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Contents lists available at ScienceDirect

Foot and Ankle Surgery

journal homepage: www.elsevier.com/locate/fas

Different types and epidemiological patterns of calcaneal fractures

based on reviewing CT images of 957 fractures$
Amir Reza Vosoughia , Roham Borazjanib , Niayesh Ghasemib , Shiva Fathib ,
Amirali Mashhadiaghab,* , Amir Human Hoveidaeib,c
a
Department of Orthopedic Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
b
Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
c
Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: Calcaneal fractures may have lifelong debilitating sequences, if not treated properly.
Received 31 August 2020 Identifying different types of calcaneal fractures based on the computed tomography (CT) scans can
Received in revised form 23 January 2021 increase our conception about these fractures.
Accepted 3 February 2021
Methods: In a cross-sectional study, the available CT images of all consecutive patients with the diagnosis
Available online xxx
of calcaneal fracture, from January 2015 to December 2018, were reviewed to determine different
patterns and types of these fractures.
Keywords:
Results: CT images of 886 patients (mean age, 41.29  14.9; range, 3–89 years; male/female, 4.86;
Calcaneocuboid
Calcaneus
pediatric: 3.7%) with 957 calcaneal fractures were evaluated. The peak incidence of calcaneal fractures
Epidemiology was seen in patients between 30 to 39 years of age (29%). The rate of open fractures and bilateral
Fracture involvements were 2.4% and 8.0%, respectively. Among 680 (71.0%) intra-articular calcaneal fractures,
Sanders classification subtalar calcaneal fractures were the most common type (94.3%). The majority of intra-articular subtalar
Subtalar joint calcaneal fractures were displaced (95.0%) with calcaneocuboid joint (CCJ) involvement (59.9%). Fracture
lines were extended to the CCJ in about 86.9% of Sanders type IV, 66.3% of type III, and 60.2% of type II.
Among 261 extra-articular fractures (27.3%), calcaneal body fracture (55.6%) was the most frequent type,
followed by medial tubercle fracture (24.1%), calcaneal tuberosity fracture (10.4%), Degan type I anterior
process fractures (5.4%), Degan type II anterior process fracture (3.4%), and isolated lateral tubercle
fracture (1.1%). Most of bilateral calcaneal fractures were intra-articular subtalar fractures with
involvement of CCJ. Although majority of intra-articular calcaneal fractures were displaced; less than half
of the extra-articular fractures were displaced.
Conclusion: Displaced intra-articular subtalar calcaneal fractures with CCJ involvement are the most
frequent type of unilateral and bilateral calcaneal fractures. It appears that there is a correlation between
Sanders type and the probability of CCJ involvement. Unlike intra-articular subtalar calcaneal fractures,
the CCJ in the majority of extra-articular calcaneal body fractures was intact.
Level of evidence: Level IV.
© 2021 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction
calcaneal fracture is about 11.5–13.7 per 100,000 person-years.
Males are affected more frequently than females. Calcaneal
Calcaneal fractures, the most frequently fractured of all the
fractures are more common among young manual workers. They
tarsal bones, comprise 1–2% of all fractures. The incidence of
often occur after falling downs, motor vehicle accidents (MVA),
and sport injuries [1–4].
$
Calcaneal fractures could be debilitating injuries with several
This study was carried out in Department of Orthopedic Surgery, Chamran
Hospital, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
sequences and complications, if not treated properly. Malunion of
* Corresponding author. calcaneal fractures may result in changes in anatomical and
E-mail addresses: [email protected], [email protected] biomechanical properties of the foot and ankle with deformities,
(A.R. Vosoughi), [email protected] (R. Borazjani), pain, and functional loss. Management of calcaneal fractures is a
[email protected] (N. Ghasemi), [email protected] (S. Fathi),
[email protected] (A. Mashhadiagha), [email protected]
technically demanding procedure with different approaches and
(A.H. Hoveidaei). devices [5]. Final functional outcomes have a close relationship

https://doi.org/10.1016/j.fas.2021.02.002
1268-7731/© 2021 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: A.R. Vosoughi, R. Borazjani, N. Ghasemi et al., Different types and epidemiological patterns of calcaneal fractures
based on reviewing CT images of 957 fractures, Foot Ankle Surg, https://doi.org/10.1016/j.fas.2021.02.002
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with perfect anatomical reduction of the fractured calcaneus, by

which the chance of upcoming degenerative arthrosis, neuritis,
and tenosynovitis of surrounding tendons would be decreased [6].
Epidemiological studies usually have an important impact on
our clinical practice by shedding a light on the causes, character-
istics, and different patterns of injuries. These studies can have a
positive effect on prevention, control, and management of the
problems. Moreover, they can help to reduce the cost burden by
determining the etiologic factors [7]. To the best of our reviewing
the literature, there are few epidemiological studies on the
calcaneal injuries [3,4,8–11]. It is noticeable that the findings
may be various in different societies and countries [12].
The aim of this study was to categorize the injury patterns of the
calcaneal fractures by reviewing computed tomography (CT) scan
of 957 fractures referred to our centers during a 4-year interval. Fig. 1. Distribution of calcaneal fractures by age groups.

2. Methods
Table 1
After approval of the study by the ethic committee of our Characteristics of the 886 patients with 957 calcaneal fractures.

university in accordance with the ethical standards laid down in Age (years), Mean  SD
the 1964 Declaration of Helsinki and its later amendments (IR. Total 41.3  14.9
SUMS.REC.1397.355), in a cross-sectional study, all consecutive Male 41.1  14.4
Female 41.8  17.3
patients with calcaneal fracture, from January 2015 to December
Gender (n = 886)
2018, admitted in the two main orthopedic trauma university Male 735 (83.0%)
hospitals of Shiraz, South of IranShiraz, South of Iran were Female 151 (17.0%)
included. All files of the patients in the database of hospitals were Affected side (n = 957)
reviewed. Demographic details and injury mechanisms were Left 506 (52.9%)
Right 451 (47.1%)
recorded. Bilateral (patient) 71 (8.0 %)
The primary radiological images and CT scans of all patients Hospital stay (day), Mean  SD 5.61  5.59
were studied by the senior author (ARV). Intra-articular calcaneal Open Vs. Closed (n = 887)
fractures, including subtalar joint and/or calcaneocuboid joint Open 21 (2.4%)
Close 866 (97.6%)
(CCJ), were differentiated from extra-articular fractures. Sanders
Mechanism of injury (n = 739)
and Degan classifications were used for intra-articular subtalar Fall 598 (81.0%)
calcaneal fractures and anterior process fractures, respectively Motor vehicle accident 123 (16.6%)
[13,14]. Displacement was defined as 2 mm in CT scan sections. Direct trauma 15 (2.0%)
We defined calcaneal combined fractures when there was no any Sport injury 3 (0.4%)
Displaced fracture 757 (79.1%)
fracture line between two separate fractured fragments.

2.1. Statistical analysis

CCJ involvement was the most common type followed by isolated
Descriptive data were expressed as frequency, mean, and intra-articular subtalar fractures, Degan type III anterior process
standard deviation after analyzing by the statistical package for the fractures, isolated sustentaculum tali fractures, and isolated intra-
social sciences version 16.0 for windows (SPSS Inc. Chicago, IL, articular CCJ fractures.
USA). The majority of intra-articular subtalar calcaneal fractures were
displaced (95.0%). About 60% of intra-articular subtalar calcaneal
3. Results fractures had displaced fractures lines extended to the CCJ. The
most common Sanders types of intra-articular subtalar calcaneal
Among 1075 calcaneal fractures, the CT images of 886 patients fractures, not only in adults but also in the pediatric group, were
(mean age, 41.29  14.9; range, 3–89 years) with 957 calcaneal Sanders IIA followed by Sanders IIB, 39.4% and 30.9%, respectively.
fractures were available to review. As demonstrated in Fig. 1, the Fourteen patients had isolated sustentaculum tali fracture with
peak incidence was seen in the patients between 30 to 39 years of mean age of 32.0  15.7 (range, 17–72) years (Table 2). All was
age (29%). Males were affected more frequently than females in all unilateral and 9 cases (64.3%) has displaced sustentaculum tali
age groups, with male to female ratio of 4.86 (Table 1). The majority fractures. More than half of them occurred on the right side (8
of patients were adults (96.3%) and only 3.7% of cases had the age cases, 57.1%) and most of them had closed injuries (92.9 %). The
under 18 years. Left side calcaneal fractures were more common most common mechanisms of injury were MVA (6 cases) and fall (5
than the right (52.9% vs 47.1%). The rate of open calcaneal fracture patients); however, the causes in the other 3 cases were unknown.
was 2.4% (among 887 feet). The most common mechanism of Overall, nine patients (64.3%) had associated injuries. One patient
injury was fall (81.0%) followed by MVA, direct trauma, and sport had concomitant fractures of both bones of forearm and
injuries. Seventy-one patients (8.0%) had bilateral calcaneal dislocation of thumb metacarpophalangeal joint. The other eight
fractures. Fig. 2 shows prevalence of different types of 957 patients had the following associated injuries in descending order
calcaneal fractures. of frequency; five talar fractures, three distal fibular fractures, one
cuboid fracture, and one Achilles tendon rupture. We had a case of
3.1. Intra-articular fractures isolated calcaneal dislocation with a fracture line in the
sustentaculum tali in association with the calcaneocuboid fracture
Overall, 680 (71.0%) intra-articular calcaneal fractures were dislocation, lateral process talus fracture, and avulsion fracture of
detected (Table 2). Intra-articular subtalar calcaneal fractures with tip of the fibula.

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Fig. 2. Anatomical patterns of all calcaneal fractures. CCJ, calcaneocuboid joint.

Table 2
Distribution of intra-articular calcaneal fractures.

Fractures (%) Mean age (SD) With CCJ involvement (%) Patients Adults Pediatrics Male Female
Total 680 (71.0%) 41.9  14.5 – 629 608 (96.7%) 21 (3.3%) 527 (83.8%) 102 (16.2%)
Subtalar 641 (94.3%) 42.1  14.4 384 (59.9%) 590 574 16 503 87
Sanders Ⅰ 32 (5.0%) 42.6  15.5 5 (15.6%) 28 28 0 22 6
Sanders A 253 (39.4%) 42.3  13.9 166 (65.6%) 240 230 10 207 33
Sanders B 198 (30.9%) 43.2  14.6 108 (54.5%) 184 179 5 159 25
Sanders C 37 (5.8%) 37.6  11.7 20 (54.0%) 32 32 0 24 8
Sanders ⅢAB 49 (7.6%) 39.7  15.6 37 (75.5%) 43 43 0 39 4
Sanders IIIAC 37 (5.8%) 43.8  15.9 22 (59.4%) 30 29 1 24 6
Sanders IIIBC 12 (1.9%) 45.5  14.5 6 (50.0%) 12 12 0 8 4
Sanders IV 23 (3.6%) 37.0  14.1 20 (86.9%) 21 21 0 20 1
Calcaneocuboid 10 (1.5%) 35.1  14.1 – 10 9 1 6 4
Sustentaculum tali 14 (2.0%) 32.0  15.7 – 14 11 3 11 3
Anterior Process type III 15 (2.2%) 47.6  16.6 – 15 14 1 7 8

CCJ: Calcaneocuboid joint.

Isolated CCJ fractures were detected in 10 CT images with eight 3.3. Combined fractures
depressed intra-articular fractures. In all of these cases, associated
fractures of the navicular and/or the cuboid were seen. It seems Totally, 16 patients (1.7%) had combined fractures in different
that this type of calcaneal fractures is a variant of transverse tarsal parts of the calcaneus. All patients were adults with mean age of
joint injuries. 48.2  13.6 (range, 24–70) years. All had unilateral calcaneal
fracture, except one patient. Most of cases were males (68.7%) and
3.2. Extra-articular fractures half of them occurred on the right side. Fifteen cases had
combination of the calcaneal body and anterior process fractures
As shown in Table 3, there were 261 extra-articular fractures and one patient had concomitant fractures of the sustentaculum
(27.3%). The distribution of these fractures was as follow in tali and type I anterior process.
descending order of frequency; calcaneal body, medial tubercle,
calcaneal tuberosity, Degan type I anterior process fractures, Degan 3.4. Bilateral fractures
type II anterior process, and lateral tubercle. Unlike intra-articular
subtalar calcaneal fractures, the CCJ in the majority of calcaneal Of 886 patients, 71 patients (8.0%) had bilateral calcaneal
body fractures (89.0%) was intact. Less than half of the extra- fractures. The mean age was 35.9  11.9 (male: 37.3  11.7, female:
articular fractures were displaced (44.1%). 30.6  11.6). The majority of patients were male (56, 78.9%) and

Table 3
Distribution of extra-articular calcaneal fractures.

Fractures (%) Mean age (SD) Displaced (%) Patients Adults Pediatrics Male Female
Total 261 (27.3%) 39.2  15.7 115 (44.1%) 242 230 (95.0) 12 (5.0%) 197 (81.4%) 45 (18.6%)
Body 145 (55.6%) 42.2  16.2 54 139 132 7 110 29
With CCJ involvement 16 (11.0%) 40.6  13.6 13 16 16 0 13 3
Without CCJ involvement 129 (89.0%) 42.4  16.5 41 123 116 7 97 26
Tuberosity 27 (10.4%) 38.0  16.0 19 26 26 0 23 3
Medial Tubercle 63 (24.1%) 33.4  12.6 29 51 48 3 45 6
Lateral Tubercle 3 (1.1%) 37.0  17.0 0 3 3 0 3 0
Anterior Process Type I 14 (5.4%) 34.2  15.3 4 14 12 2 10 4
Anterior Process Type II 9 (3.4%) 38.0  14.3 9 9 9 0 6 3

CCJ: Calcaneocuboid joint.

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Fig. 3. Anatomical patterns of bilateral calcaneal fractures.

adults (68, 95.8%). Most of bilateral calcaneal fractures (71.8%) displaced intra-articular calcaneal fractures is about 60% with 100%
were intra-articular subtalar calcaneal fractures and more than involvement of CCJ in sanders type IV, 63% of Sanders type III, and
half of them involved the CCJ (69, 67.6%). 53% of type II [17]. Kinner et al., in a clinical study, reported 68% rate
The most common mechanism of injury for bilateral calcaneal of CCJ involvement in intra-articular subtalar calcaneal fractures
fractures was fall followed by MVA. No sport injury or direct and an association between CCJ involvement and the worst
trauma was seen as the injury mechanism in bilateral calcaneal functional outcome following the surgery. The patients with CCJ
fractures. The most common Sanders classification was Sanders involvement had more limitations during gait with difficulties in
type IIB (31.4%), followed by Sanders IIA (25.5%) and Sanders IIC walking on uneven surfaces [6]. On the other hand, Gallino et al.
(10.8%). Majority of the patients suffered from bilateral subtalar did not find any differences for pain and functional scores among
calcaneal fractures followed by one side calcaneal body and the intra-articular subtalar calcaneal fractures extended to the CCJ
other one intra-articular subtalar calcaneal fractures (Fig. 3). (55% of cases) and patients without CCJ involvement (45% of cases)
[19].
4. Discussion According to our results, type Sanders classification was the
most frequent kind followed by type III, this is similar to previous
Although several studies tried to describe demographics and studies [4,20,21]. In contrary, Mitchell et al. informed more cases of
injury mechanisms of the calcaneal fracture [4,9] or describe Sanders type III than Sanders II [3]. There is a strong association
different calcaneal fracture types [3,10], no one assessed calcaneal between injury severity and calcaneal fracture complexity and the
fractures based on the CT images which had been reported by an final functional outcome at a long time [3,21]. Also, the position of
orthopedic foot and ankle surgeon. Also, by reviewing the foot during impaction may predict the type of calcaneal fracture
literature, no studies determined the different patterns of bilateral [22]. One important point is to cautiously interpret the Sanders
calcaneal fractures or combined calcaneal fractures. Our report is classification for intra-operative planning, because the correlation
the second largest population series after a study by Bohl et al. [9]. between Sanders classification and what we usually see during the
They reviewed 14516 patients by going through the American surgery is fair [20].
College of Surgeons National Trauma Data Bank. They reported There are a few studies on calcaneal fractures in the pediatric
demographic data, concomitant comorbidities, injury mecha- population. Bohl et al, reported that 4% of all calcaneal fractures
nisms, and associated injuries, without describing different types occur in patients less than 18 years of age [9]. Furthermore,
of calcaneal fractures. Although Mitchell et al. stated the several bilateral calcaneal fractures have been reported in 7.9 - 19% of
calcaneal fracture patterns in a single unit by evaluating 752 patients in the current literature [3,4,10,18]. As expected, our
calcaneal fractures in a 10-year period, they could retrospectively results are similar to these previous studies. In bilateral cases, the
review CT scan of only 80 cases [3]. Hence, to describe calcaneal most common pattern of fractures was bilateral intra-articular
fracture configurations, our data is the largest case series (957 subtalar calcaneal fractures (59.2%) followed by one side calcaneal
calcaneal fractures) with available pre-operative CT images, up to body fracture and the other side intra-articular subtalar calcaneal
now. fracture (14.1%). This characteristic of bilateral calcaneal fractures
We found 71% intra-articular calcaneal fractures, similar to has not been previously described.
what observed in the current literature (60%–76%) [3,5,10]. Regarding the mechanism of injury, our results are parallel to
Displaced intra-articular subtalar calcaneal fractures are the most previous reports with fall as the most frequent injury mechanism
challenging types for treatment [15] with the worst outcome [16]. (71.5%-75%) followed by MVA (10%) [3,4,10]. Notably, Mitchell et al.
Notably, displaced intra-articular subtalar calcaneal fractures with described fall from 6 feet or above as the most common
CCJ involvement is seen more than isolated displaced intra- mechanism of injury [3]. Among cases injured in motor vehicle
articular subtalar calcaneal fractures, based on our results. During crashes, calcaneal fractures in motorcycle accident is more
surgical approaching to these types of calcaneal fractures, we have prevalent that automobile accident [10]. We had no access to
to achieve a perfect reduction, not only for subtalar joint but also the exact kind of different mechanism of injury, so we could not
for CCJ. In our series, CCJ was involved in about 87% (20/23) of explain these data.
Sanders type Ⅳ, 66.3% (65/98) of type III, and 60.2% (294/488) of Isolated fractures of the sustentaculum tali are very rare injuries
type II calcaneal fractures. Therefore, a correlation between the of the calcaneus (1.4%). Although these fractures are sometimes
severity of injury and the probability of CCJ involvement can be considered as extra-articular fractures of the calcaneus, they
established. Studies by Miric and Patterson in 1998 [17] and Zwipp should be classified as intra-articular fractures because they result
et al. in 2004 [18] reported that the incidence of CCJ involvement in in incongruities in the middle facet of the subtalar joint [23]. This

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University of Medical Sciences, Shiraz, Iran. (Grant No. 97-01-56- [20] Vosoughi AR, Shayan Z, Salehi E, Jaberi FM, Solooki S, Kardeh B. Agreement
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