Sanders et al. prospectively treated 120 displaced intraarticular calcaneal fractures via a standardized lateral approach and developed a CT-based classification system. The study asks whether fracture pattern — defined by the number and location of posterior facet articular fragments — predicts both surgical reducibility and functional outcome. This is the paper that gave us the Sanders classification.
Before this paper, calcaneal fracture classification relied on plain radiographs (Essex-Lopresti) and focused on restoring calcaneal body shape and Böhler's angle rather than the articular surface itself. No CT-based system existed to predict what would happen in the OR or afterward.
When you see a displaced intraarticular calcaneal fracture, get a CT and classify it by the Sanders system before deciding on surgery. Type II and III fractures are reasonable ORIF candidates in experienced hands. Type IV fractures warrant a direct conversation about primary subtalar arthrodesis — these achieve 0% anatomic reduction and fail clinically 73% of the time with fixation, regardless of how experienced the surgeon is.
When counseling a patient after anatomic reduction, do not promise a good outcome. Fourteen of 17 fractures that eventually needed subtalar fusion had been anatomically fixed. The cartilage damage from the original injury is already done.
The Sanders classification became the universal language of calcaneal fracture surgery and remains the stratification tool used in every major subsequent trial, including the UK SPLASH trial comparing ORIF to nonoperative management.
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Sanders et al. prospectively treated 120 displaced intraarticular calcaneal fractures via a standardized lateral approach and developed a CT-based classification system. The study asks whether fracture pattern — defined by the number and location of posterior facet articular fragments — predicts both surgical reducibility and functional outcome. This is the paper that gave us the Sanders classification.
Before this paper, calcaneal fracture classification relied on plain radiographs (Essex-Lopresti) and focused on restoring calcaneal body shape and Böhler's angle rather than the articular surface itself. No CT-based system existed to predict what would happen in the OR or afterward.
When you see a displaced intraarticular calcaneal fracture, get a CT and classify it by the Sanders system before deciding on surgery. Type II and III fractures are reasonable ORIF candidates in experienced hands. Type IV fractures warrant a direct conversation about primary subtalar arthrodesis — these achieve 0% anatomic reduction and fail clinically 73% of the time with fixation, regardless of how experienced the surgeon is.
When counseling a patient after anatomic reduction, do not promise a good outcome. Fourteen of 17 fractures that eventually needed subtalar fusion had been anatomically fixed. The cartilage damage from the original injury is already done.
The Sanders classification became the universal language of calcaneal fracture surgery and remains the stratification tool used in every major subsequent trial, including the UK SPLASH trial comparing ORIF to nonoperative management.