AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

A true consensus regarding the management of calcaneus fractures has eluded practitioners for more than 100 years. Historically, opinions on the mechanism of injury, the decision to pursue nonoperative management versus surgical intervention, and the resultant disability caused by these fractures have differed.

Improvements in technology, particularly in the field of CT scanning, have allowed surgeons to carefully select injuries that are particularly amenable to surgical intervention, improving the long-term outcomes in many cases.

Related Medscape topics:
Resource Center Fracture
Specialty Site Orthopaedics
Orthopaedics News

History of the Procedure

Fractures of the calcaneus, or os calcis, have been observed and documented for centuries.¹ Norris correctly described a compression mechanism in calcaneus fractures in 1839, and in 1843, Malgaigne described 2 types of calcaneal fractures; this description formed the first rudimentary classification system.

With the advent of radiographic evaluation, several authors developed classification systems, including Bohler (in 1931), Essex-Lopresti (in 1951-2), Rowe et al (in 1963), and others.^{2, 3, 4, 5} Essex-Lopresti first sought to distinguish intra-articular fractures of the calcaneus from extra-articular ones, and they correctly associated the intra-articular variety with a poorer long-term prognosis.

Problem

Despite the development of these comprehensive classification systems, poor correlation with functional outcomes has hindered their widespread acceptance.^{6, 7, 8} Only with the advent of CT has the capability to evaluate accurately complex calcaneus injuries been realized. Current classification systems based on CT appearances, such as the one Sanders described, appear to provide more reliable indicators of prognosis.^{9, 10, 11, 12}

Despite improvements in imaging, as well as a better understanding of the patterns of injury in complex fractures of the calcaneus, opinions on the management of such injuries differ.^{13, 14} Prospective studies have attempted to show benefit with either early operative intervention or with nonoperative measures.^{15, 16, 17} Each modality has at times enjoyed more attention and enthusiasm in the literature. A frustrating factor that perpetuates this disagreement is the subset of calcaneus fractures with poor long-term outcomes, regardless of the management. Cotton commented in 1916 that "the man who breaks his heel bone is done so far as his industrial future is concerned."¹⁸

Frequency

Calcaneus injuries represent 2% of all fractures seen in adults. The os calcis is the most frequently fractured tarsal bone, accounting for more than 60% of tarsal fractures. Calcaneus fractures are most commonly seen in young men.

Extra-articular fractures account for 30% of all calcaneus fractures in adults. The most common extra-articular fracture is a calcaneal body fracture. Fractures of the anterior process represent 10-15% of extra-articular injuries; these are the only type of calcaneus fractures that are more common in women than in men. Fractures of the superior tuberosity beak or avulsion fractures represent 10% of extra-articular injuries. Sustentaculum tali fractures are rarely seen as isolated injuries.

Intra-articular fractures constitute 70% of all calcaneus fractures in adults.

Calcaneus fractures are rarely encountered as open fractures. Open injuries that have been reported have occurred in only 2% of cases.

Etiology

Nearly all intra-articular fractures of the calcaneus are caused by an axial loading mechanism, which is directed through the laterally situated (in relation to the weight-bearing axis of the lower extremity) plantar tuberosity of the calcaneus. Causes of fractures include the following: fall from height, usually 6 feet or more; motor vehicle collisions; impact on a hard surface while running or jumping; extra-articular fracture of the calcaneal body and plantar tuberosity caused by blunt-force injury; avulsion injuries with abrupt contraction of the Achilles tendon; and overuse injury, or stress fracture, in athletes.

Extra-articular injuries are more likely to occur with a sudden, twisting force applied to the hindfoot than with other mechanisms.

Related Medscape topics:
Resource Center Trauma
Resource Center Exercise and Sports Medicine
CME Calcium Supplementation May Reduce Fracture Risk
CME More Evidence of Increased Fractures With Thiazolidinediones

Related eMedicine topic:
Stress Fractures

Pathophysiology

The mechanism of injury in calcaneus fractures typically involves a high-energy axial load applied to the heel, which drives the talus downward onto the calcaneus. The resultant primary fracture line extends from the lateral aspect of the angle of Gissane in a posteromedial direction, initiating an oblique, primary fracture line. It is from this point that multiple secondary fracture lines may develop. The subtalar joint is involved 75% of the time.

In his work, Essex-Lopresti described 2 calcaneus fracture subtypes: joint-depression and tongue-type fractures. Both of these describe the primary fracture line. In the tongue-type fracture, the secondary fracture line directly extends in a posterior direction, producing a large superior, posterior, and lateral fragment, with the remainder of the calcaneal body forming the inferior fragment. In the more frequent joint-depression fracture, the secondary fracture line begins at the angle of Gissane, extends posteriorly, but deviates dorsally to exit the bone just posterior to the posterior articular facet. This fracture fragment contains most of the posterior facet.

Clinical

History

A history of a fall from height, a motor vehicle accident (particularly with the patient sitting in the front of the vehicle, where contact with the floorboards is more likely), or a similar mechanism should suggest a possible injury to the hindfoot. Patients are more likely to be young male individuals with intra-articular injuries.

Inquire about other areas of injury or pain. The discomfort associated with a fracture of the calcaneus may be so distracting to the patient that other significant injuries are ignored. Compression fractures of the spine are common (seen in 10-15% of cases), as are compression-type injuries to other areas of the bony skeleton, such as the proximal femur.

Document chronic medical conditions such as diabetes, peripheral vascular disease, or malignancy. Ask about prior injuries or surgeries in the affected area. In case of prior injury or surgery, ask about any orthopedic hardware that might be present.

Determine current and recent medication use, and inquire as to social habits such as alcohol and tobacco consumption.

Physical examination

Patients with a fracture of the calcaneus may present with the following: pain, edema, ecchymosis, deformity of the heel or plantar arch, and an inability to bear weight on the injured foot.

Observe all areas for evidence of open injury, particularly areas with overlying lacerations.

Hold the heel of the patient's foot in the palm of the hand, and gently squeeze. Elicited pain suggests calcaneal fracture.

Examine closely for evidence of ecchymosis, particularly that which tracks distally to the sole of the foot. This particular pattern of ecchymosis, known as the Mondor sign, is pathognomonic for calcaneal fracture.

Check for posterior tibial and dorsalis pedis pulses, and compare these to the uninjured side. Ensure that distal capillary refill is 2 seconds or less.

Pay particular attention to the presence of any paresthesia, edema, pallor, diminished pulses, or severe pain with passive flexion of the toes that might suggest compartment syndrome of the foot.

Examine the knee, ankle, and midfoot for tenderness, ecchymosis, or swelling. Radiographs of the knee, ankle, and foot may be indicated if positive findings are noted.

Inspect and palpate other areas at high risk for fracture, such as the medial, lateral, and posterior malleoli, as well as the base of the fifth metatarsal.

As many as 7% of patients with a calcaneus fracture may have fracture of the contralateral heel. Given the appropriate mechanism of injury (ie, a fall from height), care must be taken to examine both lower extremities thoroughly to exclude the presence of bilateral injuries.

Related eMedicine topics:
Compartment Syndrome, Lower Extremity
Peripheral Vascular Disease

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Goals of treatment

The use of nonoperative versus operative interventions for calcaneus fractures is a controversial topic. Treatment goals of operative modalities include the following: (1) restoration of heel height and length, (2) realignment of the posterior facet of the subtalar joint, and (3) restoration of the mechanical axis of the hindfoot.

Treatment guidelines

With these treatment goals in mind, current trends in orthopedics support the following treatment guidelines.^{19, 20}

Extra-articular fractures are generally treated in a closed manner. Exceptions include fractures of the sustentaculum tali with displacement of more than 2 mm, posterior avulsion fractures, and significant fractures of the calcaneal body.

Intra-articular fractures may be treated in a closed fashion, but they are more commonly treated with a combination of open reduction, ostectomy, osteotomy, internal fixation, and/or arthrodesis of the subtalar and calcaneocuboid joints. Nondisplaced (Sanders type I) intra-articular fractures are generally treated closed. Severely comminuted (Sanders type IV) intra-articular fractures may be treated with a combination of open reduction and internal fixation (ORIF) and arthrodesis of the subtalar joint.

Other factors influencing nonoperative versus operative intervention include the patient's age, comorbid health conditions, and any concurrent injuries.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

The calcaneus (os calcis) is the largest of the tarsal bones. The calcaneus has 4 articular facets, allowing it to articulate with the talus superiorly and the cuboid anteriorly. The 3 subtalar facets (anterior, middle, and posterior) must function as a unit, and any fracture that interrupts their alignment is, by definition, an intra-articular fracture. The posterior facet is a major weight-bearing surface, although the anterior and middle facets bear more weight per unit area.

The calcaneal composition has a significant influence on preoperative planning. The body of the calcaneus is composed primarily of cancellous bone, having a comparatively thin cortex. There are, however, several important areas of increased bony density. These areas are particularly amenable to screw placement and include the angle of Gissane, the plantar posterior tubercle, the anterior aspect of the anterior process, and the sustentaculum.

The tibial artery, nerve, posterior tibial tendon, and flexor hallucis longus tendon course along the medial wall of the calcaneus, although they are rarely damaged in calcaneus fractures caused by blunt force. These structures are thought to be shielded by the medial projection of the sustentaculum tali, which is held in place by the medial talocalcaneal interosseous ligaments during fracture of the calcaneus. Laterally, the peroneal tubercle provides a groove for the peroneal tendons (the brevis superiorly, and the longus inferiorly).

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Surgery for calcaneus fractures should be delayed, ideally for 10-14 days, in the presence of significant edema or fracture blister formation.²¹ Exceptions to this rule include open fractures and the presence of a compartment syndrome in the foot, which should prompt immediate surgery for appropriate intervention.²²

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Lab Studies

• The need for preoperative, or screening, laboratory studies usually depends on the extent of other injuries and the presence of comorbid medical conditions.
• Complete blood count determinations, blood typing, coagulation profile evaluation, and ECG are reasonable preoperative studies in calcaneus injuries.
• The need for additional studies should be individualized to the patient and are usually ordered at the discretion of the physician performing the preoperative clearance examination.

Imaging Studies

• Plain radiographs of the foot are indicated for any suspected calcaneus injury. Also, consider imaging the contralateral ankle and foot for comparative purposes. Images should include anteroposterior (AP), lateral, oblique, axial, and Broden views.
• • AP radiographs are needed to evaluate calcaneocuboid joint involvement, talonavicular subluxation, and lateral wall widening. AP views of the ankle are used to assess subfibular impingement as a result of lateral displacement of the lateral wall of the calcaneus.
  • Lateral radiographs of the foot are needed to evaluate the Bohler angle, which is the angle defined by 2 intersecting lines: one drawn from anterior process of the calcaneus to the peak of the posterior articular surface and a second drawn from the peak of the posterior articular surface to the peak of the posterior tuberosity. The average angle is 25-40°. In severe fractures with subtalar joint involvement, this angle may decrease or become negative.
  • Oblique views show the degree of displacement of the primary fracture line and the lesser facets.
  • Axial views depict the primary fracture line, varus malposition, posterior facet stepoff, lateral-wall displacement, and fibular abutment.
  • Broden views of the foot are obtained by internally rotating the leg 45° with the ankle in neutral position. The beam may then be directed toward the lateral malleolus and advanced cephalad at intervals of 10°, 20°, 30°, and 40° to fully evaluate the posterior facet.²³
• CT scans of the calcaneus are helpful in determining the degree of comminution of the posterior facet.
• • CT has revolutionized the diagnosis, treatment, and ability to render accurate prognoses of fractures of the calcaneus.
  • The patient should be positioned on the imaging table with his or her hips and knees flexed. Axial and coronal sectional images are then obtained with a minimum interval of 2 mm.
  • Axial views enable good visualization of the talonavicular and calcaneocuboid joints, the anteroinferior aspect of the posterior facet, the sustentaculum tali, and the lateral calcaneal wall.
  • Coronal views are then oriented perpendicular to the posterior facet. These views are important for distinguishing injury to the posterior facet.
  • CT results also form the basis of many of the current systems for classifying calcaneus fractures. CT-based classifications categorize intra-articular injuries according to the comminution and displacement of the posterior facet.

Other Tests

• Any additional testing is undertaken at the discretion of the physician providing the preoperative clearance.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Medical therapy

Nonoperative treatment of calcaneus fractures requires the cooperation of a multidisciplinary team involving an orthotist, a physical therapist, an occupational therapist, and a surgeon familiar with the pattern of injury involved.

Most extra-articular calcaneus fractures are managed nonoperatively, provided that the injury does not change the weight-bearing surface of the foot and provided that it does not alter hindfoot biomechanics.²⁴ Severely comminuted intra-articular fractures may be managed nonoperatively, particularly when reconstruction is likely to be unsuccessful.²⁵

Closed reduction may be attempted by plantarly displacing both the forefoot and the hindfoot to reverse the mechanism of injury, which allows for elevation of the posterior facet. However, this approach rarely results in a durable maintenance of the reduction.

Many authors recommend short leg casting and no weight bearing for 2 weeks, followed by range-of-motion exercises. Progressive weight bearing should begin at 8 weeks, with full weight bearing by 12 weeks.

Surgical therapy

Multiple surgical approaches are available for treatment of calcaneus fractures, ranging from minimally invasive percutaneous fixation to extensive open techniques. Open techniques may be performed by using medial, lateral, or combined approaches, depending on the extent of injury and the location of the fracture fragments.^{26, 27}

ORIF of a calcaneus fracture is made difficult by the complex anatomy, the presence of soft cancellous bone (which is not amenable to screw fixation), and the high incidence of postoperative wound infection and breakdown.

Most reports suggest that the functional outcome is related to the accuracy of the subtalar joint reduction, the restoration of normal heel morphology, the status regarding subfibular decompression, and the implementation of postoperative measures to decrease swelling.

Related eMedicine topic:
Wound Infection

Preoperative details

Comprehensive physical examination must be undertaken. One should exercise care to avoid overlooking additional injuries of the musculoskeletal system. As previously noted, 10-15% of trauma patients with a fracture of the calcaneus have a concomitant spinal injury.

A full history, including documentation of preexisting medical conditions such as diabetes or vascular disease, should not be unnecessarily delayed.

A multidisciplinary team consisting of the surgeon, the anesthesiologist, and the physician who is providing preoperative clearance should all be involved in planning the procedure (if indicated).

Knowledge of the relevant anatomy is important, as is having clear and comprehensive images of the injury. Thorough imaging allows for careful determination of the surgical approach and for planning of a staged procedure, if necessary.

Intraoperative details

The timing of surgery is an important factor in determining surgical success, as measured by long-term functional outcomes. Ideally, surgery should occur within 3 weeks after injury. This period allows for any swelling and fracture blisters to resolve completely, but the procedure is still sufficiently early to prevent premature healing and coalescence of the fracture fragments. In the absence of fracture blisters, the return of normal skin wrinkling is an indication that significant swelling has resolved and operative intervention may proceed.

Compared with open procedures, closed reduction with percutaneous fixation has a lower risk of wound complications, a shorter operative time, and more rapid healing because the soft tissue is handled less.^{28, 29} This approach is indicated in patients with significant comorbidities, soft-tissue compromise or impaired healing, or true tongue-type fracture patterns. The goals of this approach include improvement of heel alignment and reduction of the posterior facet. Unfortunately, the limited exposure that this technique affords sometimes prevents adequate reduction and fixation of the calcaneal injury. If anatomic joint reduction is sought, ORIF may be a preferred option.

Calcaneal ORIF has improved as a result of enhanced preoperative evaluation with CT scanning. Enhancements in equipment and surgical technique, particularly in the area of soft-tissue handling, have also improved its surgical success rates. Another exciting development is the use of subtalar arthroscopy (as Rammelt et al described) for accurate evaluation of the posterior facet after the initial reduction is performed.³⁰

The most popular incision for exposure during ORIF of calcaneus fractures is an extensile lateral approach.²⁶ This approach allows the surgeon to visualize the entire fracture. It also allows for complete reduction from the tuberosity to the anterior process and the calcaneocuboid joint. In addition, this approach permits indirect reduction of the medial wall and the sustentaculum. The extensile lateral approach should include a full-thickness skin flap. Gentle tissue handling is a must, and adequate wound closure is equally important. Flap closure that avoids excessive tension on the skin is critical to prevent skin necrosis.³¹ The use of thin plates in calcaneal fixation has significantly addressed the issue of excessive skin tension, hardware prominence, and subsequent wound breakdown.

Postoperative details

A small suction drain is frequently used after ORIF. This drain is typically removed when less than 10 mL of drainage fluid is collected over 8 hours.

Postoperatively, the foot is elevated with the ankle in the standard neutral position of a 90° angle between the foot and the tibia. This position is maintained for up to 72 hours to reduce postoperative swelling.

Early range-of-motion exercises are encouraged after the surgical incision has begun healing, usually 10-12 days after surgery. A well-fitting orthosis is provided for comfort and to prevent gastrocnemius-soleus contracture. Sutures are removed at 2-3 weeks, but weight bearing is delayed for up to 12 weeks, depending on the original degree of comminution and the subsequent rigidity of the fixation.

Follow-up

Supervised physical therapy may be of substantial benefit, both during the non–weight-bearing period and during the active weight-bearing recovery phase.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center, Breaks, Fractures, and Dislocations Center and Imaging Center. Also, see eMedicine's patient education articles Broken Foot, Understanding X-rays, and Cast Care.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

A frequent complication of a calcaneus fracture is chronic disability due to the pain of an improperly functioning subtalar or calcaneocuboid joint.³²

Specific complications after ORIF of calcaneus fractures include infection, pain, swelling, delayed wound healing, and nonunion of the fracture fragments. Lateral impingement of the peroneal tendon can occur as a result of decreased calcaneal height. Occasionally, damage to the sural nerve occurs with a lateral surgical approach.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

As Essex-Lopresti correctly noted 50 years ago, intra-articular fractures of the calcaneus result in morbidity rates substantially higher than those of extra-articular fractures.

An entire year may be required to fully assess patients for residual disability that occurs after a fracture of the calcaneus.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Advances in imaging have allowed practitioners to carefully classify and select the subset of injuries that are particularly amenable to operative intervention.

In their report of a prospective, randomized study, Buckley et al suggested that the functional results after operative fixation of displaced intra-articular calcaneus fractures were better than those undergoing nonoperative treatment, in selected groups.³³ Further prospective studies are required to validate these results.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

Media file 1:  Calcaneus fractures. Comminuted fracture of the calcaneus sustained in a motorcycle accident. Note the loss of the Bohler angle.
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Media type:  X-RAY

Media file 2:  Calcaneus fractures. Axial radiograph reveals a comminuted fracture of the calcaneal body.
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Media type:  X-RAY

Media file 3:  Calcaneus fractures. Avulsion type fracture of the calcaneus, sustained when the patient fell 6 feet from a ladder onto solid ground. Due to the distraction of the fracture fragments, this injury was treated with open reduction and internal fixation.
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Media type:  X-RAY

Media file 4:  Calcaneus fractures. The same injury as seen in Image 3, status post open reduction and internal fixation.
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Media type:  X-RAY

Media file 5:  Calcaneus fractures. Bilateral calcaneus fractures sustained in a motor vehicle collision. Compare the minimally displaced calcaneal tuberosity fracture on the patient's left side to the comminuted intra-articular (Sanders type III) fracture on the right.
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Media type:  CT

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• RELEVANT ANATOMY
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• Multimedia
• References

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2. Bohler L. Diagnosis, pathology, and treatment of fractures of the calcaneus. J Bone Joint Surg. 1931;13:75-89.
3. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis, 1951-52. Clin Orthop. May 1993;3-16. [Medline].
4. Rowe CR, Sakellarides H, Freeman P. Fractures of os calcis - a long-term follow-up study one hundred forty-six patients. JAMA. 1963;184:920-923.
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6. Browner B, Jupiter J, Levine A. Skeletal Trauma. 2003;1:2406-34.
7. Cohen M. Calcaneal Fractures. Foot and Ankle Surgery. 2001;2:1819-1863.
8. Juliano P, Myerson M. Fractures of the Hindfoot. Foot and Ankle Disorders. 2000;2:1297-1340.
9. Sanders R, Fortin P, DiPasquale T. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop. May 1993;87-95. [Medline].
10. Crosby LA, Fitzgibbons T. Intraarticular calcaneal fractures. Results of closed treatment. Clin Orthop. May 1993;47-54. [Medline].
11. Sanders R. Fractures and fracture-dislocations of the calcaneus. Surgery of the Foot and Ankle. 1999;2:1422-1464.
12. Sanders R, Hansen ST, McReynolds IS. Trauma to the calcaneus and its tendon. Fracture of the calcaneus. Disorders of the Foot and Ankle. 1991;1:2326-2354.
13. Barei DP, Bellabarba C, Sangeorzan BJ, Benirschke SK. Fractures of the calcaneus. Orthop Clin North Am. Jan 2002;33(1):263-85, x. [Medline].
14. Juliano P, Nguyen HV. Fractures of the calcaneus. Orthop Clin North Am. Jan 2001;32(1):35-51, viii. [Medline].
15. Bridgman SA, Dunn KM, McBride DJ, Richards PJ. Interventions for treating calcaneal fractures. Cochrane Database Syst Rev. 2000;(2):CD001161. [Medline].
16. Buckley RE, Meek RN. Comparison of open versus closed reduction of intraarticular calcaneal fractures: a matched cohort in workmen. J Orthop Trauma. 1992;6(2):216-22. [Medline].
17. Richards PJ, Bridgman S. Review of the radiology in randomised controlled trials in open reduction and internal fixation (ORIF) of displaced intraarticular calcaneal fractures. Injury. Oct 2001;32(8):633-6. [Medline].
18. Cotton FJ, Henderson FF. Results of fractures of the os calcis. Am J Orthop Surg. 1916;14:290.
19. Sanders R. Intra-articular fractures of the calcaneus: present state of the art. J Orthop Trauma. 1992;6(2):252-65. [Medline].
20. Thermann H, Krettek C, Hüfner T, Schratt HE, Albrecht K, Tscherne H. Management of calcaneal fractures in adults. Conservative versus operative treatment. Clin Orthop Relat Res. Aug 1998;107-24. [Medline].
21. Varela CD, Vaughan TK, Carr JB, Slemmons BK. Fracture blisters: clinical and pathological aspects. J Orthop Trauma. 1993;7(5):417-27. [Medline].
22. Thornton SJ, Cheleuitte D, Ptaszek AJ, Early JS. Treatment of open intra-articular calcaneal fractures: evaluation of a treatment protocol based on wound location and size. Foot Ankle Int. May 2006;27(5):317-23. [Medline].
23. Broden B. Roentgen examination of the subtaloid joint in fractures of the calcaneus. Acta Radiol. 1949;31:85.
24. Degan TJ, Morrey BF, Braun DP. Surgical excision for anterior-process fractures of the calcaneus. J Bone Joint Surg Am. Apr 1982;64(4):519-24. [Medline].
25. Pozo JL, Kirwan EO, Jackson AM. The long-term results of conservative management of severely displaced fractures of the calcaneus. J Bone Joint Surg Br. May 1984;66(3):386-90. [Medline].
26. Benirschke SK, Sangeorzan BJ. Extensive intraarticular fractures of the foot. Surgical management of calcaneal fractures. Clin Orthop. Jul 1993;128-34. [Medline].
27. Burdeaux BD. Fractures of the calcaneus: open reduction and internal fixation from the medial side a 21-year prospective study. Foot Ankle Int. Nov 1997;18(11):685-92. [Medline].
28. Schepers T, Vogels LM, Schipper IB, Patka P. Percutaneous reduction and fixation of intraarticular calcaneal fractures. Oper Orthop Traumatol. May 2008;20(2):168-175. [Medline].
29. Walde TA, Sauer B, Degreif J, Walde HJ. Closed reduction and percutaneous Kirschner wire fixation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2-10 years. Arch Orthop Trauma Surg. Jun 2008;128(6):585-591. [Medline].
30. Rammelt S, Gavlik JM, Barthel S. The value of subtalar arthroscopy in the management of intra-articular calcaneus fractures. Foot Ankle Int. Oct 2002;23(10):906-16. [Medline].
31. Cavadas PC, Landin L. Management of soft-tissue complications of the lateral approach for calcaneal fractures. Plast Reconstr Surg. Aug 2007;120(2):459-66; discussion 467-9. [Medline].
32. Reddy V, Fukuda T, Ptaszek AJ. Calcaneus malunion and nonunion. Foot Ankle Clin. Mar 2007;12(1):125-35. [Medline].
33. Buckley R, Tough S, McCormack R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. J Bone Joint Surg Am. Oct 2002;84-A(10):1733-44. [Medline].

Article Last Updated: Jul 9, 2008