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DOI: 10.1148/rg.255045713
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Right arrow Musculoskeletal Radiology
Right arrow Computed Tomography

Fractures of the Calcaneus: A Review with Emphasis on CT1

Aditya Daftary, MB, BS, Andrew H. Haims, MD and Michael R. Baumgaertner, MD

1 From the Departments of Radiology (A.D., A.H.H.) and Orthopedic Surgery (M.R.B.), Yale University School of Medicine, 333 Cedar St, Box 208042, New Haven, CT 06520-8042. Received June 23, 2004; revision requested August 5; final revision received December 16; accepted December 17. All authors have no financial relationships to disclose.


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  		Figure 1a.  (a) Lateral radiograph of the normal calcaneus. (b) Lateral radiograph of the calcaneus shows compression (light blue arrows) and traction (yellow arrows) trabeculae, with the neutral triangle (brown triangle) in between with sparse trabeculae. The thickened cortical or thalamic portion of the bone supporting the articular facets is shown (T). The critical angle of Gissane (G) and the Boehler angle (B) have also been drawn in. The Boehler angle is normally 20°–40°.

 


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  		Figure 1b.  (a) Lateral radiograph of the normal calcaneus. (b) Lateral radiograph of the calcaneus shows compression (light blue arrows) and traction (yellow arrows) trabeculae, with the neutral triangle (brown triangle) in between with sparse trabeculae. The thickened cortical or thalamic portion of the bone supporting the articular facets is shown (T). The critical angle of Gissane (G) and the Boehler angle (B) have also been drawn in. The Boehler angle is normally 20°–40°.

 


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  		Figure 2.  Drawing of the superior surface of the calcaneus shows the anterior (A), middle (M), and posterior (P) facets of the calcaneus, as well as the calcaneal sulcus (S) that runs between the middle and posterior facets. The canal formed by the calcaneal sulcus and overlying talus is the sinus tarsi.

 


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  		Figure 3.  Drawing of the lateral surface of the calcaneus shows the peroneal tubercle (P), as well as the lateral talocalcaneal (LTL), interosseous (IOL), and bifurcate (B) ligaments.

 


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  		Figure 4.  Drawing of the medial surface of the calcaneus shows the neurovascular bundle (N), sustentaculum tali (S), and medial talocalcaneal ligament (M).

 


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  		Figure 5a.  Optimal CT reformation planes for evaluation of calcaneal fractures. (a) Sagittal reformatted images of the calcaneus are prescribed off the axial images at the level of the ankle joint. (b) Coronal images are reformatted perpendicular to the sagittal images, also in reference to the ankle joint. (c, d) For fracture classification, particularly with the Sanders classification, we reformat our images parallel (c) and perpendicular (d) to the posterior facet off the sagittal reformatted images.

 


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  		Figure 5b.  Optimal CT reformation planes for evaluation of calcaneal fractures. (a) Sagittal reformatted images of the calcaneus are prescribed off the axial images at the level of the ankle joint. (b) Coronal images are reformatted perpendicular to the sagittal images, also in reference to the ankle joint. (c, d) For fracture classification, particularly with the Sanders classification, we reformat our images parallel (c) and perpendicular (d) to the posterior facet off the sagittal reformatted images.

 


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  		Figure 5c.  Optimal CT reformation planes for evaluation of calcaneal fractures. (a) Sagittal reformatted images of the calcaneus are prescribed off the axial images at the level of the ankle joint. (b) Coronal images are reformatted perpendicular to the sagittal images, also in reference to the ankle joint. (c, d) For fracture classification, particularly with the Sanders classification, we reformat our images parallel (c) and perpendicular (d) to the posterior facet off the sagittal reformatted images.

 


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  		Figure 5d.  Optimal CT reformation planes for evaluation of calcaneal fractures. (a) Sagittal reformatted images of the calcaneus are prescribed off the axial images at the level of the ankle joint. (b) Coronal images are reformatted perpendicular to the sagittal images, also in reference to the ankle joint. (c, d) For fracture classification, particularly with the Sanders classification, we reformat our images parallel (c) and perpendicular (d) to the posterior facet off the sagittal reformatted images.

 


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  		Figure 6a.  Diagrams of the superior (a) and lateral (b) surfaces of the calcaneus show the shear (solid black line) and compression fracture lines from joint depression (blue lines) and tongue (red lines) type fractures. The shear fracture splits the calcaneus into the anteromedial (or sustentacular) and posterolateral (or tuberosity) fragments. The compression fracture runs in the coronal plane, with the anterior limb running through the critical angle of Gissane and the posterior limb extending either horizontally toward the tuberosity as a tongue type fracture (red line) or more vertically, just posterior to the posterior facet, as a joint depression type fracture (blue line).

 


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  		Figure 6b.  Diagrams of the superior (a) and lateral (b) surfaces of the calcaneus show the shear (solid black line) and compression fracture lines from joint depression (blue lines) and tongue (red lines) type fractures. The shear fracture splits the calcaneus into the anteromedial (or sustentacular) and posterolateral (or tuberosity) fragments. The compression fracture runs in the coronal plane, with the anterior limb running through the critical angle of Gissane and the posterior limb extending either horizontally toward the tuberosity as a tongue type fracture (red line) or more vertically, just posterior to the posterior facet, as a joint depression type fracture (blue line).

 


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  		Figure 7a.  (a) Coronal CT image shows the shear fracture line (arrow) separating the anteromedial or sustentacular fragment (S) and the posterolateral or tuberosity fragment (T). Note that the articulation of the posterior facet with the talus is maintained medially and is more angulated laterally. (b) Sagittal image of the same patient shows depression of the tuberosity fragment (T). (c) Coronal CT image of a different patient shows two shear fracture lines (arrows) that separate the sustentacular (S), middle (M), and tuberosity (T) fragments, an example of the "double split."

 


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  		Figure 7b.  (a) Coronal CT image shows the shear fracture line (arrow) separating the anteromedial or sustentacular fragment (S) and the posterolateral or tuberosity fragment (T). Note that the articulation of the posterior facet with the talus is maintained medially and is more angulated laterally. (b) Sagittal image of the same patient shows depression of the tuberosity fragment (T). (c) Coronal CT image of a different patient shows two shear fracture lines (arrows) that separate the sustentacular (S), middle (M), and tuberosity (T) fragments, an example of the "double split."

 


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  		Figure 7c.  (a) Coronal CT image shows the shear fracture line (arrow) separating the anteromedial or sustentacular fragment (S) and the posterolateral or tuberosity fragment (T). Note that the articulation of the posterior facet with the talus is maintained medially and is more angulated laterally. (b) Sagittal image of the same patient shows depression of the tuberosity fragment (T). (c) Coronal CT image of a different patient shows two shear fracture lines (arrows) that separate the sustentacular (S), middle (M), and tuberosity (T) fragments, an example of the "double split."

 


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  		Figure 8a.  (a) Sagittal reformatted image of a tongue type fracture shows the fracture line, which exits the posterior aspect of the calcaneus (arrows). (b) On a sagittal reformatted image of the more common joint depression type fracture, the fracture line does not communicate with the tuberosity and runs just posterior to the articular surface (arrows).

 


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  		Figure 8b.  (a) Sagittal reformatted image of a tongue type fracture shows the fracture line, which exits the posterior aspect of the calcaneus (arrows). (b) On a sagittal reformatted image of the more common joint depression type fracture, the fracture line does not communicate with the tuberosity and runs just posterior to the articular surface (arrows).

 


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  		Figure 9a.  Common findings associated with calcaneal fractures. (a) Sagittal reformatted image shows marked impaction and rotation of the lateral aspect of the posterior articular facet (arrows). (b) Coronal reformatted CT image of the calcaneus shows widening (arrows), primarily caused by displacement of the posterolateral or tuberosity fragment (T).

 


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  		Figure 9b.  Common findings associated with calcaneal fractures. (a) Sagittal reformatted image shows marked impaction and rotation of the lateral aspect of the posterior articular facet (arrows). (b) Coronal reformatted CT image of the calcaneus shows widening (arrows), primarily caused by displacement of the posterolateral or tuberosity fragment (T).

 


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  		Figure 10.  Axial CT image shows the peroneal tendon (arrow) entrapped between the fracture fragments of the lateral surface of the calcaneus.

 


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  		Figure 11.  Schematic depicts the Sanders classification of intraarticular fractures of the calcaneus in coronal and axial views. Type I fractures are nondisplaced and are not shown. Fracture lines A, B, and C describe the position of the primary fracture line in relation to the posterior facet and the subtalar joint. Types II and III fractures have two or three fragments, respectively, which are then subdivided, depending on the medial or lateral position of the primary fracture line. Type IV fractures are severely comminuted. (Reprinted, with permission, from reference 13.)

 


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  		Figure 12.  Anterior oblique radiograph of the foot shows a fracture of the anterior process of the calcaneus (arrow). There was minimal involvement (<25%) of the calcaneocuboid articulation, and the fracture was treated conservatively.

 


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  		Figure 13a.  Coronal (a) and axial (b) CT images illustrate an isolated sustentacular fracture (arrows). In this case, the posterior articular facet was spared. S = sustentacular fragment.

 


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  		Figure 13b.  Coronal (a) and axial (b) CT images illustrate an isolated sustentacular fracture (arrows). In this case, the posterior articular facet was spared. S = sustentacular fragment.

 


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  		Figure 14a.  Lateral radiograph (a) and T1-weighted magnetic resonance (MR) image (b) show a displaced avulsion type fracture of the calcaneal tuberosity. The Achilles tendon (T) is seen on the MR image.

 


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  		Figure 14b.  Lateral radiograph (a) and T1-weighted magnetic resonance (MR) image (b) show a displaced avulsion type fracture of the calcaneal tuberosity. The Achilles tendon (T) is seen on the MR image.

 


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  		Figure 15.  Axial CT image demonstrates a minimally displaced fracture of the medial process of the calcaneus (arrows).

 




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