Overview
Calcaneal fractures require assessment of the posterior facet, tuberosity alignment, heel width and soft-tissue envelope. The aim is a plantigrade, shoeable hindfoot with preserved length, height and alignment. Even with anatomic reconstruction, subtalar arthritis, stiffness and prolonged disability may follow the initial cartilage injury. Treatment selection must balance reconstructability and functional goals against wound and infection risk. [1]
Urgent Assessment and Soft-Tissue Protection
Perform a full trauma and neurovascular assessment, inspect the plantar and posterior heel, and assess for compartment syndrome and associated injuries after axial loading. A tongue-type fragment or tuberosity avulsion can place the posterior skin under dangerous tension: threatened skin requires prompt reduction and stabilization. Do not defer that urgent step until routine swelling has settled. Open injuries require urgent open-fracture care and a coordinated debridement, stabilization and coverage plan. In other closed injuries, elevate and splint, monitor the skin and plan definitive fixation according to tissue recovery. [1]
Imaging and Fracture Mapping
Obtain lateral and axial heel views to assess height, width and tuberosity varus, with foot views for the anterior process and calcaneocuboid joint. CT in multiple planes defines posterior-facet fragments, medial-wall involvement, impaction and joint extension and helps assess peroneal tendon displacement or entrapment. Record the Sanders pattern and the overall morphology; classification alone does not select the operation. A sustentacular fragment should be inspected rather than assumed to be an intact, undisplaced reference. [1]
Procedure Selection and Evidence
Nonoperative treatment is appropriate for nondisplaced injuries and may be preferable when comorbidity, perfusion, soft tissues or patient circumstances make surgery unfavorable. For a reconstructable displaced fracture, discuss fixation in relation to deformity, joint incongruity, functional goals and the capacity to follow rehabilitation. Severe comminution may lead to reconstruction, a staged strategy or primary subtalar arthrodesis in selected patients; none is mandatory from the classification alone. [1]
What the Randomized Evidence Shows
The UK Heel Fracture Trial randomized 151 adults with typical closed displaced intra-articular fractures. Extensile lateral ORIF did not improve the main two-year functional outcome over nonoperative care and caused more complications. The trial excluded open injuries, gross hindfoot deformity and peripheral vascular disease; it did not test modern sinus tarsi fixation. Use these boundaries when counselling patients rather than treating its findings as proof for every fracture or approach. Campbell describes lower wound morbidity with sinus tarsi approaches, while emphasizing the importance of reduction and patient selection. [1,2]
Planning and Sinus Tarsi Exposure
Plan the order of reconstruction and the required screw or plate corridors from CT. Prepare lateral, axial and posterior-facet fluoroscopic views and make sure the whole heel can be imaged. A lateral position or supine position with an ipsilateral bump can provide access. The sinus tarsi incision runs from the fibular tip toward the fourth metatarsal base and is sized to visualize the reduction. Identify and protect the sural nerve, small saphenous vein and peroneal tendons; elevate only the tissue needed. The limited approach reduces exposure but does not remove the need for careful skin handling. [1]
Reduction and Provisional Fixation
Restore tuberosity length, height and coronal alignment before accepting the articular reconstruction. A controlled tuberosity joystick can help disimpact the fragments and correct varus. Visualize the posterior facet, remove interposed debris and elevate depressed segments without stripping their remaining attachments. Use the sustentacular relationship and the talus to assess the reconstructed surface, but check for a second sagittal fracture rather than treating the visible lateral fragment as the whole injury. Provisional wires must leave room for the definitive screws or plate. [1]
Definitive Fixation
Secure the reconstructed posterior facet with subchondral screws directed into sound bone, then maintain the tuberosity and anterior process relationships with an appropriate screw or plate construct. Campbell describes both screw-only fixation and sinus tarsi plates; choose according to fragment size, comminution, bone quality and the stability achieved. A residual void may require graft support, but grafting is not obligatory for every fracture. If medial-wall reduction remains inadequate, reconsider reduction aids or additional exposure rather than accepting persistent heel varus. [1]
Final Checks and Closure
Confirm posterior-facet congruency and screw clearance from the subtalar and calcaneocuboid joints. Check heel width, height and tuberosity alignment on lateral, axial and appropriate facet views. A satisfactory lateral view alone can conceal varus or a joint-penetrating screw. Check that the peroneal tendons are free of impingement. Release any tourniquet, obtain hemostasis and close without tension; use a padded neutral splint and elevation. [1]
Postoperative Care
Review the wound early and monitor for necrosis, drainage, infection and pressure from the splint. Begin ankle and subtalar motion when the soft tissues and fixation permit. Loading must follow fracture stability, clinical and radiographic healing and any associated fusion or injury. Campbell describes prolonged protection, commonly with weight bearing delayed until about 8–12 weeks; this is not an automatic clearance date. Prescribe side-specific restrictions, walking aids and individualized thromboprophylaxis. Explain that swelling, footwear limitations and recovery of walking capacity can persist long after union. [1]
Complications and Technical Pearls
Watch for wound breakdown or deep infection, sural nerve symptoms, peroneal tendon impingement, joint-penetrating screws, loss of reduction and tuberosity varus malunion. Subtalar arthritis can occur despite good fixation; symptomatic later fusion may be needed. Protect threatened skin promptly, preserve fragment attachments, verify the medial fragment rather than assuming it is constant, and assess overall heel alignment as carefully as the posterior facet. [1]
References
[1] Bettin CC. Fractures and dislocations of the foot. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell’s Operative Orthopaedics. 15th ed. Elsevier; 2026. Chapter 93, calcaneal fractures and Techniques 93.1–93.3, pp. 4063–4082.
Randomized Trial
[2] Griffin D, Parsons N, Shaw E, et al. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. BMJ. 2014;349:g4483. doi:10.1136/bmj.g4483. https://www.bmj.com/content/349/bmj.g4483