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Intra-Articular Fractures Of The Calcaneum: Role Of The CT Scan In Management

* Vinod Kumar, Ammar Hameed, Raj Bhattacharya, Ian McMurtry

*The James Cook University Hospital, Middlesbrough, TS4 3BW, United Kingdom.

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Mr Vinod Kumar,
20, The Wickets, Memorial Drive, Stokesley Road, Marton , TS7 8EL.
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This study aimed to study the role played by the CT scan in decision making in the management of intra-articular fractures of the calcaneum. Twenty-four patients with intra-articular fractures of the calcaneum were included. Their initial radiographs and CT films were blinded and assessed by three independent observers. Based on these they were selected for operative or non-operative management. The actual management was also recorded. The data was then subjected to statistical analysis to look at the association between the decision from radiograph, that from the CT scan and  the actual management undertaken. Non-parametric tests for related samples were performed to look at the association between the actual management and the decisions made by assessing the radiographs and the CT scans. There was no significant difference between the actual management and decisions made by assessing the plain radiographs or the CT scan, for all three observers. There was also no significant difference between the radiograph based decisions and CT based decisions. However, the Cochran Q test showed that there was significant variation between the three observers, for the CT based assessment. Our results, show that the CT scan should only be done when a definite decision is made to operate on a patient, based on plain radiographs. Calcaneal fractures which are selected for non-operative management, based on X rays, should not have a CT scan as a routine as it provides no valuable additional information affecting the management decision.
Key words
: Calcaneum, Computerised Tomogram, Intra-articular, Os Calcis.

J.Orthopaedics 2006;3(2)e4


Fractures of the calcaneum account for 1-2 percent of all fractures and the most common of the tarsal bones fractures1,2. They are  usually the result of a fall from a height.They are commonly bilateral and are associated with fractures of the spine.. The fractures can be classified as those involving the talo-calcaneal joint, subtalar,  ( intra-articular) and those that do not. The injury is found predominantly in young or middle aged men and causes a very significant loss to economic activity, as it make take up to 18 months for full weight bearing3. It also results in residual heel pain, deformity and swelling in many individuals. It is thus imperative to get a good pain free functional outcome in these patients.

The management of calcaneal fractures is the subject of much debate and controversy4,5,6,7 .It may be operative or non-operative, and there have been various studies in the literature which claim similar results in both these groups. However, recently published, randomised control trial, comparing operative and non-operative management, show slightly better outcomes in certain groups of patients treated surgically8. Non-operative interventions involve the use of ice, elevation, plaster splintage and early mobilisation. The operative methods involve closed reduction with pins, open reduction and internal fixation and arthrodiesis2,6. The management decision to operate or not is based on assessment of the axial and lateral radiographs and a CT scan. There have been various classification systems based on radiographs9,10 and CT11,12,13,14.The classification system proposed by Sanders15, has been found useful in determining treatment and prognosis. However this CT based classification system has high degrees of variability and inconsistencies16. It has been suggested that the best method of assessing a calcaneal fracture is a CT scan. We set out to see the role that a CT scan plays in the management of these fractures and to determine if it makes any difference in the decision making process.

Material and Methods :

This was a retrospective cohort study. Twenty three individuals with twenty four fractures of the calcaneum were included in the study. Only intra-articular fractures, involving the talo-calcaneal joint, were included. These fractures were investigated with lateral and axial radiographs, and a  CT Scan. The actual management, in dichotomous groupings, (operative or non-operative), was also documented. The films were then blinded to name and age, placed in random order and assessed by three individual observers at different points in time. The observers were asked to assign the radiographs to operative or non-operative management. The CT scan films were then similarly assessed for operative or non-operative treatment. The observers were not told of the management decision  that they had made based on the radiographs , before they graded the CT scan films. The results were then analysed using a statistical software (SPSS version 11).

Results :

The agreement between the actual management and the management decision made from assessing the radiographs, and the actual management and management decision assessing the CT scans were analysed, for each of the three observers. The data was non-parametric and related. The Sign test was used to analyse if the decisions made in each of the groups were significantly different from the actual management. The results are enumerated in table 1 and table 2.

The p value, for the Sign test, was greater than 0.05 for all sets of observations. This means that there is no statistically significant difference, at the 5 percent level, between the management decision from the radiographs and actual management ( Table 1) or the CT films  and the actual management (Table 2), for each of the observers. This implies that there is good agreement between the decisions and the actual management, for both the CT and the radiographs.

 Table 1: SIGN test Radiographs versus Actual management 



(P value)

Number of agreements

( out of 24)

Observer 1



Observer 2



Observer 3



 Table 2: SIGN test CT scan versus Actual management  


Significance, (P value)

Number of agreements

( out of 24)

Observer 1



Observer 2



Observer 3




The change in management that the CT scan brought about was also assessed for each of the observers using the McNemars test. This test is used to detect changes in responses in each case, brought about by the CT scan. This was carried out as the data was non-parametric, related and the response, dichotomous. There was no statistically significant difference ( P >0.05)  in the decision made ( i.e non-operative or operative), between the radiographs and the CT scan assessments, for all three observers. Thus, a CT scan did  not make any significant difference to the decision made based on the plain radiographs, on whether to operate.

A statistical analysis was also performed to assess the variability of the management decisions of the 24 fractures between the three observers. A Cochran Q test was used for the analysis showing that there was no significant difference ( Q=3.84, p value = 0.14) between the radiograph based assessments of the three observers. However, there was statistically significant difference (Q=9.50, p value =0.009) between the CT scan based assessments of the observers. This shows that there is more inter-observer variability in decision making, using the CT based assessment.

The results show that both the radiograph based management and the CT scan based management decision, did not significantly differ from the actual management. There was also no statistically significant difference between the decisions based on  the two modalities. A CT scan, therefore, does not significantly change the management decision, from what has already been decided from assessing the  plain radiographs.

Discussion :

The typical assessment of intra-articular fractures of the Os Calcis are lateral and axial plain radiographs, followed by a CT scan. There is a tendency to request a scan to delineate the fracture fragments, as a routine, when the plain radiograph suggests an intra-articular fracture. It has been suggested that the best method of assessing an intra-articular fracture, to decide management is a CT scan. It is thought that the scan would help to delineate the fracture fragments better than a plain radiograph and thus, help in making the management decision. However, the best known CT based classification system of Sanders, has been shown to have high degrees of variability and inconsistencies1. In our present study, it was demonstrated that there was good correlation between the final actual management and both, the plain radiograph and the CT scan. There was no difference in the management decisions ( operative or non-operative), between the plain radiographs and the CT scan. The McNemars test  performed to see if the CT scan made any change to the management decision made based on plain radiograph showed that it did not significantly alter the decision, for all three observers. In fact, the decisions based on the CT scan showed a greater degree of variability between the observers, than the decisions based on plain radiographs. This was demonstrated by the Cochran Q test , (p<0.01). These tests suggest that the management decision on whether to operate or not, can reliably be based solely on plain radiographs. Thus, there may be no need to obtain a CT scan as a routine in all intra-articular fractures of the Os Calcis. However once, the decision has been made to operate, the CT scan is useful in providing further detail of the fracture pattern.


We conclude that, the CT scan should only be requested when a decision is made to operate on the fracture, based on plain radiographs. This may help in delineating the fragments in a comminuted fracture, and may help in pre-operative planning of fracture fixation. It does not have to be obtained as a routine to assess all intra-articular fractures of the calcaneum.

Acknowledgements:We would sincerely like to thank Mr R Liow, Consultant Orthopaedic Surgeon, Friarage Hospital, Northallerton and Mr J Candal-Couto, Consultant Orthopaedic Surgeon, Wansbeck General Hospital, for kindly sparing their time to classify the radiographs and the scans.

Reference :

  1. Burns AE. Fractures of the calcaneum- Symposium on osseous trauma of the foot. Clinical  Podiatric Medicine and Surgery 1985;2:311.

  2. Gurtowski J, Ries MD, Levin PE. Fractures and Dislocations of the foot In:Dee R, Mango E, Hurst L, editor(s). Principles of Orthopaedic Practice. USA. McGraw-Hill Inc,1989:1242-1260.

  3. Bridgman SA, Dunn KM, McBride DJ, Richards PJ. Interventions for treating calcaneal fractures ( Cochrane review ) In: The Cochrane Library, Issue 2, 2004. Chichester UK, John Wiley & Sons, Ltd.

  4. Kenwright J. Fractures of the calcaneum. Journal of  Bone and  Joint Surgery (Br) 1993;75:176-77.

  5. Lowery RB, Calhoun JH. Fractures of the Calcaneus. Part 1: Anatomy, Injury mechanism and classification. Foot and Ankle International 1996;17:230-35.

  6.  Lowery RB, Calhoun JH. Fractures of the Calcaneus. Part 2: Treatment. Foot and Ankle International 1996;17:360-66.

  7. Thordarson DB, Krieger LE. Operative Vs Non-operative treatment of Intra-  articular fractures of the calcaneum. A prospective randomised trial. Foot & Ankle International 1996; 17(1): 2-9.

  8. 8. Buckley R, Tough S, McCormack R et al. Operative compared with non-operative treatment of displaced intra-articular calcaneal fractures. Journal of  Bone and  Joint Surgery (Am) 2002;84-A:1733-44.

  9. Essex-Lopresti P. The mechanism, reduction techniques and results in fractures of the Os Calcis. British  Journal of  Surgery 1952;39:395-419.

  10. Soeur R, Remy R. Fractures of the calcaneus with displacement of the thalamic   portion. Journal of  Bone and Joint Surgery(Br) 1975;57-B:413-21.

  11. Crosby LA, Fitzgibbons TC. Computerised tomography scanning of acute intra-  articular fractures of the calcaneum: a new classification system. Journal of  Bone and Joint Surgery (Am) 1990;72-A:852-9.

  12. Eastwood DM, Gregg PJ, Atkins RM. Intra-articular fractures of the calcaneum part 1: pathological anatomy and classification. Journal of  Bone and  Joint Surgery (Br)1993;75-B:183-8.

  13. Sanders R. Displaced Intra-articular fractures of the Calcaneus. Journal of  Bone and Joint   Surgery(Am) 2000;82A:225-50.

  14. Zwipp H, Tscherne H, Thermann H, Weber T. Osteosynthesis of displaced intra-articular fractures of the calacaneus: results in 123 cases. Clinical Orthopaedics 1993;290:76-86.

  15. Sanders R, Fortin P, Dipasquale T, Walling A. Operative treatment in 120 displaced intra-articular calcaneal fractures: results using a prognostic computed tomographiy scan classification. Clinical Orthopaedics 1993;290:87-95.

  16. Bhattacharya R, Vassan UT, Finn P, Port A. Sanders classification of fractures of   the Os Calcis. An analysis of inter-  and intra-observer variability. Journal of Bone and Joint  Surgery (Br) 2005;87-B:205-8.

This is a peer reviewed paper 

Please cite as : V Kumar: Intra-Articular Fractures Of The Calcaneum: Role Of The CT Scan In Management

J.Orthopaedics 2006;3(2)e4





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