The initial radiographic assessment of a calcaneal fracture involves plain radiographs and often CT. Plain radiographs should include lateral and AP views of the foot and a Harris axial heel view. On the lateral view, a decreased Böhler angle, an increased angle of Gissane, and an inferior displacement of the posterior facet can be seen (Figure 1). If only the lateral portion of the joint is displaced, a double density sign (when two portions of the posterior facet articular surface are visible on the lateral radiograph) can be seen at the posterior facet (Figure 2).
The AP foot view may show extension of the fracture into the anterior process and calcaneocuboid joint. The axial view may show varus displacement and shortening of the tuberosity. CT is useful for most intra-articular fractures to evaluate the extent of joint involvement and displacement⁴ (Figures 2, B through D and 3, A and B).

A displaced intra-articular calcaneal fracture is identified as a joint depression fracture or a tongue-type fracture, based on the Essex-Lopresti⁵ classification. With a relatively posterior-directed force, the fracture line extends into the posterior facet to produce a joint depression fracture. If the force is directed more inferiorly, the fracture line extends inferior to the posterior facet and produces a tongue-type fracture pattern.

The classification of Soeur and Remy⁶ was expanded by Sanders⁷ to define a system based on the number and location of articular fragments at the posterior facet, as seen on semi-coronal CT (Figure 4). A type I fracture is nondisplaced. A type II fracture is a two-part fracture with a subtype based on the location of the primary fracture line. A type III fracture has three parts, often with a centrally depressed fragment. A type IV fracture has at least four articular fragments and typically is highly comminuted.

The medial sustentacular fragment has been described as the “constant” fragment and was thought to remain nondisplaced because of medial ligamentous stability. However, when CT of displaced fractures were carefully evaluated, this medial fragment was found to be displaced or angulated in over 20% of fractures.⁸

The definitive treatment of patients with displaced intra-articular calcaneal fracture remains controversial. Historically, these fractures were treated nonsurgically. The benefit of surgical treatment was difficult to establish, and the rate of perioperative complications was considered too high to justify surgical treatment. In recent decades, however, surgical treatment has become the standard of care for many of these injuries. Improved understanding and management of the associated soft-tissue injury have led to the development of surgical techniques with lower complication rates. At the same time, developments in preoperative and intraoperative imaging and newer implants have improved the ability to perform open reduction and internal fixation.

Several studies compared the surgical and nonsurgical treatment of intra-articular calcaneal fractures. Many of these studies were limited by a small patient population, a lack of consistency in fracture classification, and variations in surgical technique. The first randomized prospective study was published in 1996 and showed promise for surgical treatment. Thirty patients with a displaced fracture (Sanders type II or III) were randomized to operative versus nonoperative treatment. The patients treated surgically had a statistically significant improvement in outcome at 17-month follow-up over those treated nonsurgically.¹¹

Since then, there have been three large multicenter randomized controlled trials evaluating surgical versus nonsurgical treatment for displaced fractures. None have shown a clear benefit to operative intervention over nonsurgical treatment. All of these studies used the extensile lateral approach for surgical treatment and found increased complication rates with surgery.

In a large multicenter randomized study comparing surgical and nonsurgical treatment of displaced intra-articular calcaneal fracture, validated outcomes
measures revealed no overall difference between patients in the two treatment groups at 2- to 8-year follow-up.¹² However, among patients who did not have a workers’ compensation claim, surgical treatment led to better satisfaction scores than nonsurgical treatment. Women, younger patients, and patients with a greatly displaced fracture also had a better outcome after surgical treatment. Patients treated nonsurgically were much more likely than those treated surgically to require subsequent subtalar arthrodesis for posttraumatic arthritis. Despite the large number of enrolled patients and the sound methodology, this study did not clearly establish the optimal treatment of patients with a displaced intra-articular calcaneal fracture.

Another randomized controlled multicenter study looked at surgical versus nonsurgical treatment in 82 patients with displaced fractures.¹³ Pain and functional outcome measures showed no difference between the groups at 1 year postinjury. The surgically treated group had a higher complication rate. At 8 to 12 years follow-up, there was a trend toward improved functional outcomes in the surgically treated group, although

statistical significance could not be demonstrated. The surgical group did have a lower incidence of posttraumatic subtalar arthritis.

A third large randomized controlled study evaluated 151 patients.¹⁴ This multicenter study involved 22 centers and compared operative to nonoperative treatment. They assessed pain and function with the Kerr-Atkins scale at 2 years follow-up. With an impressive 95% follow-up, they showed no difference between the groups. Complications, however, were higher in the operative group (23% versus 4%). They concluded that displaced calcaneal fractures should be treated nonoperatively.

That said, given the complexity of studying this question and the ongoing controversy about optimal treatment, others have cautioned against such a broad and definitive conclusion.¹⁵ Because of decreased wound complications, many surgeons have moved to routine use of minimally invasive approaches for surgical treatment. We have yet to see the results of a randomized controlled trial comparing surgical treatment with a minimally invasive approach to nonsurgical treatment.

Three recent meta-analysis have also been inconclusive about the benefit of surgical treatment.^16,17,18 These studies are limited by relatively small numbers and some heterogeneity in treatment protocols. The results of the studies are mixed, but none have demonstrated a clear superiority of surgical treatment compared with nonsurgical treatment. Findings included improved anatomical recovery, higher rate of return to work, and decreased rate of late subtalar arthrodesis with surgical treatment. Surgical treatment was associated with increased rates of complications.

Further prospective studies are needed to define the clear indications for surgical treatment. In recent decades, however, open reduction and internal fixation has frequently been recommended for patients with a Sanders type II or III intra-articular fracture, as long as there is no clear contraindication.³ It is clear that outcomes are poor if these injuries are treated nonsurgically.

Until recent years, most studies have reported open reduction and internal fixation through an extensile lateral approach^3,19,20,21 (Figure 5). For decades, this was the most common for surgical treatment of displaced intra-articular calcaneal fractures. A recent study presented long-term follow-up (average 15.2 years) on 108 of 208 fractures that underwent open reduction and internal fixation with the extensile lateral approach.²² Clinical and functional results were maintained and acceptable if subtalar arthrodesis was not needed (77 of 108 fractures). Initial postoperative CT indicated 95% of patients with an anatomic articular reduction. At final follow-up, only three fractures demonstrated loss of reduction. Sanders classification was predictive of late subtalar fusion.

The use of intraoperative three-dimensional imaging has potential to aid surgeons with reduction and
placement of hardware. This technology is not routinely available to most surgeons but has shown some promise in large centers. These studies have demonstrated improved articular reduction of the posterior facet with use of intraoperative three-dimensional CT.^23,24 Thus far, improved clinical results have not been demonstrated.

One of the key elements in this surgical treatment approach is the management of the associated soft-tissue injury and swelling. The most common and serious early complications of surgical treatment are delayed wound healing and infection.^25,26 To minimize wound complications, surgical treatment should not be attempted before resolution of the soft-tissue swelling, as indicated by the absence of pitting edema and by the presence of skin wrinkling at the lateral heel^27,28 (Figure 6). Some surgeons recommend the use of an aggressive soft-tissue protocol to decrease the delay to surgery and minimize the risk of complications.²⁹ Delay of more than 3 weeks after the injury makes fracture reduction extremely difficult because early fracture healing has occurred.

With the use of alternate small-incision approaches and indirect reduction techniques, earlier surgical intervention has been recommended. In fact, one retrospective study showed no benefit with regard to wound complications to delaying surgical treatment with the extensile lateral approach.³⁰ In patients undergoing minimally invasive approaches, delay in surgical treatment actually resulted in increased wound complications.

A displaced tongue-type fracture may require urgent surgical treatment. A severely displaced superior tuberosity fragment places the posterior skin under tension and can lead to soft-tissue injury and even skin necrosis within a few hours (Figure 7). A 21% incidence of posterior soft-tissue compromise was found in a study of 139 tongue-type fractures.³¹ Six soft-tissue coverage procedures and one amputation resulted. The patients treated with emergency percutaneous reduction avoided soft-tissue complications.

In general, simple or extra-articular tongue-type fractures (Sanders type IIC) are treated with percutaneous fixation (Figure 8). Guidewires are placed percutaneously on either side of the Achilles tendon and into the displaced tuberosity.³² The guidewires are used to reduce the fracture and subsequently are advanced toward the anterior process. Definitive fixation can be achieved with large cannulated screws placed over the guidewires. Alternatively, multiple small fragment screws can be placed percutaneously to maintain the reduction. Early mobilization is generally encouraged to minimize stiffness.

Complex intra-articular fractures with a tongue-type component (Sanders types IIA, IIB, and III) may not be amenable to reduction using the percutaneous Essex-Lopresti technique. Sagittal fracture lines and comminution at the articular surface cannot be appropriately reduced. These fractures should be treated with open reduction and internal fixation through an extensile lateral approach or with a minimally invasive technique.

Because of multiple joint fragments and comminution, Sanders type IV fractures generally are not amenable to anatomic reduction and stable fixation. Even if anatomic reduction is possible, the articular cartilage damage from the time of impact is significant, and progression to posttraumatic arthritis is inevitable. For these reasons, primary arthrodesis is the surgical treatment of choice. Multiple researchers have reported on open reduction and internal fixation of the calcaneus combined with primary arthrodesis of the subtalar joint, using the extensile lateral approach.^33,34 In this technique, the extra-articular calcaneal anatomy is restored with open reduction and internal fixation, and iliac crest bone graft is used at the arthrodesis site. High union rates, more rapid return to work, and generally good clinical outcomes have been reported when this method was used to treat these severe injuries.³⁵ Primary arthrodesis with open reduction and internal fixation through a sinus tarsi approach has also been reported with good fusion rates.³⁶ Primary subtalar arthrodesis may be a good treatment option for a type IV fracture even without formal fracture reduction. Good results

were obtained in a series of seven fractures treated with primary arthrodesis but not with formal open reduction and internal fixation.³⁷