REVIEW Controversies in calcaneus fracture management: a systematic review of the literature Mandeep S. Dhillon • Kamal Bali • Sharad Prabhakar Received: 30 October 2010 / Accepted: 1 March 2011 Ó Springer-Verlag 2011 Abstract Despite the fact that the calcaneus is the com- monest tarsal bone fractured, many controversies exist in the literature regarding the management options. This stems from the fact that the understanding of the fracture pattern has evolved only recently, surgical approaches have lately been standardized, surgical timing has become more clear, and newer implants are regularly being introduced. Despite the significant advances, complications and con- troversies related to this common fracture abound. The present paper looks at all aspects of modern management options of calcaneus fractures and tries to review the lit- erature with regard to the controversial issues that still persist. Keywords Calcaneus fracture Á Treatment Á ORIF Á Controversy Introduction The calcaneus is the largest tarsal bone, with 4 articular facets, allowing it to articulate with the talus superiorly and the cuboid anteriorly. The posterior facet is the major weight-bearing surface, and fractures through this are the most difficult to manage and have often been the focus of much controversy. Calcaneus injuries represent 2% of all adult fractures and are the most frequent tarsal fracture ( [ 60%) [1–3]. Extra-articular fractures account for 30%, with 15% anterior process fractures and 10% tuberosity beak or avulsion fractures. Intra-articular fractures com- prise around 70% of all calcaneal fractures in adults; it is in the management of these intra-articular fractures that the challenges and poor outcomes are most frequently encountered. Various controversies in management still exist, despite modern diagnostics and an evolution of management pro- tocols. Subtalar stiffness and arthritis often result, regard- less of type of treatment, and heel widening, peroneal impingement, implant-related problems, and heel pad pain may give less than optimal outcomes. Further, there could be some late problems like anterior impingement resulting from the loss of calcaneus height in the long run. In an effort to address these controversies, we evaluated the published literature and have attempted to review the current concepts in the management of cal- caneal fractures. Fracture mechanism Many controversial issues have been put to rest by a better understanding of the fracture mechanism; we now know that nearly all intra-articular calcaneal fractures are caused by an axial loading mechanism, which is directed through the somewhat laterally situated calcaneal tuberosity. Most common causes are falls from height or motor vehicle collisions; there is a high-energy axial load applied to the heel, which drives the talus downward onto the calcaneus. The resultant primary fracture line extends from the lat- eral aspect of the angle of Gissane in a posteromedial direction, initiating an oblique primary fracture line. It is from this point that multiple secondary fracture lines may develop. M. S. Dhillon Á K. Bali (&) Á S. Prabhakar Department of Orthopedic Surgery, PGIMER, Chandigarh 160012, India e-mail: kamalpgi@gmail.com 123 Musculoskelet Surg DOI 10.1007/s12306-011-0114-y