Calcaneal fractures

Last evidence check Nov 2013

Minor fractures

posterior avulsionfracture

Achilles tendon insertion avulsion fracture

tuberosity fracture

Tuberosity fracture

anterior process fracture

Anterior process fracture

Body fractures

Fractures of the body are divided into those which are extra-articular and those which are intra-articular, mainly into the subtalar joint.

Early classifications were based on plain radiography. The best known is that of Essex-Lopresti, who recognised peripheral and extra-articular injuries, and divided intra-articular injuries into:

joint depression1
joint depression2

joint-depression type, in which the primary fracture line exited the bone close to the subtalar joint


tongue-type, in which the primary fracture line exited the bone posteriorly

Review the pathomechanics of these fracture types

This classification was related to his percutaneous reduction technique. As minimally invasive fixation has attracted more interest in the last few years, it is once again important to know the Essex-Lopresti classification. The minimally invasive techniques for reduction are different for tongue-type and joint depression fractures.

Modern classifications are based on CT imaging of the posterior subtalar articular facet. Crosby and Fitzgibbons (1993) divided 30 intra-articular fractures into undisplaced, displaced but non-comminuted, and comminuted, and showed that severity corelated with outcome and response to surgery.

The main CT classification is that of Sanders (1993). The main axis of classification is into

The type-2 and 3 fractures are subdivided on the position of the articular fracture lines, producing types 2A, 2B and 2C, and types 3AB, 3AC and 3BC.

sanders classn1

The basis of the Sanders classification.The groups are denoted by the number of main fragments and the approximate main fracture lines as marked

sanders classn2

A two-part fracture with the main fracture line through the mid-part of the joint - type 2B

sanders classn3

A three-part fracture with the main fracture lines lateral and central - type 3AB

sanders classn4

A four-part fracture with fracture lines lateral, medial and central - type 4ABC

The main typings have been shown to influence prognosis and surgical complexity (Sanders 1993), and overall benefit from surgery (Buckley et al 2002). Rubino (2009) found that the Sanders and Regazzoni (AO) calssifications were best corelated with typical foot and ankle outcome measures.

Furey (2003) studied interobserver variability using the Sanders classification and found moderate agreement with a weighted kappa value of 0.48 for the main classes and 0.56 including the subclasses. De Souza et al (2004) found 37/150 calcaneal fractures that could not be classified according to Sanders and described additional types and appropriate surgical strategies. Schepers (2009) also found kappa values of around 0.5 for the Sanders, Essex-Lopresti and Crosby/Fitzgibbons classification when these were applied by trauma surgeons, but less for radiologists. Sayed-Noor (2011) and Howells (2013) produced even lower values for agreement, suggesting that a critical revision of existing classification systems is required.