The medial wall of the calcaneus is associated closely with the posterior tibial neurovascular bundle and its branches making the surgical approach challenging. The flat nature of the lateral calcaneal wall allows easier surgical access and direct visualization of intra-articular fractures, but is associated with higher wound and infectious complications. Fractures that require medial/combined approaches or lead to more difficulty with reduction will increase intraoperative time and are less likely to result in surgical success. The most commonly used and optimal surgical approach is the lateral approach.

In addition, the surgical reconstruction becomes more difficult not only with the comminution but with the translation of the fracture lines closer to the medial wall. In general, the prognosis worsens with the increase of articular comminution, for example, type III fractures were four times more likely to require subtalar arthrodesis than type II fractures. It correlates with the clinical outcome with little interobserver variability. It is not only helpful in pre-operative planning but also of significant prognostication value. It is primarily based on CT coronal oblique image with the plane perpendicular to the posterior subtalar joint and depends on the number of fractures and the fracture line position at the posterior calcaneal facet. On the other hand, the Sanders classification, which was developed in 1993, is currently the most widely used system. The limited popularity of the classification system is due to its limited prognostic relevance.

Tongue-type fractures can be distinguished from joint depression type by the involvement of the posterior tuberosity. It is primarily based on radiographic findings and distinguishes intraarticular fracture patterns into two types (depending on the exit point of the secondary fracture line): “tongue type” and “joint depression” fractures. The Essex-Lopresti classification system was developed in 1952. CLASSIFICATION SYSTEMS FOR INTRA-ARTICULAR FRACTURESįor intra-articular fractures, the two most commonly used classification systems for calcaneal fractures are the Essex-Lopresti classification and Sanders classification. All of these are important in deciding further management and affect patients’ prognosis. CT also allows better visualization of the surrounding soft tissues compared to radiography and may show tendon entrapment or dislocation. Modern evaluation of calcaneal fractures heavily relies on CT with multiplanar reformats with the use of volume rendering reconstruction allowing better characterization of fracture lines, displacement of bone fragments, and visualization of subtalar joint involvement. The more common intra-articular fractures involve axial loading mechanisms (e.g.

Extra-articular fractures (accounting for 25% of fractures) do not involve the posterior facet, while the intra-articular fractures (accounting for 75% of fractures) involve the posterior facet. In general, calcaneal fractures are divided into extra- or intra-articular fractures, depending on the involvement of the posterior facet which carries the majority of axial load during weight-bearing. It is an uncommon fracture that could cause significant patient morbidity due to its role in gait, axial load transmission, and foot motion. It is the most inferior bone in the body that constantly supports the axial load from the weight of the body. The calcaneus is the largest tarsal bone and most commonly injured tarsal bones that account for 2% of all fractures.

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