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Calcaneus Compression Fracture
Aka: Calcaneus Compression Fracture, Calcaneus Fracture, Calcaneal Fracture
- See Also
- Calcaneus Stress Fracture
- Calcaneus Anterior Process Fracture
- Epidemiology
- Most commonly Fractured tarsal bone
- Approximately 75% of Calcaneal Fractures are intra-articular
- Calcaneal Fracture is much more common in men
- 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
- 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
- Symptoms
- Severe Heel Pain
- Unable to bear weight on affected foot
- 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)
- Imaging: Foot XRay
- Standard Foot Anteroposterior and lateral views
- Obtain calcaneal views (with Harris axial heel view)
- Isolates Calcaneus on imaging
- Bohler Angle
- Technique
- Measure Bohler angle on lateral XRay
- Draw one line tangent to the anterior aspect of the superior Calcaneus
- Draw one line tangent to the posterior aspect of the superior Calcaneus
- Bohler Angle is the acute angle (<90 degrees) between the lines
- Interpretation
- Bohler angle is normally 25-40 degrees
- Suspect Fracture when Bohler Angle <20-23 degrees
- Test Sensitivity: 100%
- Test Specificity: 99%
- Isaacs (2013) J Emerg Med 45(6): 879-84 [PubMed]
- 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
- Imaging: Other
- CT Foot (or less commonly MRI Foot)
- Have a low threshold to obtain in higher suspicion for Calcaneal Fracture
- Often needed to guide surgical management
- Consider thoracolumbar imaging (esp. lumbar imaging)
- Imaging: Classification
- Extra-articular Fracture (25%)
- Anterior Process Avulsion Fracture accounts for 25% of cases
- Intra-articular Fracture (75%)
- Essex-Lopresti Classification System
- Based on XRay
- Divided in joint depression vs Tongue-type Fracture (posterior exit)
- Tongue-type Fractures require emergent management
- Sanders Classifications System
- Based on CT
- Scored on number of articular bone fragments
- Correlated with prognosis
- 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)
- 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
- Management: Surgical Management
- Emergent Surgery Indications
- Compartment Syndrome (or other neurovascular injury)
- Open Fracture
- Fracture Dislocation
- Tongue-Type (intraarticular Fracture)
- Risk of skin necrosis from ankle tendons (gastrocnemius, achilles tendon) that pulls Calcaneus proximally
- Optimal repair time is within 1-2 hours of Fracture
- Other surgical indications
- Large extraarticular Fracture
- Sanders Type 2, 3 or 4 Fractures
- May be necessary to Restore accurate anatomy
- 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
- 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