Calcaneus Fracture: Symptoms, Types, Causes and Treatment

A calcaneus fracture—more commonly known as a heel bone fracture—is a serious injury that can have lasting effects on mobility and quality of life. As the largest tarsal bone in the foot, the calcaneus plays a pivotal role in bearing weight and enabling movement. Injuries to this bone often occur from high-impact trauma and can involve not only the bone itself but also the surrounding soft tissues and joints. This comprehensive guide walks you through the symptoms, types, causes, and treatment options for calcaneus fractures, with insights drawn from current medical literature and trauma data.

Symptoms of Calcaneus Fracture

Recognizing a calcaneus fracture early is crucial for optimal treatment and recovery. These fractures can manifest with a range of symptoms, from overt to subtle, and often occur alongside other injuries due to the forceful mechanisms involved.

Symptom	Description	Severity Spectrum	Source(s)
Heel Pain	Sudden, intense pain after trauma	Mild to severe	6 7
Swelling	Rapid swelling of the heel/ankle	Mild to extensive	6 7 12
Bruising	Discoloration around heel and ankle	Localized to large	6 7 12
Inability to Bear Weight	Difficulty or inability to walk	Partial to complete	6 7
Deformity	Change in heel shape	Subtle to obvious	2 7 12
Blisters/Open Wounds	Skin breakdown, especially in tongue-type or open fractures	Threatened skin to open wounds	1 7 12
Associated Injuries	Other fractures or systemic injuries	Common in severe cases	6 7

Table 1: Key Symptoms

Common Presentation

Most patients with a calcaneus fracture report a sudden onset of sharp pain in the heel following a traumatic event, such as a fall from height or a motor vehicle accident. Swelling and bruising develop rapidly, making it difficult or impossible to walk or put weight on the affected foot. In severe cases, the heel may appear deformed or widened.

Soft Tissue and Skin Issues

Certain fracture types—especially tongue-type fractures—can cause the bone fragments to press against the skin at the back of the heel, threatening skin integrity. This can lead to blisters, partial- or full-thickness skin breakdown, and open wounds, dramatically increasing the risk of infection and other complications 1 7 12.

Associated Injuries

Calcaneus fractures, particularly those resulting from high-energy trauma, are frequently accompanied by injuries elsewhere—most commonly to the spine (especially lumbar fractures), other bones in the foot and ankle, or even head and chest injuries 6 7. The presence of additional injuries can complicate diagnosis and management, making a thorough assessment essential.

Types of Calcaneus Fracture

Understanding the different types of calcaneus fractures is vital, as they vary widely in severity, complexity, and required treatment. Fractures are typically classified based on their anatomical location, involvement of the joint, and specific fracture patterns.

Type	Description	Clinical Implications	Source(s)
Intra-articular	Involves subtalar joint (posterior facet)	Most common (70–75%), more severe, risk of arthritis	2 4 5 12
Extra-articular	Does not involve joint surface	25–30% of cases, less severe	2 4 5
Tongue-type (special case)	Posterior tuberosity fragment displaced	High risk of skin compromise	1 2
Open Fracture	Bone breaks through the skin	High infection/amputation risk	7 12
Pathologic Fracture	Occurs due to disease (e.g., osteomyelitis, cancer)	Often in diabetics, poor prognosis	8
Displaced/Non-displaced	Fragments moved or not	Displacement guides treatment	5 12

Table 2: Calcaneus Fracture Types

Intra-articular vs. Extra-articular

• Intra-articular fractures are the most common, accounting for about 70-75% of all calcaneus fractures. These involve the subtalar joint, which is crucial for foot movement and stability. Intra-articular fractures are often complex, can be severely disabling, and carry a high risk of post-traumatic arthritis if not properly treated 2 4 5 12.
• Extra-articular fractures (25–30%) do not involve the joint surface and typically have a better prognosis. Examples include fractures of the anterior process, sustentaculum tali, or calcaneal tuberosity 2 4 5.

Special Fracture Patterns

• Tongue-type fractures are a subset of intra-articular injuries where the posterior part of the calcaneus is displaced. This displacement can press against the overlying skin, risking skin breakdown or even open wounds. Immediate recognition is critical to prevent severe soft tissue complications 1 2.
• Open fractures occur when the bone fragments pierce the skin. These are usually the result of high-energy trauma and carry a high risk of infection, soft tissue loss, and sometimes require amputation 7 12.
• Pathologic fractures are rare and typically result from underlying bone disease, such as infection (osteomyelitis) or cancer. These have a worse prognosis and often affect patients with chronic illnesses like diabetes 8.

Classification Systems

Specialized classification systems, such as the Sanders and Hannover systems, are used to further describe intra-articular fractures based on CT imaging. These classifications help guide treatment decisions and predict outcomes 2 4 5.

Causes of Calcaneus Fracture

The causes of calcaneus fractures are closely linked to the amount and type of force applied to the heel. Understanding these mechanisms is essential for prevention, diagnosis, and management.

Cause	Mechanism	Typical Scenario	Source(s)
High-Energy Trauma	Axial load, direct force	Falls, car accidents	3 5 6 7
Fall From Height	Land on feet	Workplace, ladder falls	3 5 6 7
Motor Vehicle Accident	Sudden impact	Car or motorcycle crashes	6 7
Low-Energy/Repetitive Stress	Repeated microtrauma	Athletes, military training	5
Pathologic	Weakened bone, minimal trauma	Osteomyelitis, cancer, diabetes	8

Table 3: Major Causes of Calcaneus Fracture

High-Energy Trauma

Most calcaneus fractures result from high-energy events, such as falling from a significant height or being involved in a motor vehicle collision. The force is transmitted upward through the heel, shattering the calcaneus and often affecting the surrounding joints and soft tissues 3 5 6 7. These mechanisms often lead to complex, displaced, and intra-articular fractures.

Falls from Height

A classic scenario is a fall from a ladder or scaffolding, landing on the feet. The vertical force compresses the calcaneus, leading to shearing and crushing injuries. In many cases, this mechanism also results in associated injuries, such as lumbar spine fractures 6 7.

Motor Vehicle Accidents

Car and motorcycle accidents are another leading cause. The sudden, direct impact can fracture the calcaneus and cause extensive soft tissue damage, especially in open fractures 6 7.

Low-Energy and Pathologic Fractures

Though less common, repetitive microtrauma—such as in athletes or military recruits—can cause stress fractures of the calcaneus 5. Additionally, pathologic fractures may occur in weakened bone due to chronic infection (osteomyelitis), cancer, or metabolic bone disease. These usually require little force and are more likely in patients with diabetes or other chronic illnesses 8.

Treatment of Calcaneus Fracture

Treating a calcaneus fracture is complex and depends on the severity, type, and associated soft tissue injuries. The goal is to restore function, minimize pain, and prevent long-term complications.

Treatment Option	Approach/Indication	Key Points	Source(s)
Non-operative	Stable, non-displaced, or minimally displaced fractures	Functional bracing, rest, elevation, early mobility	9 10 12
Operative	Displaced intra-articular, open, or unstable fractures	Open reduction, internal fixation, plates/screws	4 5 11 12 13
Percutaneous Fixation	Minimally invasive, select patterns	Fewer wound complications	12 13
Emergency Debridement	Open or severely compromised fractures	Prevent infection, soft tissue loss	7 12
Amputation	Severe soft tissue loss, infection	Last resort	1 7 8
Arthrodesis (Fusion)	Post-traumatic arthritis, malunion	Salvage procedure	4 12

Table 4: Common Treatment Approaches

Non-operative Management

Non-operative treatment is usually reserved for non-displaced or minimally displaced fractures, and for patients unable to undergo surgery due to medical risk. Management involves:

• Elevation and immobilization (splint or cast)
• Early range of motion exercises as pain allows
• Gradual progression to weight-bearing

Recent randomized trials have shown that, for many displaced intra-articular fractures, non-operative management can yield outcomes similar to surgical intervention, but with fewer complications 9 10. However, careful patient selection is essential.

Operative Management

Surgery is indicated for:

• Displaced intra-articular fractures
• Open fractures
• Fractures with threatened or actual soft tissue compromise

The main surgical techniques include open reduction and internal fixation (ORIF) with plates and screws, often via a lateral approach that allows visualization and realignment of the joint surfaces 4 5 11 12 13. The goal is to restore the anatomy and allow early movement. Minimally invasive or percutaneous fixation may be chosen for select fracture patterns or when soft tissue is at high risk 12 13.

Special Considerations

• Tongue-type fractures with threatened skin must be reduced immediately to prevent skin necrosis. Percutaneous reduction and plantarflexion splinting may be lifesaving for the soft tissue envelope 1.
• Open fractures require urgent antibiotics, tetanus prophylaxis, and surgical debridement to prevent infection 7 12.
• Pathologic fractures may require customized approaches, often including management of the underlying disease and, in severe cases, amputation 8.

Complications and Rehabilitation

Common complications include:

• Wound healing problems and infection (especially after surgery)
• Post-traumatic arthritis of the subtalar joint
• Malunion (healed in poor position), leading to pain and disability
• Stiffness and chronic pain

Post-traumatic arthritis sometimes requires salvage surgery in the form of subtalar arthrodesis (joint fusion) 4 12.

Rehabilitation with early motion, as tolerated, is critical for restoring function, but weight-bearing is delayed until healing is confirmed 11 13.

Conclusion

Calcaneus fractures are complex injuries with the potential for significant long-term disability. A comprehensive, individualized approach to diagnosis and management is essential for optimal outcomes.

Key Points:

• Calcaneus fractures present with heel pain, swelling, bruising, and difficulty walking; severe cases may involve visible deformity or open wounds.
• Most fractures are intra-articular and result from high-energy trauma such as falls or vehicle accidents; associated injuries are common.
• Treatment ranges from non-operative management for stable fractures to complex surgical reconstruction for displaced or open fractures; patient and fracture characteristics guide decision-making.
• Complications can be serious, including infection, skin breakdown, arthritis, and even amputation in extreme cases.
• Early recognition, careful soft tissue management, and appropriate rehabilitation are essential for recovery.

Understanding the full spectrum of calcaneus fracture symptoms, types, causes, and treatments can empower patients and clinicians to navigate these challenging injuries with confidence and hope for recovery.