Intra-articular calcaneal fractures are a significant challenge in orthopedic surgery due to the complex nature of the injury and its potential for long-term complications. The calcaneus, or heel bone, is the largest of the tarsal bones in the foot and plays a crucial role in weight-bearing and movement. These fractures typically result from high-energy trauma such as falls from heights or motor vehicle accidents and often involve the posterior facet, the most critical weight-bearing surface of the calcaneus, complicating both diagnosis and treatment.
How Common It Is and Who Gets It? (Epidemiology)
Calcaneal fractures are relatively uncommon, representing only about 2% of all adult fractures. However, they are one of the most frequent fractures among the tarsal bones. These fractures occur more commonly in individuals who experience high-energy trauma, such as falls from significant heights or motor vehicle collisions. The condition is often observed in labor-intensive professions or activities that involve high-impact movements.
Why It Happens – Causes (Etiology and Pathophysiology)
The primary cause of calcaneal fractures is axial loading, where the force from an impact is transmitted directly through the calcaneus, causing it to fracture. This typically occurs during falls or accidents when the heel bone is crushed under the body’s weight. The fracture may involve the subtalar joint, resulting in damage to the articular cartilage and leading to long-term complications such as arthritis or loss of motion.
How the Body Part Normally Works? (Relevant Anatomy)
The calcaneus is located at the rear of the foot, forming part of the ankle joint. It has four primary articular surfaces: the posterior, middle, and anterior facets that articulate with the talus, and the distal surface for the cuboid. Medially, the sustentaculum tali supports the middle facet and provides a groove for the flexor hallucis longus tendon. The calcaneus, along with the talus, forms the subtalar joint, which allows for side-to-side movement of the foot and is essential for balance during walking and running.
What You Might Feel – Symptoms (Clinical Presentation)
Symptoms of a calcaneal fracture typically include:
- Pain in the heel and surrounding areas, especially when weight is placed on the foot.
- Swelling and bruising around the ankle and heel.
- Inability to bear weight on the affected foot.
- Heel deformity or visible changes in the foot’s shape, particularly in severe fractures.
- Difficulty with walking, standing, or performing other weight-bearing activities.
How Doctors Find the Problem? (Diagnosis and Imaging)
Diagnosis of calcaneal fractures involves a combination of clinical examination and imaging studies:
- X-rays: Initial radiographs (AP, lateral, and oblique views) are typically used to confirm the fracture and assess its severity.
- CT scans: Given the complex nature of calcaneal fractures, CT scans are frequently used to assess the degree of articular involvement, fracture pattern, and alignment of bone fragments.
- MRI: Used to evaluate soft tissue damage, including ligament and tendon involvement, and to assess cartilage damage in the subtalar joint.
- Böhler’s Angle: A critical measurement on radiographs that is typically reduced in cases of calcaneal fracture.
Classification
Calcaneal fractures are classified based on the Sanders classification, which evaluates the involvement of the posterior facet, and the Essex-Lopresti classification, which divides fractures by their mechanism of injury:
- Sanders Classification: Based on the number of fracture lines in the posterior facet, ranging from Type I (non-displaced) to Type IV (highly comminuted).
- Essex-Lopresti Classification: Divides fractures into joint depression fractures and tongue-type fractures, based on the mechanism and fracture pattern.
Other Problems That Can Feel Similar (Differential Diagnosis)
Conditions that may mimic the symptoms of calcaneal fractures include:
- Ankle sprains: These can present with similar pain and swelling but often follow a clear injury history.
- Peroneal tendonitis: Inflammation of the tendons can cause lateral foot pain.
- Rheumatoid arthritis: Joint involvement can cause pain and stiffness in the foot.
- Achilles tendonitis: This causes pain in the heel, often in the area where the tendon attaches.
Treatment Options
Non-Surgical Care
For non-displaced or minimally displaced fractures, non-surgical management is often sufficient:
- Rest and immobilization: Use of a splint or cast for 6–8 weeks to hold the bone in place while it heals.
- Pain management: NSAIDs or other pain medications to reduce inflammation and discomfort.
- Crutches or walker: To avoid weight-bearing on the affected foot.
- Physical therapy: To regain mobility and strength once the fracture heals sufficiently.
Surgical Care
Surgery is recommended for displaced fractures or those affecting the joint surface:
- Open Reduction and Internal Fixation (ORIF): Surgical procedure to reposition the bone fragments and stabilize them with plates and screws.
- Percutaneous Fixation: Minimally invasive technique for less severe fractures, where small incisions are made, and pins or screws are inserted to align the bone.
- Subtalar Arthrodesis: In cases of severe comminution or arthritis in the subtalar joint, fusion of the joint may be necessary.
Recovery and What to Expect After Treatment
- Non-surgical recovery: Healing typically takes 6–8 weeks, with gradual return to weight-bearing activities. Full recovery may take several months, with rehabilitation to restore strength and range of motion.
- Surgical recovery: Following surgery, recovery may take 3–6 months, with early mobilization and physical therapy to promote healing and prevent stiffness.
Possible Risks or Side Effects (Complications)
- Wound healing issues: Particularly in open fractures or those with significant soft tissue damage.
- Infection: A risk with surgical treatment.
- Nerve damage: Possible injury to the sural or tibial nerves during surgery.
- Malunion or nonunion: Failure of the bone to heal properly may require additional surgery.
- Post-traumatic arthritis: A long-term risk, especially when the joint surface is involved.
Long-Term Outlook (Prognosis)
The prognosis for calcaneal fractures largely depends on the severity of the fracture and the effectiveness of treatment. Most patients with nondisplaced fractures recover well, though those with severe fractures or joint involvement may experience chronic pain, arthritis, or loss of motion. Early diagnosis and appropriate treatment improve the likelihood of a successful recovery.
Out-of-Pocket Costs
Medicare
CPT Code 28415 – Open Reduction and Internal Fixation (ORIF) of Calcaneal Fracture: $262.38
CPT Code 28420 – Open Reduction and Internal Fixation (ORIF) of Calcaneal Fracture with Multiple Fragments: $307.14
CPT Code 28725 – Calcaneal Fusion (Arthrodesis) or Other Bony Procedures: $182.74
Medicare Part B covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield typically cover the remaining 20%, reducing or eliminating out-of-pocket expenses for Medicare-approved procedures. These plans work in coordination with Medicare to fill the coverage gap.
If you have Secondary Insurance such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it serves as a secondary payer. These plans usually cover any remaining balance, including coinsurance or small deductibles, which typically range from $100 to $300 depending on your plan and provider network.
Workers’ Compensation
If your calcaneal fracture is work-related, Workers’ Compensation will cover all treatment costs, including surgery and rehabilitation. You will not have any out-of-pocket expenses, as the employer’s insurance carrier will cover all costs directly.
No-Fault Insurance
If your calcaneal fracture occurred due to an automobile accident, No-Fault Insurance will typically cover the full cost of treatment, including surgery and follow-up care. The only possible out-of-pocket cost may be a small deductible or co-payment based on your policy.
Example
David Miller required open reduction and internal fixation (ORIF) of his calcaneal fracture (CPT 28415) after an accident. His estimated Medicare out-of-pocket cost was $262.38. Since David had supplemental insurance through Blue Cross Blue Shield, his remaining balance was fully covered, leaving him with no out-of-pocket expenses for the procedure.
Frequently Asked Questions (FAQ)
Q. What is a calcaneal fracture?
A. A calcaneal fracture is a break in the heel bone, commonly caused by high-energy trauma like a fall from a height or a car accident.
Q. What are the common causes of calcaneal fractures?
A. Calcaneal fractures are often caused by high-impact injuries such as falls from significant heights or motor vehicle accidents.
Q. What are the symptoms of a calcaneal fracture?
A. Symptoms include heel pain, swelling, bruising, and an inability to put weight on the affected foot.
Q. How is a calcaneal fracture diagnosed?
A. Diagnosis is typically made through physical examination and confirmed using imaging techniques such as X-rays and CT scans.
Q. What are the treatment options for a calcaneal fracture?
A. Treatment options include non-surgical methods like immobilization or surgical interventions such as open reduction and internal fixation, depending on the severity of the fracture.
Q. When is surgery required for a calcaneal fracture?
A. Surgery is often needed for displaced fractures or when the fracture affects the joint surface of the heel bone.
Q. What is open reduction and internal fixation?
A. Open reduction and internal fixation is a surgical procedure where the bone fragments are repositioned and held together with plates and screws.
Q. Can calcaneal fractures be treated without surgery?
A. Yes, non-displaced or minimally displaced fractures can be managed with rest, immobilization, and restricted weight-bearing.
Q. How long is the recovery period for a calcaneal fracture?
A. Recovery may take several months, with restricted weight-bearing for 6 to 8 weeks and physical therapy afterward.
Q. What complications can arise from a calcaneal fracture?
A. Complications may include arthritis, chronic pain, deformity, and difficulty walking.
Q. What is the role of physical therapy in recovery?
A. Physical therapy helps restore strength, flexibility, and function in the foot after the fracture has healed.
Q. Can calcaneal fractures lead to arthritis?
A. Yes, fractures involving the joint surface can increase the risk of developing post-traumatic arthritis.
Q. What type of imaging is most helpful in assessing calcaneal fractures?
A. CT scans provide detailed views of the fracture pattern and are especially useful for surgical planning.
Q. Are calcaneal fractures more common in certain populations?
A. They are more common in people who experience high-impact trauma, such as construction workers or individuals in motor vehicle accidents.
Q. What should be avoided during the healing of a calcaneal fracture?
A. Weight-bearing on the affected foot should be avoided until the fracture has sufficiently healed, as directed by a physician.
Summary and Takeaway
Calcaneal fractures, particularly those involving the posterior facet, pose significant challenges in orthopedic care. A detailed understanding of the anatomy, injury mechanism, and available treatment options is essential for successful management. While nonoperative management may be appropriate for less severe fractures, surgical intervention is often required for displaced or complex fractures. Advances in surgical techniques, including minimally invasive approaches, have improved outcomes and reduced complications.
Clinical Insight & Recent Findings
A 2025 retrospective study from the Medical University of Vienna analyzed 288 calcaneal fractures over 20 years and found that one in five cases developed complications.
Open fractures, multiple injuries, and a negative Böhler angle were the strongest predictors of wound problems and delayed recovery. Interestingly, patients with psychiatric disorders—often those sustaining injuries from suicide attempts—had a markedly higher risk of complications (84%) due to compliance and trauma severity.
The study also reported that spinal injuries occurred in over 20% of patients, emphasizing the need for full-body assessment after high-energy trauma. Notably, operative and nonoperative treatments showed similar complication rates, reinforcing that management decisions should be individualized based on fracture type and soft tissue condition (“Study on complication risks and associated injuries in calcaneal fractures – see PubMed.“)
Who Performs This Treatment? (Specialists and Team Involved)
Treatment for calcaneal fractures is typically managed by orthopedic surgeons, particularly those specializing in foot and ankle surgery.
When to See a Specialist?
See a specialist if you experience persistent pain, swelling, or deformity following an ankle injury, particularly if you are unable to bear weight on the affected foot.
When to Go to the Emergency Room?
Go to the emergency room if you experience severe pain, visible deformity, or signs of infection, such as redness, warmth, or fever.
What Recovery Really Looks Like?
Recovery may take several months, with restricted weight-bearing for 6 to 8 weeks. Physical therapy is essential for restoring ankle function.
What Happens If You Ignore It?
If left untreated, calcaneal fractures can lead to chronic pain, arthritis, deformity, and difficulty walking.
How to Prevent It?
Prevent falls by using proper safety measures in high-risk environments. Wear supportive footwear and take care to avoid repetitive stress on the ankle.
Nutrition and Bone or Joint Health
A balanced diet rich in calcium, vitamin D, and omega-3 fatty acids supports bone health and promotes healing.
Activity and Lifestyle Modifications
Once healed, focus on strengthening exercises and gradually return to low-impact activities. Avoid high-impact movements until fully recovered.
Dr. Mo Athar
