Definition: Fracture of the calcaneus bone


  • Traumatic axial loading is the most common cause (eg fall from height)
  • Can also occur in MVCs when the accelerator/brake pedal impacts the foot
  • Stress fractures seen with overuse from repetitive impact (e.g. runners)


  • 2% of all fractures
  • Most frequently fractured tarsal bone
  • 90% occur in men between 21 and 45 years of age with majority being industrial workers
  • Approximately 10% are open fractures (Egol 2010)
The Calcaneus (

The Calcaneus (

Ecchymosis after Calcaneus Fracture (

Ecchymosis after Calcaneus Fracture (

Physical Exam

  • Moderate to severe heel tenderness
  • Swelling
  • Shortened wide heel with varus deformity
  • Ecchymosis around heel extending to arch is highly suggestive, may also see fracture blisters
  • Compartment syndrome occurs in 10% of calcaneal fractures and can result in clawing of the toes after recovery (Egol 2010)
  • Concomitant Achilles tendon rupture may be present

Calcaneus Fracture Classification (See Images in Gallery Below)

  • Extra-articular (subtalar joint)
    • 25% of all calcaneus fractures
    • Avulsion injury of:
      • Anterior process by bifurcate ligament
      • Sustenaculum tali
      • Calcaneal tuberosity (Achilles tendon avulsion)
  • calcaneus-bone-radiopaedia-orgIntra-articular
    • 75% of calcaneus fractures
    • 2 classification systems
      • Essex-Lopresti Classification
        • The primary fracture line runs obliquely through the posterior facet forming two fragments.
        • The secondary fracture line runs in one of two planes:
          • “Tongue-Type” Fracture
            • Axial plane beneath the posterior facet exiting posteriorly
            • This fracture tends to cause tension on the skin with possible necrosis. Consider an emergent orthopedics consult for all patients with this pattern (Snoap 2017)
          • Behind the posterior facet in joint depression fractures
      • Sanders (based on CT)- based on number and location of articular fragments seen on the coronal CT image at the widest point of the posterior facet (E)
        • Type I: all nondisplaced fractures
        • Type II: two-part fractures of the posterior facet
        • Type II: three-part fractures with centrally-depressed fragment
        • Type IV: four-part articular fractures
Sanders Classification (

Sanders Classification (

Bohler Angle (

Bohler Angle (

Diagnostic Imaging

  • Standard X-rays: AP, lateral, oblique foot
  • Optional X-rays (See Image Gallery below)
    • Broden views: allows visualization of posterior facet
    • Harris View: visualizes tuberosity fragment widening, shortening, and varus positioning
    • AP ankle: demonstrates fibular impingement if lateral wall extrusion is present
  • Findings in calcaneal fractures:
  • Reduced Bohler angle
    • Created with lines drawn tangiental to anterior and posterior aspects of superior calcaneus
    • Normal is 20-40 degrees
  • Increased angle of Gissane
    • Formed by downward and upward slopes of calcaneus
    • Normal is 95-105 degrees
  • Non-contrast CT
    • Obtain when clinical suspicion of a fracture is high despite negative x-rays
    • Gold standard imaging test for any calcaneal fracture (except for stress fractures)
    • Will almost always be obtained for pre-operative planning but does not necessarily need to be obtained in the ED
Angle of Gissane (

Angle of Gissane (

Associated Injuries

  • Vertebral injuries secondary to axial loading injury (10%)
  • Contralateral calcaneal injury (10%) (Hatch)

ED Management

  • Provide analgesia
  • Complete neurovascular exam
  • Consider compartment syndrome
  • Can initially be placed in Bulky Jones dressing with supportive posterior splint to provide flexion
  • Conservative therapy (casting + nonweightbearing)
    • Casting and nonweightbearing for 6 weeks for calcaneal stress fractures
    • Casting and nonweightbearing for 10-12 weeks if:
      • Small extra-articular fracture (<1 cm) with intact Achilles tendon and <2 mm displacement
      • Sanders Type I (nondisplaced)
      • Anterior process fracture involving <25% of calcaneocuboid joint
      • Comorbidities that preclude good surgical outcome (smoker, diabetes, PVD)
  • All other fractures require surgical intervention

Prognosis: Relatively poor with overall 40% complication rate (malunion, subtalar arthritis, clawing of toes)

Take Home Points

  • Always suspect calcaneus fractures in patients with axial loading injuries to the lower extremities. If a calcaneus injury is found, look for concomitant fractures of the ankle and vertebrae.
  • Patients with calcaneal fractures will always be nonweightbearing on ED discharge
  • Watch out for compartment syndrome of the foot which occurs in 10% of calcaneal fractures and results in significant morbidity

Read More

Ortho Bullets: Calcaneus Fractures


  • Barrie J. (2013) Calcaneal fractures. [East Lancashire Foot and Ankle Hyperbook]. Link
  • Egol KA et al. Handbook of Fractures 4th ed. Lipincott 2010: 507-519.
  • Gitajn IL et al. Anatomic alignment and integrity of the sustenaculum tali in intra-articular calcaneal fractures. J Bone Joint Surg Am. 2014; 96(12): 1000-1005. PMID: 24951735.
  • Snoap T et al. Calcaneal Fractures: A Possible Musculoskeletal Emergency. J Emerg Med 2017.52 (1), 28-33 PMID: 27658550