tarsal bone, accounting for 1–2% of all fractures, and is most often caused by axial loading from a fall from height or high-energy trauma such as motor vehicle accidents. [1-2] These fractures predominantly affect younger, working-age men and carry significant long-term morbidity, with patients potentially incapacitated for up to three years. [2]
1. History
- Mechanism: Fall from height (most common), motor vehicle accident, crush injury, or high-impact landing. Ask about the height of fall and landing surface [2]
- Symptom characterization: Severe heel pain, inability to bear weight, diffuse rearfoot pain (intra-articular) vs. focal pain (extra-articular) [3]
- Timing: Acute onset at time of injury; stress fractures present with gradual onset after increased weight-bearing activity [4-5]
- Associated symptoms: Swelling, inability to ambulate, numbness/tingling in the plantar foot (compartment syndrome concern)
- Important negatives: Back pain (rule out concomitant lumbar spine fracture), bilateral heel pain (8% are bilateral), contralateral extremity pain [2][6]
2. Alarm Features
- Skin tenting or blanching over the posterior heel — tongue-type and tuberosity fractures can cause full-thickness skin necrosis within hours if not reduced emergently [7]
- Open fracture (2–3% of calcaneal fractures) — requires emergent irrigation, debridement, IV antibiotics, and tetanus prophylaxis [2][8]
- Compartment syndrome of the foot — tense swelling, severe pain out of proportion, pain with passive toe extension; occurs in up to 10% of calcaneal fractures [1][9]
- Neurovascular compromise — diminished pulses, sensory deficits, pallor
- Bilateral calcaneal fractures — high suspicion for associated spinal fracture [6]
- Sanders type IV fractures are the strongest predictor of compartment syndrome (OR 21.67) [10]
3. Medications
- Acute pain management: NSAIDs, acetaminophen, opioids for severe pain; multimodal analgesia preferred
- Nerve blocks: Posterior tibial nerve block or ankle block for ED pain control
- DVT prophylaxis: Consider LMWH given prolonged non-weight-bearing status
- Antibiotics: Required for open fractures — typically a first-generation cephalosporin ± aminoglycoside for Gustilo type III [8]
- Cautions: Avoid anticoagulants acutely if surgery anticipated; NSAIDs may theoretically impair bone healing (controversial)
4. Diet
- Calcium and vitamin D supplementation to support bone healing
- Adequate protein intake for fracture recovery
- Nutritional assessment is important in stress fractures — screen for relative energy deficiency in sport (RED-S) in athletes, particularly those with oligomenorrhea/amenorrhea [4]
- Smoking cessation — smoking is a significant risk factor for wound complications and nonunion
5. Review of Systems
- MSK: Back pain (lumbar spine fracture), bilateral heel pain, knee/hip pain from associated injuries
- Neurologic: Numbness/tingling in the foot (compartment syndrome, nerve injury), lower extremity weakness (spinal cord injury)
- Vascular: Coolness, pallor, diminished pulses
- Psychiatric: Screen for suicidal ideation if fall from height was intentional; calcaneal fractures are associated with preexisting mental health conditions [4]
- GU/GI: Urinary retention, bowel/bladder dysfunction (if spinal injury suspected)
6. Collateral History and Family History
- Circumstances of fall: Intentional vs. accidental; workplace injury; height of fall
- Witnesses: Mechanism confirmation, loss of consciousness
- Occupational history: Manual labor, construction work — significant implications for return to work and disability [2]
- Family history: Osteoporosis, metabolic bone disease
- Social context: Workers' compensation, substance use (alcohol intoxication at time of fall)
7. Risk Factors
- Falls from height (most common mechanism) [1-2]
- Young working-age males — highest incidence [2]
- Motor vehicle accidents and crush injuries [8]
- Osteoporosis — increases fracture risk with lower-energy mechanisms
- Smoking — increases wound complication rates and impairs healing [11]
- Diabetes and peripheral vascular disease — poor soft tissue healing, higher complication rates
- Athletes — stress fractures from repetitive loading, especially with RED-S [4]
8. Differential Diagnosis
- Calcaneal stress fracture — gradual onset, positive squeeze test, may require MRI for diagnosis [4-5]
- Subtalar dislocation — similar mechanism, deformity pattern differs
- Talus fracture — axial loading mechanism, tenderness more dorsal
- Plantar fascia rupture — acute arch pain, may mimic calcaneal fracture on exam [3]
- Achilles tendon rupture — posterior heel pain, positive Thompson test
- Lisfranc injury — midfoot pain/swelling, can coexist with calcaneal fracture
- Retrocalcaneal bursitis — posterior heel pain without trauma history
- Calcaneal apophysitis (Sever disease) — in adolescents, posterior heel pain
9. Past Medical History
- Previous calcaneal or foot fractures
- Osteoporosis/osteopenia — affects fracture pattern and healing
- Diabetes mellitus — wound healing concerns, neuropathy may mask symptoms
- Peripheral vascular disease — relative contraindication to extensile surgical approaches [12]
- Smoking history — significantly increases surgical complication rates
- Prior foot/ankle surgery
- Mental health history — relevant if mechanism involves intentional fall
10. Physical Exam
- Inspection: Significant heel swelling, ecchymosis along the heel and arch (pathognomonic), skin blistering, widened heel, loss of heel height, skin tenting posteriorly [1-2]
- Palpation: Diffuse tenderness of the calcaneus; positive calcaneal squeeze test (medial-lateral compression) [3-4]
- Neurovascular exam: Dorsalis pedis and posterior tibial pulses, capillary refill, sensation in all nerve distributions (sural, tibial, deep peroneal)
- Compartment assessment: Tense plantar swelling, pain with passive toe dorsiflexion, firmness of foot compartments
- Functional: Inability to bear weight, inability to perform single-leg hop [4]
- Spine exam: Palpate entire spine for tenderness — mandatory given association with lumbar fractures [6][13]
- Contralateral heel: Examine for bilateral injury (8% bilateral) [2]
11. Lab Studies
- Routine labs are generally not required for isolated calcaneal fractures
- CBC, BMP, coagulation studies — if surgical intervention planned or polytrauma
- Lactate — if concern for compartment syndrome or significant polytrauma
- Vitamin D, calcium — consider in stress fractures or suspected metabolic bone disease
- Urine pregnancy test — in women of childbearing age before imaging
- Blood alcohol level/urine drug screen — if mechanism suggests intoxication
12. Imaging
- First-line: Lateral, AP, and Harris axial view radiographs of the foot/heel [1]
- Böhler's angle (normal 25–40°): Measured on lateral radiograph; an angle ≤20° is highly accurate for diagnosing calcaneal fracture (sensitivity 99%, specificity 99%) [14-15]
- Angle of Gissane (normal 120–145°): Less reliable than Böhler's angle in the ED [16]
- CT scan: Gold standard for fracture characterization — determines extent, displacement, comminution, intra-articular involvement, and Sanders classification [17-18]
- MRI: Preferred for stress fractures, especially within the first few weeks when radiographs may be negative [4]
- Lumbar spine imaging: Obtain in all calcaneal fractures from falls — concomitant vertebral fractures occur in ~7–22% of cases, predominantly lumbar [6][11]
13. Special Tests
- Sanders Classification (CT-based, most widely used for intra-articular fractures): [18-19]
- Type I: Nondisplaced (<2 mm), regardless of number of fracture lines
- Type II: Two-part fracture of the posterior facet (subtypes A, B, C based on location)
- Type III: Three-part fracture of the posterior facet
- Type IV: Comminuted, ≥4 fragments — worst prognosis, highest compartment syndrome risk [10]
- Essex-Lopresti Classification (radiograph-based): Tongue-type vs. joint-depression type [20]
- Calcaneal squeeze test: Medial-lateral compression of the calcaneus — positive = pain [3-4]
- Single-leg hop test: Inability to perform suggests fracture vs. stress reaction [4]
- Compartment pressure measurement: Stryker device; pressures >30 mmHg or within 30 mmHg of diastolic pressure warrant fasciotomy [21-22]
14. ECG
- Not routinely indicated for isolated calcaneal fractures
- Obtain if:
- Polytrauma or fall from significant height with hemodynamic instability
- Preoperative evaluation in patients with cardiac risk factors
- Syncope or cardiac event suspected as cause of the fall
15. Assessment
- Extra-articular fractures (~25–30%): Generally less severe, managed conservatively [2][19]
- Intra-articular fractures (~65–75%): Involve the posterior facet of the subtalar joint; treatment is more complex and controversial [2][19]
- Severity stratification: Sanders classification correlates with prognosis — higher types predict worse outcomes and greater risk of post-traumatic arthritis [23]
- Atypical presentations: Stress fractures may present with insidious heel pain without clear trauma; bilateral fractures may distract from spinal injuries
- Complications: Compartment syndrome (up to 10%), post-traumatic subtalar arthritis, chronic pain, malunion, wound complications (especially with ORIF), claw toe deformity from missed compartment syndrome [1][9][24]
- A negative Böhler's angle (<0°) is associated with significantly higher complication rates [11]
16. Treatment Plan
Initial stabilization (ED)
- Elevation, ice, compression (Jones dressing or bulky splint)
- Tongue-type and tuberosity fractures: Splint in plantarflexion to relieve skin tenting — emergent orthopedic consultation if skin compromise is present [7]
- All other fractures: Posterior splint in neutral position
- Strict non-weight-bearing with crutches
- Multimodal analgesia
Nonsurgical management (nondisplaced, extra-articular, <25% calcaneal cuboid joint involvement): [1]
- Short leg non-weight-bearing cast or boot for 4–6 weeks
- Early subtalar range-of-motion exercises when pain allows
- Progressive weight-bearing after 6 weeks
Surgical management (displaced intra-articular fractures): [2][25-26]
- ORIF via extensile lateral approach or sinus tarsi (minimally invasive) approach — trend toward minimally invasive techniques to reduce wound complications
- Surgery typically delayed 7–14 days until soft tissue swelling subsides (wrinkle test positive)
- Operative treatment yields better anatomical reduction (Böhler's angle restoration) and slightly better functional outcomes, but carries higher wound complication rates [25][27]
- The UK HeFT trial found no significant functional difference between ORIF and nonoperative treatment at 2 and 5 years for typical displaced intra-articular fractures, with more complications in the surgical group [12][28]
- Subtalar arthrodesis: Reserved for severe comminution (Sanders IV) or post-traumatic arthritis [2]
Compartment syndrome: Emergent fasciotomy if diagnosed [9][29]
17. Disposition
Admission criteria
- Open fractures
- Compartment syndrome or concern for evolving compartment syndrome
- Tongue-type/tuberosity fractures with skin compromise requiring emergent reduction
- Polytrauma or associated spinal injuries
- Bilateral calcaneal fractures (non-ambulatory)
- Planned urgent/emergent surgical intervention
Discharge criteria
- Closed, nondisplaced extra-articular fractures without skin compromise
- Adequate pain control, able to use crutches safely
- Reliable follow-up arranged within 1 week with orthopedics
- No signs of compartment syndrome
Specialist consultation triggers
- All intra-articular fractures → orthopedic surgery
- Comminuted, displaced (>2 mm), or >25% calcaneal cuboid joint involvement [1]
- Skin compromise, open fracture, or compartment syndrome → emergent orthopedics
- Nonunion after 6 weeks [1]
18. Follow Up / Return Precautions
Follow-up timing
- Orthopedic follow-up within 5–7 days for all calcaneal fractures
- Repeat radiographs every 2–4 weeks to monitor alignment [1]
- CT at follow-up if surgical planning needed
- Nonsurgical patients: reassess at 6 weeks for union and transition to weight-bearing
Return precautions (patient counseling)
- Return immediately for: increasing pain, numbness/tingling in toes, toes turning white/blue, inability to move toes, worsening swelling, skin breakdown over the heel, fever
- Cast/splint care: keep dry, do not insert objects, report any foul odor
- Strict non-weight-bearing compliance is critical
Expected recovery
- Non-weight-bearing for minimum 6 weeks regardless of treatment approach [2]
- Full recovery may take 6–12 months; some patients experience residual pain and stiffness for years [2]
- Return to work is often delayed, especially in manual laborers — operative treatment may improve return-to-work rates (91% vs. 72% in one study) [26]
- Long-term complications include subtalar arthritis, chronic heel pain, difficulty with shoe wear, and heel widening
References
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2. Surgical Versus Non-Surgical Interventions for Displaced Intra-Articular Calcaneal Fractures. — Lewis SR, Pritchard MW, Solomon JL, Griffin XL, Bruce J. The Cochrane Database of Systematic Reviews. 2023.
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10. Predictors of Compartment Syndrome of the Foot After Fracture of the Calcaneus. — Park YH, Lee JW, Hong JY, Choi GW, Kim HJ. The Bone & Joint Journal. 2018.
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23. Correlation of Fracture Energy With Sanders Classification and Post-Traumatic Osteoarthritis After Displaced Intra-Articular Calcaneus Fractures. — Rao K, Dibbern K, Day M, et al. Journal of Orthopaedic Trauma. 2019.
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25. Surgical Treatment of Calcaneal Fractures by Minimally Invasive Technique Using a 2-Point Distractor Versus ORIF and Conservative Therapy-a Retrospective Multicenter Study. — Nia A, Hajdu S, Sarahrudi K, et al. Journal of Clinical Medicine. 2025.
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