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Calcaneal Fractures

By Danielle Campagne, MD, Assistant Clinical Professor, Department of Emergency Medicine, University of San Francisco - Fresno

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Calcaneal fractures occur in the calcaneus (heel bone), often resulting from great force. Diagnosis is by x-rays and, if needed, CT. Treatment requires orthopedic consultation and includes casting and sometimes surgery.

Calcaneal fractures are serious but uncommon injuries; they account for only 1 to 2% of all fractures. However, if not diagnosed and treated promptly, they can result in long-term disability. Up to 10% of these fractures are missed at initial presentation in an emergency department.

Typically, these fractures result from a high-energy axial load to the foot (eg, a fall from a height onto the heels). Because these fractures require great force, they are often accompanied by other serious injuries; 10% of patients with a calcaneal fracture have a thoracolumbar compression fracture.

Stress fractures may also occur in the calcaneus, particularly in athletes, such as long-distance runners.

Calcaneal fractures may be intra-articular.

Symptoms and Signs

Usually, the area around the heel and the hindfoot is tender and very swollen.

Acute compartment syndrome occurs in up to 10% of patients.

Diagnosis

  • X-rays

  • Sometimes CT

If a calcaneal fracture is suspected, x-rays that include axial and lateral views should be taken.

CT is done if

  • X-rays are negative but clinical findings suggest a calcaneal fracture.

  • The Bohler angle is < 20°.

  • More detail about the fracture is needed.

The Bohler angle is determined on the lateral x-ray. This angle is formed by the intersection of a line drawn from the superior aspect of the posterior calcaneal tuberosity to the superior subtalar articular surface and a line drawn from the superior subtalar articular surface to the superior aspect of the anterior calcaneal process. Normally, the angle is 20 to 40°. An angle of < 20° suggests a fracture.

Pearls & Pitfalls

  • If patients have calcaneal swelling and tenderness after a high-energy axial load to the calcaneus, check the Bohler angle on x-ray, and check for thoracolumbar compression fracture and compartment syndrome.

Clinicians should also check for other injuries, such as thoracolumbar compression fractures and compartment syndrome.

Treatment

  • Orthopedic consultation

  • Casting or possibly surgery, depending on the type of fracture

Orthopedic consultation is necessary.

Whether intra-articular calcaneal fractures should be treated surgically or nonsurgically is much debated.

Extra-articular calcaneal fractures are treated symptomatically with rest (avoiding weight bearing), a compression dressing (which also provides protection), ice, and elevation (PRICE). When the swelling resolves, a cast is applied.

Key Points

  • If calcaneal fractures are not diagnosed and treated promptly, they can result in long-term disability.

  • Because these fractures usually result from a high-energy axial load to the foot, other injuries (eg, thoracolumbar compression fracture) are often also present; other complications include compartment syndrome (in up to 10%).

  • Diagnose based on x-rays and, if needed, CT.

  • Whether intra-articular calcaneal fractures should be treated surgically or nonsurgically is controversial.

  • When diagnosing a calcaneal fracture, always check for a thoracolumbar fracture.

  • Treat extra-articular calcaneal fractures symptomatically with PRICE, followed by casting.

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