(See also Overview of Fractures.)
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.
Usually, the area around the heel and the hindfoot is tender and very swollen. Patients cannot put weight on their foot.
Acute compartment syndrome occurs in up to 10% of patients.
If a calcaneal fracture is suspected, x-rays that include axial and lateral views should be taken.
CT is done if
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.
Clinicians should also check for other injuries, such as thoracolumbar compression fractures and compartment syndrome.
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 protection, rest (avoiding weight bearing), a compression dressing (which also provides protection), ice, and elevation (PRICE). When the swelling resolves, a cast is applied.
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.