II. Epidemiology
- Most commonly Fractured tarsal bone
- Approximately 75% of Calcaneal Fractures are intra-articular
- Calcaneal Fracture is much more common in men
III. Mechanism: Compression Fracture most common
- Trauma due to fall from high height or Motor Vehicle Accident (high energy axial load)
- Forced foot dorsiflexion may also cause Fracture
- Calcaneal Stress Fracture occurs in runners
- Older patients with Osteoporosis may sustain a Calcaneal Fracture with minor Trauma
IV. Associated Conditions: Fall from Height
- Lower thoracic or Lumbar Fracture (10% of Calcaneus Fracture)
- Vertebral Compression Fractures (typically anterior column, stable)
- Burst Fracture (high axial load affecting any column)
- Posterior Column with retropulsion may require emergent Spine Surgery
- Pelvic Fracture
- Other external injury (26% of Calcaneus Fractures)
- Bilateral Calcaneal Fractures are common in fall from height
- Pilon Ankle Fracture
- Hip Dislocation
V. Symptoms
- Severe Heel Pain
- Unable to bear weight on affected foot
VI. Signs
- Swelling, pain, and Ecchymosis at Calcaneus and foot arch
- Heel deformity and shortening may be present
- Evaluate distal circulation, motor function and Sensation (risk of Compartment Syndrome)
- Evaluate for Skin Tenting or skin breakage (open Fracture)
VII. Imaging: Foot XRay
- Standard Foot Anteroposterior and lateral views
- Obtain calcaneal views (with Harris axial heel view)
- Bohler Angle
- Technique
- Interpretation
- Bohler angle is normally 25-40 degrees
- Suspect Fracture when Bohler Angle <20-23 degrees
- Critical Angle (Angle of Gissane)
- Technique
- As with Bohler angle, measure critical angle on lateral XRay
- Draw similar lines as Bohler angle
- Critical angle is the up facing, obtuse angle (90-180) between the upward slopes of the lines
- Interpretation
- Critical angle is normally 130-145 degrees
- Suspect Fracture when Critical angle >145 degrees
- Technique
VIII. Imaging: Other
IX. Imaging: Classification
X. Management: Acute
- Opioid Analgesics
- Serial neurovascular exams (for Compartment Syndrome, esp. in displaced Fractures)
- Evaluate for surgical emergencies (see below)
- Compartment Syndrome (10% of cases)
- Tongue-Type Fracture
-
Splinting
- Bulky Bobby Jones splint with both sugar tong and posterior splint applied
- Copious padding should be applied (especially at heel) to prevent ulcers
- Avoid trapping the fifth toe under the fourth (risk of Skin Ulcer)
- Uncomplicated Fractures may be placed in short leg non-weight bearing cast or boot
- Initial immobilization and non-weight bearing for at least 4 to 6 weeks
- Bulky Bobby Jones splint with both sugar tong and posterior splint applied
- Other measures
- Close interval follow-up and evaluation for possible surgical repair
- Consider DVT Prophylaxis (e.g. Lovenox 40 mg SQ daily)
- Non-weight bearing for 6-8 weeks
- Elevate the leg
XI. Management: Surgical Management
- Emergent Surgery Indications
- Other surgical indications
- May be necessary to Restore accurate anatomy
- Large extraarticular Fracture
- Sanders Type 2, 3 or 4 Fractures
- Comminuted Calcaneal Fractures
- Fracture displacement >2 mm
- Medical comorbidities may dictate a conservative approach despite greater displacement
- Calcaneal Cuboid joint with >25% involvement
- Nonunion after 6 weeks
- Subtalar fusion indications (and risk factors)
- Bohler's Angle <0 degrees
- Sanders Type 4 Fracture
- Workers compensation claim
- Male gender
- Indications for non-surgical, conservative management
- Small, extraarticular Fractures (without achilles tendon involvement)
- Small anterior process Fracture
- Calcaneal Stress Fracture
XII. Complications
- Acute Compartment Syndrome (10% of cases)
- Associated multisystem Trauma (fall from height)
XIII. References
- Feden and Kiel (2017) Crit Dec Emerg Med 31(11): 3-10
- Orman and Ramadorai in Herbert (2017) EM:Rap 17(3): 12-3
- Silver (2024) Am Fam Physician 109(2): 119-29 [PubMed]
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Related Studies
Concepts | Injury or Poisoning (T037) |
ICD10 | S92.0 |
SnomedCT | 208706003, 208676009, 157251006, 263247007 |
English | Fracture of calcaneus, fracture of calcaneus, fracture of calcaneus (diagnosis), Fractured os calcis, Os calcis, Heel bone, fracture calcaneus, fracture heel, heel fracture, calcaneus fracture, fractured os calcis, heel bone fracture, fractures heel, calcaneus fractures, fracture of os calcis, of calcaneus fracture, Calcaneus fracture, Os calcis fracture, Fracture of os calcis, Heel bone fracture, Fracture of calcaneus (disorder), calcaneus; fracture, fracture; calcaneus, fracture; heel bone, fracture; os calcis, heel bone; fracture, os calcis; fracture, os calcis, fractured calcaneus, Fracture;calcaneus |
Dutch | gebroken os calcis, calcaneusfractuur, calcaneus; fractuur, fractuur; calcaneus, fractuur; hielbeen, fractuur; os calcis, hielbeen; fractuur, os calcis; fractuur, Fractuur van calcaneus |
French | Fracture du calcanéum, Calcanéum fracturé |
German | gebrochener Os calcis, Fersenbeinfraktur, Fraktur des Kalkaneus |
Italian | Calcagno fratturato, Frattura del calcagno |
Portuguese | Os calcis fracturado, Fractura do calcâneo |
Spanish | Calcáneo fracturado, Fractura del calcáneo, fractura del calcáneo (trastorno), fractura de calcáneo (trastorno), fractura de calcáneo, fractura del calcáneo |
Japanese | 踵骨骨折, ショウコツコッセツ, シュコツコッセツ |
Czech | Zlomená kost patní, Zlomenina kosti patní |
Korean | 발꿈치뼈의 골절 |
Hungarian | Fractura ossis calcanei, Calcaneus törés |