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Calcaneal fracture

71 citationsUpdated Sep 2026

Overview

Calcaneal fractures are challenging injuries to manage, characterized by high complication rates and poor outcomes regardless of the treatment modality employed [3]. Intra-articular fractures lead to a fair to poor functional outcome in the majority of patients, whereas extra-articular fractures, which account for one-third of all calcaneal fractures, demonstrate a better functional outcome [1, 5]. Patients sustaining these injuries report a significantly lower health-related quality of life than the Dutch reference population and suffer from chronic disability [6]. While conservative treatment can produce satisfactory outcomes with lower morbidity than surgically treated fractures [19], good midterm outcomes in terms of functional outcome and quality of life are observed following surgical fixation [18].

Indications for surgical management remain controversial, depending on fracture pattern, patient demographics, and surgeon experience [8]. There is still no evidence that open reduction and internal fixation (ORIF) results in better outcomes than conservative therapy [11], and the conclusion that there is no significant outcome difference between the two cannot be supported from available data due to inadequate study design and size [15]. Consequently, patients should be consented that ORIF for displaced intraarticular calcaneal fractures is still experimental [21]. Surgical management of displaced intra-articular fractures carries a very high complication rate and should not be recommended when literature suggests only marginally better outcomes [42]. Wound complications following operative fixation remain a problem [9], although high-risk patients meeting criteria for surgical management can be managed with percutaneous techniques with low risk of wound complications [20].

Alternative approaches include the minimally invasive technique of closed reduction and percutaneous Kirschner wire fixation, which showed comparable results with a low rate of serious complications and is a viable alternative for intraarticular, dislocated fractures [43]. Calcaneoplasty appears to be a valid option and a reliable alternative to ORIF [63]. In children, operative treatment of severe calcaneal fractures can give an early return to normal anatomy and function [14]. The adverse sequelae assumed to be associated with starting partial weightbearing within six weeks after internal fixation are not supported by literature data [10]. Socio-demographic factors influence the utilization of surgical treatment in the US patient population [13], and there has been a significant increase in the number of calcaneal fractures being treated surgically using less invasive procedures in England between 2000 and 2017 [16]. Selection bias in the UK Heel Fracture Trial prevents firm conclusions that surgery is unjustified for most intra-articular calcaneal fractures; the correct conclusion is that surgery benefits do not outweigh risks only in the specific subset of patients who did not care about treatment choice and were offered only an extended lateral approach or nothing [65]. The axial view should not be used routinely in assessing a patient with a possible calcaneal fracture [12].

Anatomy & Pathophysiology

Bony Anatomy

The calcaneus is the largest tarsal bone in the foot [81]. It is irregularly shaped, possessing six posterior and four anterior facets [81]. Three of these facets articulate with the talus, while one articulates with the cuboid [81]. The posterior facet is oval and convex along the longitudinal axis, articulating with the underside of the talus [81]. The middle facet is concave and oval, articulating with the middle facet on the head of the talus [81]. The sinus tarsi and the floor of the tarsal canal separate the posterior facet from the anterior and middle facets [81]. The sustentaculum tali projects from the medial side of the calcaneus and forms the lateral boundary of the tarsal tunnel [81]. The inferior surface of the sustentaculum tali is grooved by the tendon of the flexor hallucis longus [81]. The shape of the talus and calcaneus, especially the arrangement of trabeculae within the calcaneus, are essential factors for calcaneal fractures [32].

Radiographic Angles

The Bohler angle is formed by a line from the superior point on the posterior articular surface to the superior point of the calcaneal tuberosity and a line from the anterior process to the highest aspect of the posterior articular surface [81]. In a mature patient, the Bohler angle varies from 25 to 40 degrees [81]. It serves as a relative measurement of the degree of compression and deformity in calcaneal fractures [81]. The "crucial angle" of Gissane is formed by a line drawn from the sulcus calcanei to the tip of the anterior process [81]. This angle varies between 120 and 145 degrees [81].

Mechanism of Injury

The mechanism of injury in most calcaneal fractures is an axial load applied to the lower extremity, most often as a result of a fall from a height [81]. The force is transmitted through the talus, which is driven down into the calcaneus, resulting in fracture [81]. With a calcaneal fracture, the talus compresses onto the crucial angle and produces the primary fracture line in older patients [81]. In young children, the height fallen for calcaneal fractures is usually less than 4 feet [81]. In children older than 10 years, the fall height for calcaneal fractures is usually greater than 14 feet [81]. Motor vehicle accidents, lawnmower injuries, and a direct blow from an object can also result in calcaneal fractures in children [81].

Pathophysiology & Biomechanics

The normal biomechanics of the ankle-hindfoot are severely disrupted by abnormal calcaneus morphology [77]. Reestablishment of the geometric parameters of the calcaneus can restore the relative positions of the three superior calcaneal facets [77]. This restoration can minimize subtalar pain associated with the development of arthrosis and stiffness [77]. A prerequisite for a well-functioning foot is the restoration of an essentially normal contour to the arch and heel and restoration of normal malleolar height [112]. The mean heel pad thickness on the fractured side was 17.4 mm compared to 16.1 mm on the uninjured side [36]. Essex-Lopresti subtypes strongly influence clinical and gait outcomes following calcaneal fractures [31]. The severity of a displaced intra-articular calcaneal fracture (DIACF) is related to subsequent foot function and quality of life [40]. The morphology of calcaneal fractures in adolescents is similar to those in adults, though less comminuted [22].

Classification

Imaging and Assessment: Computed tomography is an absolute necessity for the comprehensive assessment of calcaneal fracture patterns, accurate classification, and treatment planning [25]. The addition of three-dimensional CT imaging did not increase inter- and intra-observer reliability for the classification of calcaneal fractures [60]. A deep-learning algorithm coupled with data augmentation provides a feasible and efficient approach to the use of a computer-aided system in assisting physicians in evaluating calcaneal fracture types [58].

Anatomical Factors: The shape of the talus and calcaneus and the architecture within the calcaneus, especially the arrangement of the trabeculae, are essential factors for calcaneal fractures [32]. The morphology of calcaneal fractures in adolescents was found to be similar to those in adults, though less comminuted [22].

Other Considerations: The severity of a displaced intra-articular calcaneal fracture is related to subsequent foot function and quality of life [40]. High-grade displaced intraarticular calcaneal fractures (Sanders IV) had worse functional results irrespective of the type of operation [115]. The severity of the initial calcaneocuboid joint injury and subsequent arthritic changes do not correlate with clinical outcome in displaced intra-articular calcaneal fractures involving the calcaneocuboid joint [64].

Clinical Presentation

Patients who sustain a calcaneal fracture experience chronic disability and a significantly lower health-related quality of life compared to the Dutch reference population [6]. The prognosis of these fractures is unrelated to three-dimensional factors, including patient age, gender, length, width, height, volume of the calcaneus, area of the posterior joint, and number of fracture fragments [29].

Red-Flag Patterns

Clinicians must maintain a high index of suspicion for specific injury patterns. The association of a swollen hindfoot, talar tilt, and a flake fracture of the lateral malleolus must alert clinicians to a calcaneal injury [17]. The combination of ipsilateral talar and calcaneal fractures represents a severe injury pattern associated with significant morbidity [30]. Additionally, up to 60% of subtalar dislocations have associated fractures [44].

Delayed diagnosis of stress fractures in the foot and ankle can lead to protracted pain, disability, non-union, and the need for operative intervention [38].

Investigations

CT: Computed tomography is essential for characterizing the extent of talocalcaneal coalition, particularly for operative planning [56]. In pediatric patients with a symptomatic hindfoot, CT may identify talocalcaneal coalition earlier than other methods [93]. Following reduction of a subtalar dislocation, obtaining a CT scan is emphasized because patients often have additional abnormalities identified on CT that are initially missed on plain radiographs [92]. Analysis of CT images demonstrated a 28% prevalence of peroneal tendon displacement accompanying intraarticular calcaneal fractures [117]. However, the reliability of CT scan interpretation for calcaneal fractures was found to be unsatisfactory [69]. In one ORIF series, incongruencies in the posterior calcaneal facet were detected in 12 cases (25.5%), despite seemingly correct reduction as judged fluoroscopically, necessitating repeated reduction [119].

MRI: MRI may be helpful in depicting all types of talocalcaneal coalitions, including fibrous coalitions [56].

Other Considerations: A scoring protocol for the radiological evaluation of operatively treated calcaneal fractures is reliable in terms of inter- and intra-rater reliability [47]. A proposed deep-learning algorithm coupled with data augmentation provides a feasible and efficient approach to the use of a computer-aided system in assisting physicians in evaluating calcaneal fracture types [58]. Intra-articular calcaneal fractures lead to a fair to poor functional outcome in the majority of patients, while extra-articular fractures show a better functional outcome [1]. By selecting the most relevant variables to be assessed, an effective calcaneal fracture scoring system can be based on as few as four categories of questions [2]. The association of a swollen hindfoot, talar tilt and a flake fracture of the lateral malleolus must alert clinicians to this injury [17]. The combination of ipsilateral talar and calcaneal fractures represents a severe injury pattern that is associated with significant morbidity [30].

Treatment

General Principles and Outcomes

Patients with calcaneal fractures experience significantly lower health-related quality of life and chronic disability compared to the Dutch reference population [6]. The association of a swollen hindfoot, talar tilt, and a flake fracture of the lateral malleolus must alert clinicians to a primarily calcaneal fracture rather than an ankle injury [17]. Goals common to all treatment types include restoration of congruity of the posterior facet of the subtalar joint, restoration of calcaneal height (Böhler’s angle), reduction of calcaneal width, decompression of the subfibular space for peroneal tendons, realignment of the tuberosity into a valgus position, and reduction of the calcaneocuboid joint if fractured [103]. There has been a significant increase in the number of calcaneal fractures treated surgically using less invasive procedures [16].

Non-Operative

A 15-year follow-up of a randomised controlled trial for displaced intra-articular calcaneal fractures demonstrated equivalent results between conservative and operative treatment, with findings similar to those at one year [4]. Although conservative treatment is recommended in the literature for severe calcaneal fractures in children, operative treatment can provide an early return to normal anatomy and function [14]. Patients with isolated anterolateral calcaneal dislocations, even with multiple associated fractures, can achieve acceptable outcomes if the injury is urgently diagnosed and properly managed [33].

Operative

Indications: Selection bias in the UK Heel Fracture Trial prevents firm conclusions that surgery is unjustified for most intra-articular calcaneal fractures; the correct conclusion is that surgical benefits do not outweigh risks only in the specific subset of patients who did not care about treatment choice and were offered only an extended lateral approach or nothing [65]. A majority of displaced intraarticular dislocated calcaneal fractures profit from open reduction and stable fixation, which yields more consistent functional results than conservative treatment [118]. Patients with clear indications for open reduction and internal fixation benefit from this procedure using individually tailored approaches, implants, and fixation techniques [111]. Consideration for operative intervention to restore calcaneal height, alignment, and articular reduction should be strongly considered in young patients [103]. Open reduction appears to be an acceptable method of treatment for displaced calcaneal fractures in elderly patients [106]. Minimally invasive osteosynthesis techniques, when used appropriately, can result in functional recovery [7].

Contraindications: Nonoperative treatment is advised in patients with severe osteopenia, limited ambulatory abilities, and significant medical comorbidities [103]. An insensate limb caused by trauma (sciatic or tibial nerve disruption) or disease (diabetes or other neuropathy) is a strong relative contraindication to open treatment [103]. Tobacco use increases complication rates with operative intervention; however, some surgeons consider this only a contraindication to an extensile lateral approach and favor less invasive techniques in this setting [103]. Active infection and noncompliance are contraindications to the use of internal fixation for subtalar fusion after displaced intra-articular calcaneal fractures [107].

Fracture Pattern Specifics: Sanders type I or nondisplaced fractures should be treated by a closed method [103]. Type II and type III fractures can be treated with open reduction in consideration with other patient characteristics [103]. Type IV fractures can be treated conservatively or operatively [103]. Long-term studies indicate that type IV injuries are more likely to progress to subtalar arthrodesis in the future [103]. In type IV fractures, consideration should be given to minimally invasive techniques to restore calcaneal architecture for later subtalar arthrodesis or primary subtalar arthrodesis in experienced hands [103]. Sanders types III and IV fractures sustain a significantly higher amount of energy than lesser types [103]. A Sanders type IV is the best predictor of compartment syndrome after a fracture of the calcaneus [103]. Higher Sanders types III and IV injuries have poorer outcomes than Sanders types I and II injuries with both operative and nonoperative interventions [103].

Surgical Approach / Technique: In patients with Sanders type 2 calcaneal fractures, the sinus tarsi approach resulted in fewer wound complications and equivalent, if not superior, clinical outcomes compared with the extensile lateral approach [41]. The final clinical and radiographic outcomes between the sinus tarsi approach and the extensile lateral approach for Sanders type-II and type-III intra-articular calcaneal fractures were comparable and equally successful [96]. Lateral calcaneal apical wound issues are minimised and patients experience an overall low complication rate when using threaded K-wire fixation for displaced intra-articular calcaneal fractures [35]. Percutaneous distractional reduction and fixation appears to be a safe technique with overall good results and an acceptable complication rate, compared with other treatment modalities for displaced intra-articular calcaneal fractures [94]. Super-cutaneous fixation with percutaneous reduction of calcaneal fracture is an effective method in type II and III and can be effective with type IV but with less favorable results [101]. Emergency surgery using the sinus tarsi approach with a modified reduction technique is reliable, effective, and safe for treatment of calcaneal fractures [104]. Despite poor prognostic indicators, early aggressive soft tissue treatment followed by minimally invasive reduction and stabilization with an Ilizarov frame is a relatively safe treatment option for open calcaneal fractures [98].

Implant Selection: The Calcanail device demonstrates either equivalent stiffness than plates in all testing modes under 2000 N [23].

Adjuncts: Robot-assisted minimally invasive treatment is effective for calcaneal fractures, providing precise reduction, faster recovery, and minimal complications [91].

Post-Operative Management: The adverse sequelae which are assumed to be associated with starting partial weightbearing already within six weeks after internal fixation of calcaneal fractures is not supported by literature data [10].

Complications

Wound complications: Surgical management of displaced intra-articular calcaneal fractures carries a very high complication rate [42]. The sinus tarsi approach results in fewer wound complications compared with the extensile lateral approach in patients with Sanders type 2 fractures [41]. Percutaneous surgical techniques for high-risk patients with intra-articular calcaneus fractures present a low risk of wound complications [20]. Lateral calcaneal apical wound issues are minimised when using threaded K-wire fixation for displaced intra-articular calcaneal fractures [35]. A personalized medial incision integrated with a sinus-tarsi approach minimizes soft tissue complications in older adults with calcaneal fractures [24].

Infection: Delay prior to calcaneal fracture surgery is not associated with a lower infection rate [39]. Surgical experience is an important factor influencing infection rates after calcaneal fracture fixation [39]. In experienced hands, surgical timing may not affect postoperative infection rates in strictly selected patients without potential risk factors for wound complication [62].

Other Considerations: Patients treated with threaded K-wire fixation for displaced intra-articular calcaneal fractures experience an overall low complication rate [35]. The minimally invasive technique for dislocated calcaneal fractures shows a low rate of serious complications [43]. The combination of ipsilateral talar and calcaneal fractures is associated with significant morbidity [30]. Patients who sustained a calcaneal fracture suffer from a chronic disability [6]. Surgically treated intra-articular calcaneal fractures demonstrate only an average clinical outcome and clear pathological gait patterns characterized by a lateralization of the gait line [61].

Recovery

Functional Outcomes and Quality of Life: Anatomic reconstruction of the calcaneus is associated with improved long-term clinical results [66]. An effective calcaneal fracture scoring system can be based on as few as four categories of questions [2].

Comparative Treatment Outcomes: The results of a 15-year follow-up of a displaced intra-articular calcaneal fracture randomised controlled trial were equivalent between conservative and operative treatment [4]. The 15-year follow-up findings for displaced intra-articular calcaneal fractures demonstrate similar findings to those at one year follow-up [4].

Prognostic Factors: Several socio-demographic factors influence the utilization of surgical treatment of calcaneus fractures in the US patient population [13]. Surgeon experience is a particularly relevant influencing variable for the outcome of calcaneal fractures treated with locking compression plates [45]. Experienced surgeons achieve significantly better clinical scores and shorter operation times for calcaneal fractures treated with locking compression plates [45]. Surgical experience is important for the treatment of calcaneal fractures, and these difficult fractures should be treated in specialised centres [39].

Complications and Wound Issues: Postoperative wound infection leads to lower functional outcome scores following calcaneal fracture surgery, though statistical significance was not reached [109]. In experienced hands, surgical timing may not affect postoperative infection rates in calcaneal fracture among strictly selected patients who do not have potential risk factors for wound complication [62]. Complications following the extended lateral approach for calcaneal fractures do not influence mid- to long-term outcome [66]. Patients experience an overall low complication rate when using threaded K-wire fixation for displaced intra-articular calcaneal fractures [35].

Key Evidence

  • [L3] Intra-articular calcaneal fractures lead to a fair to poor functional outcome in the majority of patients, while extra-articular fractures show a better functional outcome. [1] (10.3389/fsurg.2021.620964)
  • [L4] By selecting the most relevant variables to be assessed, an effective calcaneal fracture scoring system can be based on as few as four categories of questions. [2] (10.1016/0020-1383(95)00165-4)
  • [L5] Calcaneus fractures remain challenging injuries to manage because of high complication rates and poor outcomes regardless of treatment modality. [3] (10.5435/jaaos-d-24-00567)
  • [L1] The results of this 15-year follow-up of displaced intra-articular calcaneal fracture randomised controlled trial were equivalent between conservative and operative treatment and demonstrate similar findings to those at one year follow-up. [4] (10.1016/j.injury.2007.01.003)
  • [L4] One-third of all calcaneal fractures are extra-articular. [5] (10.1007/s00402-007-0517-2)
  • [L2] This study demonstrates that patients who sustained a calcaneal fracture have a significantly lower HRQoL than the Dutch reference population and suffer from a chronic disability. [6] (10.1016/j.injury.2016.04.008)
  • [L5] In their experience, this technique can, when used appropriately, result in a functional recovery of the patient suffering a calcaneal fracture. [7] (10.1016/s0020-1383(01)00061-4)
  • [L4] Wound complications following operative fixation of calcaneal fractures remain a problem. [9] (10.1016/s0020-1383(00)00026-7)
  • [L1] The adverse sequelae which are assumed to be associated with starting partial weightbearing already within six weeks after internal fixation of calcaneal fractures, is not supported by literature data. [10] (10.1016/j.injury.2018.02.021)
  • [L4] There is still no evidence that open reduction and internal fixation of calcaneal fractures results in better outcomes than conservative therapy. [11] (10.1007/s00264-015-3042-x)
  • [L4] We suggest that the axial view should not be used routinely in assessing a patient with a possible calcaneal fracture. [12] (10.1016/s0020-1383(99)00303-4)
  • [L3] Besides different clinical variables, several socio-demographic factors influence the utilization of surgical treatment of calcaneus fractures in the US patient population. [13] (10.1186/s13018-019-1402-8)
  • [L4] Although conservative treatment of severe calcaneal fractures in children is recommended in the literature, the authors suggest that operative treatment of a severe calcaneal fracture can give an early return to normal anatomy and function. [14] (10.1007/s004020050326)
  • [L5] The conclusion that there is no significant outcome difference between conservative and surgical treatment of calcaneal fractures cannot be supported from the data presented due to inadequate study design and size. [15] (10.1016/j.injury.2004.11.014)
  • [L4] There has been a significant increase in the number of calcaneal fractures being treated surgically using less invasive procedures. [16] (10.1302/0301-620x.101b2.bjj-2018-0289.r3)
  • [L4] The association of a swollen hindfoot, talar tilt and a flake fracture of the lateral malleolus must alert clinicians to this injury. [17] (10.1016/0020-1383(93)90200-p)
  • [L4] Good midterm outcomes in terms of functional outcome and quality of life are observed following surgical fixation of calcaneal fractures. [18] (10.1016/j.injury.2017.08.027)
  • [L3] This study has found that the conservative treatment of calcaneal fractures can produce satisfactory outcomes with lower morbidity than surgically treated fractures. [19] (10.1016/s0020-1383(03)00025-1)
  • [L4] High-risk patients with intra-articular calcaneus fractures that meet the criteria for surgical management can be managed with percutaneous surgical techniques with low risk of wound complications. [20] (10.1016/j.injury.2013.01.033)
  • [L1] Patients should be consented that ORIF for displaced intraarticular calcaneal fractures is still experimental. [21] (10.1016/s0020-1383(01)00053-5)
  • [L4] The morphology of calcaneal fractures in adolescents was found to be similar to those in adults, though less comminuted. [22] (10.1016/s0020-1383(02)00366-2)
  • [Paper] The Calcanail device demonstrates either equivalent stiffness than plates in all testing modes under 2000 N. [23] (10.1016/s0020-1383(12)70007-4)
  • [L4] A personalized medial incision based on fracture morphology provides better exposure and reduction compared to traditional methods, and its integration with a sinus-tarsi approach minimizes soft tissue complications. [24] (10.1186/s13018-025-05934-6)
  • [L5] Computed tomography is an absolute necessity for comprehensive assessment of calcaneal fracture patterns, accurate classification, and treatment planning. [25] (10.2106/00004623-199072060-00027)
  • [L3] The prognosis of calcaneal fractures is unrelated to three-dimensional factors such as patient age, gender, length, width, height, volume of the calcaneus, area of the posterior joint, and number of fracture fragments. [29] (10.1186/s13018-024-04975-7)
  • [Paper] The combination of ipsilateral talar and calcaneal fractures represents a severe injury pattern that is associated with significant morbidity. [30] (10.1016/j.injury.2008.07.016)
  • [L3] Essex-Lopresti subtypes strongly influence clinical and gait outcomes following calcaneal fractures. [31] (10.1186/s13018-025-06533-1)
  • [L4] The shape of the talus and calcaneus and the architecture within the calcaneus, especially the arrangement of the trabeculae, are essential factors for calcaneal fractures. [32] (10.1186/s13018-022-02930-y)
  • [Case_report] Patients with isolated anterolateral calcaneal dislocations, even with multiple associated fractures, can have acceptable outcomes, if it is urgently diagnosed and properly managed. [33] (10.1186/s12891-022-05506-3)
  • [L4] Lateral calcaneal apical wound issues are minimised and patients experience an overall low complication rate. [35] (10.1016/j.injury.2009.03.017)
  • [L4] The mean heel pad thickness on the fractured side was 17.4 mm compared to 16.1 mm on the uninjured side. [36] (10.1016/0020-1383(94)90182-1)
  • [L5] This article outlines the epidemiology, aetiology, presentation, and management of stress fractures in the foot and ankle to improve awareness, as delayed diagnosis can lead to protracted pain, disability, non-union, and the need for operative intervention. [38] (10.1016/j.injury.2015.06.015)
  • [Paper] Delay prior to calcaneal fracture surgery is not associated with a lower infection rate, but surgical experience is important, and these difficult fractures should be treated in specialised centres. [39] (10.1016/j.injury.2009.03.044)
  • [L4] We found the severity of a DIACF related to subsequent foot function and quality of life. [40] (10.1007/s11999-013-3062-z)
  • [L1] In patients with Sanders type 2 calcaneal fractures, the STA resulted in fewer wound complications and equivalent, if not superior, clinical outcomes compared with the ELA. [41] (10.2106/jbjs.21.00684)
  • [L5] Surgical management of displaced intra-articular calcaneal fractures has a very high complication rate and should not be recommended when literature suggests only marginally better outcomes. [42] (10.5435/00124635-200405000-00005)
  • [L4] The minimally invasive technique showed comparable results with a low rate of serious complications and is a viable alternative for the treatment of intraarticular, dislocated calcaneal fractures. [43] (10.1007/s00402-008-0590-1)
  • [L4] Up to 60% of these injuries have associated fractures. [44] (10.5435/jaaosglobal-d-21-00295)
  • [L3] Surgeon experience is a particularly relevant influencing variable for the outcome of calcaneal fractures treated with locking compression plates, with experienced surgeons achieving significantly better clinical scores and shorter operation times. [45] (10.1007/s00402-020-03649-3)
  • [L4] The scoring protocol for the radiological evaluation of operatively treated calcaneal fractures is reliable in terms of inter- and intra-rater reliability. [47] (10.1007/s00402-017-2744-5)
  • [L5] The proposed deep-learning algorithm coupled with data augmentation provides a feasible and efficient approach to the use of computer-aided system in assisting physicians in evaluating calcaneal fracture types. [58] (10.1016/j.injury.2020.09.010)
  • [L4] The addition of three-dimensional CT imaging did not increase inter- and intra-observer reliability for the classification of calcaneal fractures. [60] (10.1016/j.injury.2014.01.022)
  • [L4] The study found only an average clinical outcome and clear pathological gait patterns in the cohort, characterized by a lateralization of the gait line. [61] (10.1007/s00402-012-1655-8)
  • [L3] In experienced hands, surgical timing may not affect postoperative infection rates in calcaneal fracture among strictly selected patients who do not have potential risk factors for wound complication. [62] (10.1016/j.injury.2013.03.014)
  • [L4] Calcaneoplasty appears to be a valid option of treatment for calcaneal fractures and a reliable alternative to ORIF. [63] (10.1016/j.injury.2018.09.047)
  • [L3] The severity of the initial calcaneocuboid joint injury and subsequent arthritic changes do not correlate with clinical outcome. [64] (10.1016/j.injury.2008.10.021)
  • [L5] The paper argues that selection bias in the UK Heel Fracture Trial prevents firm conclusions that surgery is unjustified for most intra-articular calcaneal fractures, and that the correct conclusion is that surgery benefits do not outweigh risks only in the specific subset of patients who did not care about treatment choice and were offered only an extended lateral approach or nothing. [65] (10.1302/0301-620x.97b7.35305)
  • [L4] Anatomic reconstruction of the calcaneus was associated with improved long-term clinical results. [66] (10.1016/j.injury.2013.06.014)
  • [L4] The reliability of the interpretation of CT scans for calcaneal fractures was found to be unsatisfactory. [69] (10.1007/s00402-011-1312-7)
  • [Paper] The normal biomechanics of the ankle-hindfoot were severely disrupted by the abnormal calcaneus morphology, and reestablishment of the geometric parameters of the calcaneus could restore the relative positions of the 3 superior calcaneal facets and minimize subtalar pain associated with the development of arthrosis and stiffness. [77] (10.1016/j.otsr.2017.05.013)
  • [L5] Robot-assisted minimally invasive treatment is effective for calcaneal fractures, providing precise reduction, faster recovery, and minimal complications. [91] (10.1186/s12891-026-09807-9)
  • [Paper] Percutaneous distractional reduction and fixation appears to be a safe technique with overall good results and an acceptable complication rate, compared with other treatment modalities for displaced intra-articular calcaneal fractures. [94] (10.1007/s00402-009-0915-8)
  • [L3] The final clinical and radiographic outcomes between the two approaches for Sanders type-II and type-III intra-articular calcaneal fractures were comparable and equally successful. [96] (10.1186/s12891-015-0519-0)
  • [L4] Despite poor prognostic indicators, early aggressive soft tissue treatment followed by minimally invasive reduction and stabilization with an Ilizarov frame is a relatively safe treatment option for open calcaneal fractures. [98] (10.1016/j.injury.2005.08.024)
  • [L4] Super-cutaneous fixation with percutaneous reduction of calcaneal fracture is an effective method in type II and III and can be effective with type IV but with less favorable results. [101] (10.1016/j.injury.2017.01.014)
  • [L4] Emergency surgery using STA with modified reduction technique is reliable, effective, and safe for treatment of calcaneal fractures. [104] (10.1186/s12891-023-06636-y)
  • [L4] Open reduction appears to be an acceptable method of treatment for displaced calcaneal fractures in elderly patients. [106] (10.2106/jbjs.d.01765)
  • [L4] [107] (10.2106/jbjs.i.01267)
  • [L3] Postoperative wound infection leads to lower functional outcome scores following calcaneal fracture surgery, though statistical significance was not reached. [109] (10.1007/s00402-015-2219-5)
  • [Paper] Patients with clear indications for ORIF benefit from this procedure using individually tailored approaches, implants, and fixation techniques. [111] (10.1016/j.injury.2004.07.011)
  • [L4] A prerequisite for a well functioning foot is the restoration of an essentially normal contour to the arch and heel and restoration of normal malleolar height. [112] (10.2106/00004623-196345040-00023)
  • [L3] High-grade displaced intraarticular calcaneal fractures (Sanders IV) had worse functional results irrespective of the type of operation. [115] (10.1016/j.injury.2015.10.061)
  • [L3] Analysis of CT images showed a 28% prevalence of peroneal tendon displacement accompanying intraarticular calcaneal fractures. [117] (10.2106/jbjs.l.01378)
  • [L4] This report confirms that a majority of displaced intraarticular dislocated calcaneal fractures do profit from open reduction and stable fixation, which seems to give more consistent functional results than conservative treatment. [118] (10.1016/s0020-1383(98)80213-1)
  • [L4] In 12 cases (25.5%) of the ORIF series, despite seemingly correct reduction as judged fluoroscopically, incongruencies in the posterior calcaneal facet were detected and reduction was repeated. [119] (10.1016/s0020-1383(01)00077-8)

See Also

References

[1] Patient-Reported Outcome Following Operative and Conservative Treatment of Calcaneal Fractures: A Retrospective Analysis of 79 Patients at Short- to Midterm Follow-Up. Frontiers in Surgery. 2021. DOI: 10.3389/fsurg.2021.620964

[2] Assessing outcome following calcaneal fracture: a rational scoring system. Injury. 1996. DOI: 10.1016/0020-1383(95)00165-4

[3] Calcaneus Fractures: A Review of Management, Treatment, and Recent Advances. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00567

[4] Displaced intra-articular calcaneal fractures: 15-Year follow-up of a randomised controlled trial of conservative versus operative treatment. Injury. 2007. DOI: 10.1016/j.injury.2007.01.003

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