Calcaneal fracture classification: a comparative study

Comparing different types of calcaneal fractures, associated treatment options, and outcome data is currently hampered by the lack of consensus regarding fracture classification. A systematic search for articles dealing with calcaneal fracture was performed, and the prevalence of use of each classification system determined. Twelve observers classified 30 intra-articular calcaneal fractures according to the 3 most prevalent classification systems; interobserver reliability (kappa [kappa] statistic) and the correlation of the system with the choice of treatment and clinical outcomes were calculated. Forty-nine conventional and 15 computerized tomographic scan classification systems were identified. The most prevalent systems were the Essex-Lopresti, Zwipp, Crosby, and Sanders classifications; and none of these showed a direct correlation with treatment, although each of these systems showed positive correlations with outcome. Moderate interobserver agreement and variability were found for the Crosby and Sanders classifications (overall kappa = 0.48), whereas interobserver reliability among radiologists was poor for the Essex-Lopresti classification (overall kappa = 0.26). Four classifications systems showed positive correlations with outcome, but no correlation with choice of treatment. The Sanders and Crosby classifications displayed comparable, moderate interobserver variability among surgeons and radiologists, and both of these systems are likely to be useful for classification of intra-articular calcaneal fractures. Level of Clinical Evidence: 5