Calcaneal and talar fractures

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Mechanism establishes the search pattern. Axial load from a fall can fracture both calcanei and transmit force to thoracolumbar vertebrae, pelvis or tibial plateaux. Forced dorsiflexion and rotation produce talar neck or body injuries, often with subtalar or ankle dislocation. Record height, surface, footwear, energy, loss of consciousness and other pain before focusing on the spectacular heel. In older adults, establish bone health, pre-injury mobility, vascular status and medicines; in neuropathy, pain severity is unreliable.

Inspect before swelling hides the anatomy. Note hindfoot width, shortening, varus or valgus, open wounds, contamination, blisters and posterior skin colour. A calcaneal tuberosity fragment pulled superiorly by Achilles can blanch or tent the posterior skin and needs emergency action. Palpate the talar neck, malleoli, calcaneus, navicular, fifth-metatarsal base and midfoot. Test Achilles continuity, dorsalis pedis and posterior tibial pulses and superficial fibular, deep fibular, tibial, sural and saphenous sensation.

Talar dislocation is reduced urgently because persistent displacement harms skin, cartilage and neurovascular structures. Provide appropriate analgesia, sedation or theatre anaesthesia, avoid repeated forceful attempts and use an open reduction when soft-tissue interposition or fracture blocks safe closed reduction. Document examination before and after, splint the restored position and obtain radiographs followed by CT. Extrusion and open injury demand meticulous contamination control and orthoplastic planning.

Radiographs start the anatomical assessment. For calcaneus, lateral and axial hindfoot views show height, length, width, tuberosity displacement and subtalar involvement; ankle and foot views identify associated injury. Talar views show neck, body and joint alignment but subtle process injuries are easily missed. CT with multiplanar reconstructions is the key pattern-defining study for displaced intra-articular injury after emergency alignment. MRI is usually reserved for occult fracture, osteochondral or later vascular questions rather than acute obvious high-energy trauma.

Calcaneal treatment respects skin. Elevation, well-padded splintage and repeated checks allow swelling and blisters to settle. Stable extra-articular and selected minimally displaced intra-articular patterns may receive protected non-operative care with early motion when safe. Displaced joint surfaces, major varus or widening, open injury and skin-threatening tuberosity fragments need specialist surgery. Timing and method range from urgent fragment fixation to delayed reconstruction or selected primary subtalar fusion, based on tissue and reconstructability.

Talar treatment prioritises joint reduction and blood supply preservation. Undisplaced stable fractures may use strict immobilisation and non-weight bearing with CT confirmation and close films. Displaced neck or body fractures usually need reduction and fixation; timing of definitive fixation depends on skin after the dislocation is reduced. Process fractures range from protected care to fragment fixation or excision according to displacement, cartilage involvement and symptoms. AVN risk is related to initial displacement and cannot be abolished by a normal early radiograph.

Follow-up is long enough to detect biology and function. Serial radiographs assess union, alignment and talar vascular change. A subchondral radiolucent Hawkins sign at 6–8 weeks suggests preserved talar perfusion, but its absence does not prove osteonecrosis. CT evaluates union and articular position; MRI may clarify suspected AVN when it will change loading or surgery. Rehabilitation restores ankle and subtalar movement, strength and gait, while loading advances only against clinical and imaging evidence.

Key points

Treat high-energy hindfoot trauma as a whole-patient injury: complete ABCDE and examine the thoracolumbar spine, pelvis, knees, both heels and the entire ipsilateral limb.
Inspect posterior heel and medial and lateral skin early and repeatedly; a displaced tongue-type or tuberosity fragment can cause urgent posterior skin necrosis.
A talar dislocation needs urgent reduction after rapid neurovascular documentation and analgesia or anaesthesia; do not postpone reduction for CT when skin or circulation is threatened.
Obtain ankle and hindfoot radiographs, including lateral and calcaneal axial views where feasible; use CT after provisional alignment for intra-articular calcaneal, talar-neck, talar-body and process-fracture mapping.
Open wounds receive sterile cover, prompt intravenous network antibiotics, tetanus assessment, alignment and orthoplastic management without emergency-department probing or repeated irrigation.
Non-operative care is reserved for selected stable extra-articular or acceptably aligned patterns and patients in whom operative harm exceeds benefit; it still needs strict loading, motion and imaging instructions.
Definitive fixation or primary fusion decisions depend on articular displacement, joint congruity, soft tissue, contamination, comorbidity and function, not a classification label alone.
Warn that talar osteonecrosis, subtalar arthritis, heel widening, stiffness and prolonged inability to work on uneven ground can occur despite correct emergency care.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Axial-load impact

Falls from height and high-energy collisions drive the talus into the calcaneus, producing intra-articular comminution and transmitting force to the spine and proximal limb.

Forced inversion or dorsiflexion

Twisting and extreme ankle position can fracture talar neck, body or processes, sometimes with subtalar or ankle dislocation.

Low-energy avulsion

Muscular or ligamentous traction causes extra-articular calcaneal tuberosity or anterior-process fragments, which range from stable avulsion to skin-threatening displacement.

Fragility and neuropathy

Osteoporosis permits lower-energy hindfoot fracture, while diabetic neuropathy may hide pain and allow displacement, pressure damage and infection.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Calcaneal joint collapse
Posterior-facet depression, widening and varus deformity disturb subtalar congruity and heel mechanics, leading to impingement, stiffness and post-traumatic arthritis.
2
Talar vascular disruption
The talus has extensive cartilage and limited segmental blood supply; neck or body displacement can interrupt perfusion and cause osteonecrosis and collapse.
3
Skin compression
A superiorly displaced tuberosity fragment is pulled by Achilles tension against thin posterior skin, causing rapid pressure ischaemia and necrosis.
4
Energy-related soft-tissue injury
Swelling, fracture blisters, open contamination and muscle injury can be more important than the bone geometry when determining safe timing and approach.
5
Cartilage injury
Even anatomically reduced fractures have direct chondral impact and inflammatory damage that can progress to subtalar, ankle or talonavicular arthritis.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Intra-articular calcaneal fracture

A widened bruised heel after axial load with loss of calcaneal height and posterior-facet disruption indicates high-energy subtalar injury.

Tongue-type skin threat

A superior posterior fragment, skin blanching and Achilles tension creates an urgent pressure-necrosis pattern even if distal perfusion remains present.

Talar-neck fracture-dislocation

A fracture between talar head and body with subtalar or ankle malalignment threatens blood supply in proportion to initial displacement.

Talar-body fracture

Axial compression through the ankle creates a body fracture with tibiotalar and subtalar cartilage damage, often requiring CT to define comminution.

Talar-process fracture

Persistent anterolateral or posteromedial hindfoot pain after an apparent sprain may represent lateral or posterior process injury missed on routine views.

Hindfoot compartment syndrome

Escalating pain, tense foot swelling, passive-stretch pain and sensory change after calcaneal trauma needs emergency assessment despite palpable pulses.

Red flags requiring action

Blanching, tenting, blistering or threatened necrosis over the posterior heel with a displaced tuberosity or tongue fragment requires immediate reduction or fixation rather than delayed routine clinic care.
A dislocated talus, extruded bone, open wound, absent pulse, cold foot or progressive nerve deficit needs emergency reduction and coordinated orthopaedic, plastic and vascular management.
Severe escalating hindfoot pain, tense swelling, pain on passive toe motion or new sensory change raises foot compartment syndrome; palpable pulses do not exclude it.
An axial-load hindfoot fracture should trigger examination for calcaneal injury on the other side and thoracolumbar, pelvic, tibial-plateau and other load-transmission injuries.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line hindfoot radiographsFirst stepFirst line
Why
Identify fracture, gross displacement and joint malalignment.
Interpretation and limitations
Use lateral calcaneal and ankle views with a calcaneal axial view when tolerable; add AP ankle and foot views according to talar and associated injury.
02
Essential CT for intra-articular calcaneal mapping
Why
Define posterior-facet fragments, comminution, heel shape and joint congruity.
Interpretation and limitations
Obtain after urgent alignment for displaced injury; use multiplanar anatomy to assess the subtalar and calcaneocuboid joints and plan reconstruction.
03
Gold-standard CT for talar fracture anatomy
Why
Define fracture extension, comminution, occult fragments and articular congruity.
Interpretation and limitations
Obtain after emergency reduction and review tibiotalar, subtalar and talonavicular alignment; CT guides fixation but does not predict future perfusion by itself.
04
Trauma-axis imaging
Why
Detect associated vertebral, pelvic or contralateral limb injury after axial load.
Interpretation and limitations
Image from clinical findings and major-trauma protocol rather than ordering isolated heel studies while ignoring spinal tenderness or neurological deficit.
05
Serial neurovascular and skin examination
Why
Detect pressure necrosis, recurrent displacement and evolving nerve or vessel compromise.
Interpretation and limitations
Record posterior skin perfusion, wounds, blisters, named pulses and nerve territories before and after reduction and through the swelling phase.
06
Follow-up radiographs
Why
Assess union, alignment, collapse and signs of talar revascularisation.
Interpretation and limitations
Interpret Hawkins sign as reassuring when present but do not diagnose AVN solely because it is absent; correlate symptoms and serial imaging.
07
MRI for selected occult or vascular questions
Why
Detect radiographically occult stress injury, osteochondral damage or suspected talar osteonecrosis.
Interpretation and limitations
Use when the result changes protection or surgery; metal artefact and early post-traumatic marrow change can complicate interpretation.
08
CT for delayed union or malunion
Why
Define bridging, nonunion, collapse and arthritic joint anatomy.
Interpretation and limitations
Use before changing prolonged loading restrictions or planning corrective osteotomy, fixation revision, fusion or arthroplasty.
09
Targeted peri-operative tests
Why
Prepare safely for anaesthesia and quantify systemic injury.
Interpretation and limitations
Select FBC, renal profile, coagulation, group and screen, glucose and ECG from injury, blood loss, anticoagulation, age and comorbidity without delaying reduction.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Severe ankle sprain

Lateral swelling after inversion may conceal a talar lateral-process or anterior calcaneal-process fracture when routine ankle views appear reassuring.

Ankle or pilon fracture

Distal tibial and malleolar injury can coexist with hindfoot trauma and may dominate deformity or radiographic appearance.

Achilles tendon rupture

Posterior pain and weak plantarflexion with an abnormal calf-squeeze test suggests tendon failure, although tuberosity avulsion can produce similar dysfunction.

Lisfranc injury

Midfoot swelling, plantar bruising and tarsometatarsal instability localise injury anterior to the hindfoot and require weight-bearing imaging when safe.

Bone bruise or stress injury

Progressive load-related heel or talar pain without acute major trauma may have normal early radiographs and need MRI-based assessment.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01EmergencyRestore alignment and protect skinFirst stepThe hindfoot is open, dislocated, neurovascularly compromised or pressing on posterior heel skin.

1Complete trauma assessment and inspect both heels, spine and whole limb while documenting skin, pulses and named nerve function.
2Cover any open wound, give immediate protocol antibiotics and tetanus care and avoid repeated probing or emergency-department washout.
3Urgently reduce talar or hindfoot dislocation and relieve a skin-threatening posterior fragment, using theatre when safe closed reduction is blocked.
4Splint, elevate without impairing perfusion, repeat examination, obtain post-reduction films and CT, and continue frequent tissue surveillance.

02CalcaneusReconstruct the heel around its tissueCT defines a calcaneal fracture after emergency skin and alignment threats are controlled.

1Classify extra-articular versus intra-articular injury and assess height, width, varus, posterior facet, joints and Achilles-driven displacement.
2Protect stable patterns in a padded device with exact loading and early movement instructions plus scheduled imaging.
3DefinitiveTreat posterior skin-threatening avulsion urgently and delay other definitive approaches until swelling and blisters permit when clinically safe.
4Choose fixation, minimally invasive reconstruction or selected fusion from articular reconstructability, tissue, contamination, comorbidity and functional demand.

03TalusPreserve joints and monitor perfusionA talar fracture has been reduced and CT has established displacement and joint involvement.

1Immobilise truly undisplaced stable injury with strict loading limits and close specialist radiographic surveillance.
2Reduce and fix displaced neck or body injury to restore length, rotation and joint congruity while preserving remaining soft-tissue attachments.
3Individualise process-fracture fixation, protection or excision according to displacement, cartilage area, impingement and symptoms.
4Follow union and AVN risk over months and advance loading only through specialist clinical and imaging review.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

Provides baseline analgesia while preserving alertness for repeated trauma, compartment and neurovascular examination and later rehabilitation.

Paracetamol

Give 1 g orally up to four times in 24 hours as required, separated by at least 4 hours; use a lower maximum in adults under 50 kg or with frailty, malnutrition, chronic alcohol excess or hepatic impairment.

Check combined cold and opioid preparations and total daily exposure; pain relief must not justify delay in reducing a dislocation or relieving threatened posterior skin.

Reduces infection risk before formal debridement of a contaminated calcaneal or talar fracture.

Intravenous prophylaxis for an open hindfoot fracture

Administer the major-trauma network's specified intravenous antibiotic and weight-based adult dose immediately and ideally within 1 hour of injury; document the time and continue or broaden only through the open-fracture and contamination protocol.

Check severe allergy and renal factors but do not postpone the first suitable dose for CT; extrusion, water or farm contamination and delayed presentation require microbiology and orthoplastic decisions rather than an invented universal regimen.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Talar avascular necrosis

Loss of perfusion can produce patchy sclerosis, collapse and secondary arthritis; risk rises with displacement but remains possible despite prompt reduction.

Subtalar or ankle arthritis

Cartilage impact and residual incongruity cause chronic pain, stiffness and loss of uneven-ground function, sometimes requiring later fusion.

Heel malunion

Calcaneal shortening, widening and varus produces peroneal impingement, altered shoe fit, weakness, lateral overload and a persistently painful gait.

Wound failure and infection

Swollen lateral heel skin, open injury, smoking, diabetes and premature surgery increase necrosis, deep infection and osteomyelitis.

Complex pain and disability

Neuropathic pain, stiffness, weakness and prolonged work restriction can persist even after union and technically satisfactory reconstruction.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Inspect posterior, medial and lateral skin, blisters and wounds repeatedly and escalate blanching, necrosis, drainage or unexpected swelling immediately.
Repeat pulses, capillary refill and tibial, superficial fibular, deep fibular, sural and saphenous nerve findings after reduction, splintage and every clinical change.
Use serial radiographs and selected CT to track joint alignment, union, implant position, talar revascularisation and collapse before advancing load.
Assess wound healing and infection risk closely in smokers, diabetes, neuropathy, vascular disease and open injury and address modifiable factors.
Measure ankle and subtalar motion, calf power, heel alignment, shoe tolerance, gait on uneven ground and return-to-work function through rehabilitation.
Review VTE and bleeding risk throughout prolonged non-weight bearing, including changes in surgery, pregnancy, oestrogen exposure, cancer or anticoagulation.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

The spine may hurt later

Distracting heel pain can initially mask a thoracolumbar compression or burst fracture after axial load, so examine before analgesia fades.

Posterior skin outranks classification

A seemingly small calcaneal tuberosity avulsion can be more urgent than a comminuted fracture when Achilles pull threatens skin viability.

Reduction and fixation have different clocks

A talar dislocation is reduced immediately, while definitive internal fixation can wait for safer skin if joint alignment is maintained.

Hawkins sign is asymmetric evidence

Its presence supports talar vascularity, but absence alone is insufficient to diagnose osteonecrosis or determine salvage surgery.

Normal ankle views can miss processes

Talar lateral-process and anterior calcaneal-process injuries commonly masquerade as sprains and need targeted CT when focal symptoms persist.

Heel width determines footwear

Calcaneal malunion causes lateral impingement and shoe conflict even when overall fracture union looks satisfactory.

11Common pitfallsFrequent interpretation and management errors.

01
Focusing on the heel radiograph and failing to assess thoracolumbar spine, pelvis, knees and the contralateral calcaneus after axial load.
02
Delaying reduction of a talar dislocation or posterior skin-threatening calcaneal fragment until CT is available.
03
Calling a persistent focal hindfoot injury a sprain after routine ankle films without considering talar or calcaneal process fracture.
04
Operating through tense blistered lateral heel skin without a staged tissue plan.
05
Treating absence of Hawkins sign as proof of avascular necrosis or presence as permission for unsupervised loading.
06
Describing radiographic union without assessing subtalar motion, heel width, shoe fit, uneven-ground gait and work capacity.