Calcaneal fracture

Changed by Calum Worsley, 7 Feb 2022

Back to revision history

Updates to Article Attributes

Body was changed:

Show markup changes

Calcaneal fractures are the most common tarsal fracture and can occur in a variety of settings.

Epidemiology

The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures ² and ~60% of all tarsal fractures ³.

Pathology

Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint ^2,7,8:

extra-articular: 25-30%
- anterior calcaneal process fracture
- calcaneal tuberosity avulsion fracture
- extra-articular body fracture
  - lover's fracture
- medial sustentaculum
intra-articular: 70-75%
- intra-articular body fracture

The calcaneus is also a common site of stress fractures, occurring in the posterosuperior aspect.

Another method of classification is as

type A fractures: the anterior process of the calcaneus is fractured
type B: fracture of the mid calcaneus, trochlear process, and sustentaculum tali
type C: fracture of the posterior tuberosity

Radiographic features

Plain radiograph

~~Böhler's angle~~
Calcaneal fractures are best assessed with a calcaneal series~~is the angle between two tangent lines drawn across the anterior and posterior borders~~ of ~~the calcaneus in the lateral view. When Böhler's angle becomes <20º it indicates a calcaneal fracture. On~~radiographs, though are often identified on a lateral ankle radiograph~~, an angle~~ if the presentation does not lead the requesting of ~~Gissane~~ ~~of >130° suggests depression of the posterior facet of the subtalar joint.~~
~~normal~~calcaneal views specifically. The Böhler~~'s angle~~ ~~does not exclude a fracture~~ and ~~is unreliable in children~~ ⁹
Gissane angles are used to assess the severity of calcaneal ~~stress fracture shows vertical linear sclerotic~~fractures, and their postoperative appearance is correlated with functional outcomes ⁹¹²

CT

CT is the modality of choice to evaluate calcaneal fracture. It can show the extent and extra- or intra-articular components of the fracture and haematoma along the sole of the foot (Mondor sign). Intra-articular fractures are often classified using the Sander classification system, which is one of the only systems that correlate well with patient outcome.

Practical points

If bilateral calcaneal fractures are seen, then the spine should also be evaluated for fracture as the mechanism of injury is often a large load to the axial skeleton, such as ~~jumping~~a fall from ~~a second-story window~~height.

If an ~~intraarticular~~intra-articular calcaneal fracture is seen, the images should be scrutinized for a lateral malleolar fleck sign (ankle), which raises the likelihood of peroneal tendon instability ¹⁰.

~~-</ul><h4>Radiographic features</h4><h5>Plain radiograph</h5><ul>~~
~~-<li>~~
-<a href="/articles/bohler-angle-2">Böhler's angle </a>is the angle between two tangent lines drawn across the anterior and posterior borders of the calcaneus in the lateral view. When Böhler's angle becomes <20º it indicates a calcaneal fracture. On a lateral radiograph, an angle of <a href="/articles/gissane-angle">Gissane </a>of >130° suggests depression of the posterior facet of the subtalar joint.</li>
~~-<li>normal <a href="/articles/bohler-angle-2">Böhler's angle</a> does not exclude a fracture and is unreliable in children <sup>9</sup>~~
~~-</li>~~
~~-<li>calcaneal stress fracture shows vertical linear sclerotic appearance <sup>9</sup>~~
~~-</li>~~
-</ul><h5>CT</h5><p>CT is the modality of choice to evaluate calcaneal fracture. It can show the extent and extra- or intra-articular components of the fracture and haematoma along the sole of the foot (<a href="/articles/mondor-sign-foot">Mondor sign</a>). Intra-articular fractures are often classified using the <a href="/articles/sanders-ct-classification-of-calcaneal-fracture-2">Sander classification</a> system, which is one of the only systems that correlate well with patient outcome.</p><h4>Practical points</h4><p>If bilateral calcaneal fractures are seen, then the spine should also be evaluated for fracture as the mechanism of injury is often a large load to the axial skeleton, such as jumping from a second-story window.</p><p>If an intraarticular calcaneal fracture is seen, the images should be scrutinized for a lateral malleolar <a href="/articles/fleck-sign-ankle">fleck sign (ankle)</a>, which raises the likelihood of peroneal tendon instability <sup>10</sup>.</p>
+</ul><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>Calcaneal fractures are best assessed with a <a href="/articles/calcaneus-series">calcaneal series</a> of radiographs, though are often identified on a lateral ankle radiograph if the presentation does not lead the requesting of calcaneal views specifically. The <a href="/articles/bohler-angle-2">Böhler</a> and <a href="/articles/gissane-angle">Gissane</a> angles are used to assess the severity of calcaneal fractures, and their postoperative appearance is correlated with functional outcomes <sup>12</sup>.</p><h5><strong>CT</strong></h5><p>CT is the modality of choice to evaluate calcaneal fracture. It can show the extent and extra- or intra-articular components of the fracture and haematoma along the sole of the foot (<a href="/articles/mondor-sign-foot">Mondor sign</a>). Intra-articular fractures are often classified using the <a href="/articles/sanders-ct-classification-of-calcaneal-fracture-2">Sander classification</a> system, which is one of the only systems that correlate well with patient outcome.</p><h4>Practical points</h4><p>If bilateral calcaneal fractures are seen, then the spine should also be evaluated for fracture as the mechanism of injury is often a large load to the axial skeleton, such as a fall from height.</p><p>If an intra-articular calcaneal fracture is seen, the images should be scrutinized for a lateral malleolar <a href="/articles/fleck-sign-ankle">fleck sign (ankle)</a>, which raises the likelihood of peroneal tendon instability <sup>10</sup>.</p>

References changed:

1. Borut Marincek, Robert F. Dondelinger. Emergency Radiology. (2006) ISBN: 9783540262275 - <a href="http://books.google.com/books?vid=ISBN9783540262275">Google Books</a>
2. Daftary A, Haims A, Baumgaertner M. Fractures of the Calcaneus: A Review with Emphasis on CT. Radiographics. 2005;25(5):1215-26. <a href="https://doi.org/10.1148/rg.255045713">doi:10.1148/rg.255045713</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/16160107">Pubmed</a>
3. Badillo K, Pacheco J, Padua S, Gomez A, Colon E, Vidal J. Multidetector CT Evaluation of Calcaneal Fractures. Radiographics. 2011;31(1):81-92. <a href="https://doi.org/10.1148/rg.311105036">doi:10.1148/rg.311105036</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21257934">Pubmed</a>
4. Heger L, Wulff K, Seddiqi M. Computed Tomography of Calcaneal Fractures. AJR Am J Roentgenol. 1985;145(1):131-7. <a href="https://doi.org/10.2214/ajr.145.1.131">doi:10.2214/ajr.145.1.131</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/3873833">Pubmed</a>
5. Matherne T, Tivorsak T, Monu J. Calcaneal Fractures: What the Surgeon Needs to Know. Curr Probl Diagn Radiol. 2007;36(1):1-10. <a href="https://doi.org/10.1067/j.cpradiol.2006.07.006">doi:10.1067/j.cpradiol.2006.07.006</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/17198887">Pubmed</a>
6. Wechsler R, Schweitzer M, Karasick D, Deely D, Morrison W. Helical CT of Calcaneal Fractures: Technique and Imaging Features. Skeletal Radiol. 1998;27(1):1-6. <a href="https://doi.org/10.1007/s002560050325">doi:10.1007/s002560050325</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/9507601">Pubmed</a>
7. Bruce D. Browner. Skeletal Trauma. (2009) ISBN: 9781416022206 - <a href="http://books.google.com/books?vid=ISBN9781416022206">Google Books</a>
8. Jacob Mandell. Core Radiology. (2013) ISBN: 9781107679689 - <a href="http://books.google.com/books?vid=ISBN9781107679689">Google Books</a>
9. Lee A. Grant, Nyree Griffin. Grainger & Allison's Diagnostic Radiology Essentials E-Book. (2018) ISBN: 9780323568845 - <a href="http://books.google.com/books?vid=ISBN9780323568845">Google Books</a>
10. Mahmoud K, Mekhaimar M, Alhammoud A. Prevalence of Peroneal Tendon Instability in Calcaneus Fractures: A Systematic Review and Meta-Analysis. J Foot Ankle Surg. 2018;57(3):572-8. <a href="https://doi.org/10.1053/j.jfas.2017.11.032">doi:10.1053/j.jfas.2017.11.032</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29548632">Pubmed</a>
11. Yu S & Yu J. Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis. AJR Am J Roentgenol. 2015;205(5):1061-7. <a href="https://doi.org/10.2214/AJR.14.14190">doi:10.2214/AJR.14.14190</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/26496554">Pubmed</a>
12. Su Y, Chen W, Zhang T, Wu X, Wu Z, Zhang Y. Bohler's Angle's Role in Assessing the Injury Severity and Functional Outcome of Internal Fixation for Displaced Intra-Articular Calcaneal Fractures: A Retrospective Study. BMC Surg. 2013;13(1):40. <a href="https://doi.org/10.1186/1471-2482-13-40">doi:10.1186/1471-2482-13-40</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24330592">Pubmed</a>
1. Marinček B, Dondelinger RF. Emergency radiology, imaging and intervention. Springer Verlag. (2007) ISBN:354026227X. <a href="http://books.google.com/books?vid=ISBN354026227X">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/354026227X?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=354026227X">Find it at Amazon</a><div class="ref_v2"></div>
2. Daftary A, Haims AH, Baumgaertner MR. Fractures of the calcaneus: a review with emphasis on CT. Radiographics. 25 (5): 1215-26. <a href="http://dx.doi.org/10.1148/rg.255045713">doi:10.1148/rg.255045713</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/16160107">Pubmed citation</a><div class="ref_v2"></div>
3. Badillo K, Pacheco JA, Padua SO et-al. Multidetector CT evaluation of calcaneal fractures. Radiographics. 31 (1): 81-92. <a href="http://dx.doi.org/10.1148/rg.311105036">doi:10.1148/rg.311105036</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/21257934">Pubmed citation</a><div class="ref_v2"></div>
4. Heger L, Wulff K, Seddiqi MS. Computed tomography of calcaneal fractures. AJR Am J Roentgenol. 1985;145 (1): 131-7. <a href="http://www.ajronline.org/content/145/1/131.abstract">AJR Am J Roentgenol (abstract)</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/3873833">Pubmed citation</a><div class="ref_v2"></div>
5. Matherne TH, Tivorsak T, Monu JU. Calcaneal fractures: what the surgeon needs to know. Curr Probl Diagn Radiol. 36 (1): 1-10. <a href="http://dx.doi.org/10.1067/j.cpradiol.2006.07.006">doi:10.1067/j.cpradiol.2006.07.006</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/17198887">Pubmed citation</a><div class="ref_v2"></div>
6. Wechsler RJ, Schweitzer ME, Karasick D et-al. Helical CT of calcaneal fractures: technique and imaging features. Skeletal Radiol. 1998;27 (1): 1-6. - <a href="http://www.ncbi.nlm.nih.gov/pubmed/9507601">Pubmed citation</a><div class="ref_v2"></div>
7. Levine AM, Jupiter JB et-al. Skeletal Trauma. Saunders. (2009) ISBN:1416022201. <a href="http://books.google.com/books?vid=ISBN1416022201">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/1416022201">Find it at Amazon</a><span class="ref_v3"></span>
8. Mandell J. Core Radiology. Cambridge University Press. (2013) ISBN:1107679680. <a href="http://books.google.com/books?vid=ISBN1107679680">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/1107679680">Find it at Amazon</a><span class="auto"></span>
9. Lee A Grant, Nyree Griffin. Grainger & Allison's Diagnostic Radiology Essentials. (2018) ISBN: 9780323568845
10. Mahmoud K, Mekhaimar MM, Alhammoud A. Prevalence of Peroneal Tendon Instability in Calcaneus Fractures: A Systematic Review and Meta-Analysis. (2018) The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. 57 (3): 572-578. <a href="https://doi.org/10.1053/j.jfas.2017.11.032">doi:10.1053/j.jfas.2017.11.032</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29548632">Pubmed</a> <span class="ref_v4"></span>
11. Sarah M. Yu, Joseph S. Yu. Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis. (2015) American Journal of Roentgenology. <a href="https://doi.org/10.2214/AJR.14.14190">doi:10.2214/AJR.14.14190</a> <span class="ref_v4"></span>

ADVERTISEMENT: Supporters see fewer/no ads

{"current_user":null,"inclusions":[{"imageId":566052,"studyId":11633,"caseSlug":"calcaneal-fracture-2","caption":"Case 1: intra-articular fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/566052/9736309a423f5377677d769b62a1a2d5641ca68918d34f78799a47a22dcbac76_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":266499,"studyId":9336,"caseSlug":"lover-s-fracture-of-the-heel","caption":"Case 2: extra-articular fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/266499/7e78b4347f53078e3724796dd0581b_big_gallery.jpg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":841,"studyId":37529,"caseSlug":"calcaneal-tuberosity-avulsion-fracture-1","caption":"Case 3: tuberosity avulsion fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/841/3ae1e22ddc6dcb21a1ff176875cca9_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":24595129,"studyId":51988,"caseSlug":"anterior-calcaneal-process-fracture","caption":"Case 4: anterior process fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/24595129/6c98a29b038da4739ba4d7667c4cf2_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":3324849,"studyId":22890,"caseSlug":"calcaneal-fracture-10","caption":"Case 5: axial projection","thumbnail":"https://prod-images-static.radiopaedia.org/images/3324849/88c3968197072cf4f4cc78265c5304_big_gallery.jpg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":4828769,"studyId":25484,"caseSlug":"fractured-calcaneus-2","caption":"Case 6: body fracture (MRI)","thumbnail":"https://prod-images-static.radiopaedia.org/images/4828769/e47e07ecdc5151e6ace66b5fc8d0e9_big_gallery.jpg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":12546311,"studyId":36481,"caseSlug":"calcaneal-stress-fracture-2","caption":"Case 7: stress","thumbnail":"https://prod-images-static.radiopaedia.org/images/12546311/e7b48280ff2326e5d11c3cd758fa483280af7b045be2c165cc6bd20604e65536_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":28924745,"studyId":57339,"caseSlug":"calcaneal-anterior-process-fracture","caption":"Case 8: calcaneal anterior process fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/28924745/2741242ae313af1767b03cfe2fb250_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":29979278,"studyId":58788,"caseSlug":"extra-articular-calcaneal-fracture","caption":"Case 9: extra-articular calcaneal fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/29979278/82f14eccbc98aca59b303ab171ddcd3bef952d361bbfe6cd61c2581520bf6a27_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":35649062,"studyId":65249,"caseSlug":"anterior-process-of-calcaneum-fracture","caption":"Case 10: anterior process fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/35649062/52b91d2a2c83d3955320f97fb2997a40fcb322cf3c234904dcfcd15fef3d825b_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":26394,"studyId":7890,"caseSlug":"lovers-fracture-15","caption":"Case 11: intra-articular","thumbnail":"https://prod-images-static.radiopaedia.org/images/26394/6ecf3ae371918e71be2c33dd9dd0412fc8a1e6c9ec5d520118f763b2733ab720_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52104664,"studyId":85611,"caseSlug":"anterior-calcaneal-process-fracture-3","caption":"Case 12: anterior calcaneal process fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/52104664/33cf44340968173307fe7b2eda3189_big_gallery.jpeg","isStack":true,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":52663230,"studyId":89876,"caseSlug":"diffuse-axonal-haemorrhage-grade-iii","caption":"Case 13: comminuted fracture","thumbnail":"https://prod-images-static.radiopaedia.org/images/52663230/6295faaadb531051811f64e25ee26f_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_unsubstantiated"},{"imageId":53185246,"studyId":93825,"caseSlug":"fracture-of-the-anterior-process-of-the-calcaneum-on-lateral-ankle-radiograph","caption":"Case 14: anterior process","thumbnail":"https://prod-images-static.radiopaedia.org/images/53185246/6a45b98596a1cb0ec2974ac66e2332_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":55650845,"studyId":109791,"caseSlug":"calcaneal-fracture-21","caption":"Case 15","thumbnail":"https://prod-images-static.radiopaedia.org/images/55650845/110002_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"},{"imageId":59435752,"studyId":125607,"caseSlug":"intra-articular-calcaneal-fracture-1","caption":"Case 16: intra articular","thumbnail":"https://prod-images-static.radiopaedia.org/images/59435752/6eb8cb5e9db853adfa2a465fb34d6ec4d5c403b8013d6018b49726eed1871e77_big_gallery.jpeg","isStack":false,"diagnosticCertainty":"confirmed_substantiated"}],"ddx_inclusions":[],"lang":"us"}