Intra-articular calcaneal fractures: contemporary concepts and treatment strategies

Displaced intra-articular calcaneal fractures (DIACFs) present a significant challenge in orthopedic traumatology, disproportionately affecting young, working-age adults and carrying a high risk of long-term disability and socioeconomic burden. While historical management often relied on “benign neglect,” advancements in computed tomography (CT) and internal fixation have driven a paradigm shift toward surgical intervention. This narrative review synthesizes contemporary evidence published between January 2005 and February 2026 to evaluate current concepts, treatment strategies, and complication profiles associated with DIACFs. The objective is to provide an evidence-informed, practice-oriented decision framework for individualized treatment selection. The CT-based Sanders classification remains the most prevalent and reliable system for prognostic stratification and surgical planning. Analysis of current literature reveals a definitive shift away from the traditional extensile lateral approach (ELA) toward minimally invasive surgery (MIS) and the sinus tarsi approach (STA). This transition is largely driven by soft-tissue vulnerability; ELA is associated with major wound complication rates of 15-22%, compared to just 2-5% for STA and percutaneous methods. Although MIS techniques present a steeper learning curve and restrict posterior facet visualization, they achieve comparable long-term functional outcomes and significantly reduce surgical morbidity. Additionally, external fixation serves as a critical adjunct for staged management or as a definitive option when open reconstruction is contraindicated. The management of DIACFs has evolved beyond a simple operative versus non-operative dichotomy into a highly personalized algorithm prioritizing both joint restoration and soft-tissue preservation. The STA and MIS techniques are now strongly recommended as primary modalities for reconstructible Sanders Type II and III fractures, especially in patients with comorbidities. ELA remains indicated but should be strictly reserved for complex, highly comminuted Sanders Type IV fractures in medically optimized patients.