Calcaneus Compression Fracture

Aka: Calcaneus Compression Fracture, Calcaneus Fracture, Calcaneal Fracture

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II. Epidemiology

  1. Most commonly Fractured tarsal bone (2% of all Fractures)
  2. Approximately 75% of Calcaneal Fractures are intra-articular
  3. Calcaneal Fracture is much more common in men (RR 2.7)

III. Mechanism: Compression Fracture most common

  1. Trauma due to fall from high height or Motor Vehicle Accident (high energy axial load)
  2. Forced foot dorsiflexion may also cause Fracture
  3. Calcaneal Stress Fracture occurs in runners
  4. Older patients with Osteoporosis may sustain a Calcaneal Fracture with minor Trauma

IV. Associated Conditions: Fall from Height

  1. Lower thoracic or Lumbar Fracture (10% of Calcaneus Fracture)
    1. Vertebral Compression Fractures (typically anterior column, stable)
    2. Burst Fracture (high axial load affecting any column)
      1. Posterior Column with retropulsion may require emergent Spine Surgery
  2. Pelvic Fracture
  3. Other external injury (26% of Calcaneus Fractures)
    1. Bilateral Calcaneal Fractures are common in fall from height
    2. Pilon Ankle Fracture
    3. Hip Dislocation

V. Symptoms

  1. Severe Heel Pain
  2. Unable to bear weight on affected foot

VI. Signs

  1. Careful exam
    1. Evaluate distal circulation, motor function and Sensation (risk of Compartment Syndrome)
    2. Evaluate for Skin Tenting or skin breakage (Open Fracture)
    3. Evaluate for Musculoskeletal Injury up the axial chain (up to Lumbosacral Spine)
  2. Swelling, pain, and Ecchymosis at Calcaneus and foot arch
  3. Heel deformity and shortening may be present
  4. Mondor sign
    1. Pathognomonic for Calcaneal Fracture, but variably present
    2. Heel Ecchymosis extending to the plantar foot

VII. Imaging: Foot XRay

  1. Standard Foot Anteroposterior and lateral views
  2. Obtain calcaneal views (with Harris axial heel view)
    1. Foot in dorsiflexion, angled 45 degrees toward the head
    2. Isolates Calcaneus on imaging
  3. Bohler Angle
    1. Technique
      1. Measure Bohler angle on lateral XRay
      2. Draw one line tangent to the anterior aspect of the superior Calcaneus
        1. Highest point of the Calcaneus posterior process (superior aspect of Calcaneus)
        2. Calcaneus anterior process (most anterior aspect of the Calcaneus)
      3. Draw one line tangent to the posterior aspect of the superior Calcaneus
        1. Highest point of the calcaneal tuberosity (very posterior aspect of the Calcaneus)
        2. Highest point of the Calcaneus posterior process (superior aspect of Calcaneus)
      4. Bohler Angle is the acute angle (<90 degrees) between the lines
    2. Interpretation
      1. Bohler angle is normally 25-40 degrees
      2. Suspect Fracture when Bohler Angle <20-23 degrees
        1. Test Sensitivity: 100%
        2. Test Specificity: 99%
        3. Isaacs (2013) J Emerg Med 45(6): 879-84 [PubMed]
  4. Critical Angle (Angle of Gissane)
    1. Technique
      1. As with Bohler angle, measure critical angle on lateral XRay
      2. Draw similar lines as Bohler angle
      3. Critical angle is the up facing, obtuse angle (90-180) between the upward slopes of the lines
    2. Interpretation
      1. Critical angle is normally 130-145 degrees
      2. Suspect Fracture when Critical angle >145 degrees

VIII. Imaging: Other

  1. CT Foot (or less commonly MRI Foot)
    1. Have a low threshold to obtain in higher suspicion for Calcaneal Fracture
    2. Often needed to guide surgical management
  2. Consider thoracolumbar imaging (esp. lumbar imaging)

IX. Imaging: Classification

  1. Extra-articular Fracture (25%)
    1. Anterior Process Avulsion Fracture accounts for 25% of cases
  2. Intra-articular Fracture (75%)
    1. Essex-Lopresti Classification System
      1. Based on XRay
      2. Divided in joint depression vs Tongue-type Fracture (posterior exit)
        1. Tongue-type Fractures require emergent management
    2. Sanders Classifications System
      1. Based on CT
      2. Scored on number of articular bone fragments
      3. Correlated with prognosis

X. Management: Acute

  1. Opioid Analgesics
  2. Serial neurovascular exams (for Compartment Syndrome, esp. in displaced Fractures)
  3. Evaluate for surgical emergencies (see below)
    1. Compartment Syndrome (10% of cases)
    2. Tongue-Type Fracture
    3. Associated Thoracolumbar Trauma
  4. Splinting
    1. Bulky Bobby Jones splint with both sugar tong and posterior splint applied
      1. Copious padding should be applied (especially at heel) to prevent ulcers
      2. Avoid trapping the fifth toe under the fourth (risk of Skin Ulcer)
      3. Foot in neutral position or slightly plantar flexed
    2. Uncomplicated Fractures may be placed in short leg non-weight bearing cast or boot
      1. Initial immobilization and non-weight bearing for at least 4 to 6 weeks
  5. Other measures
    1. Close interval follow-up and evaluation for possible surgical repair
    2. Consider DVT Prophylaxis (e.g. Lovenox 40 mg SQ daily)
    3. Non-weight bearing for 6-8 weeks
    4. Elevate the leg

XI. Management: Surgical Management

  1. Emergent Surgery Indications
    1. Compartment Syndrome (or other neurovascular injury)
    2. Open Fracture
    3. Fracture Dislocation
    4. Tongue-Type (intraarticular Fracture)
      1. Achilles tendon pulls posterior Calcaneus upwards (superiorly, posteriorly)
      2. Risk of skin necrosis from ankle tendons (gastrocnemius, achilles tendon) that pulls Calcaneus proximally
      3. Optimal repair time is within 1-2 hours of Fracture
  2. Other surgical indications
    1. May be necessary to Restore accurate anatomy
    2. Large extraarticular Fracture
    3. Sanders Type 2, 3 or 4 Fractures
    4. Comminuted Calcaneal Fractures
    5. Fracture displacement >2 mm
      1. Medical comorbidities may dictate a conservative approach despite greater displacement
    6. Calcaneal Cuboid joint with >25% involvement
    7. Nonunion after 6 weeks
  3. Subtalar fusion indications (and risk factors)
    1. Bohler's Angle <0 degrees
    2. Sanders Type 4 Fracture
    3. Workers compensation claim
    4. Male gender
  4. Other high risk features warranting early orthopedic evaluation
    1. Smoker
    2. Peripheral Vascular Disease
    3. Immunocompromised patients
  5. Indications for non-surgical, conservative management
    1. Small, extraarticular Fractures (without achilles tendon involvement)
    2. Small anterior process Fracture
    3. Calcaneal Stress Fracture

XII. Complications

  1. Acute Compartment Syndrome (10% of cases)
  2. Associated multisystem Trauma (fall from height)

XIII. References

  1. Feden and Kiel (2017) Crit Dec Emerg Med 31(11): 3-10
  2. Orman and Ramadorai in Herbert (2017) EM:Rap 17(3): 12-3
  3. Riveros (2025) Crit Dec Emerg Med 39(10): 24
  4. Silver (2024) Am Fam Physician 109(2): 119-29 [PubMed]

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