Calcaneal fractures account for 1–2% of all fractures in adults and some 65% are intra-articular. In contrast this is a rare injury in children (below the age of 14) with the majority (70%) being extra-articular. In adolescents as the skeleton nears maturity the fracture patterns tend to resemble those of the adult with a greater proportion (60–80%) being intra-articular.

As in the adult population the majority of injuries are as a result of a fall from a height (47%), road traffic accidents (15%) and lawnmowers (13%). Up to one-third are associated with other fractures, with lower extremity fractures occurring more frequently than lumbar spine fractures. Fractures in children and adolescents also tend to be less comminuted. This may reflect the fact that these fractures in children are much lower energy injuries and the more cartilaginous immature calcaneum predisposes it to simpler fracture patterns.

One of the early and most widely accepted classifications of calcaneal fractures was proposed by Essex-Lopresti. This was then modified by Schmidt and Weiner for use in the paediatric population (Table 10.2).

Children sustaining fractures of the calcaneum are likely to have been involved in high-energy trauma. With displaced fractures, the injury to the soft tissue envelope will be directly related to the energy of the injury. The foot is often very swollen with substantial bruising and blistering. The possibility of compartment syndrome must be considered.

Standard radiographs for the calcaneum include the lateral and axial projections. Oblique views may help with identifying anterior process fractures. Bohler’s angle has been used in determining the presence of an intra-articular fracture and to quantify the degree of displacement. In adults the angle is quoted as being between 20° and 40°. In young children, the range is higher than in the adult, due to the incomplete ossification of the calcaneus. It then rapidly increases with age. By the age of 7 years the estimated mean angle is 42°. The angle tends to decline towards adult values as the child enters adolescence. Measuring the non-injured foot angle is recommended for comparative purposes, although in the case of displaced fractures the modality of choice is a CT scan.

The great majority of calcaneal fractures in growing young children can be treated non-operatively due to the potential for remodelling. In the adolescent, fractures resemble the patterns seen in adults and the remodelling potential is greatly reduced. In this group, excellent results have been reported with the operative treatment of displaced intra-articular fractures.