Calcaneus Compression Fracture

Aka: Calcaneus Compression Fracture, Calcaneus Fracture, Calcaneal Fracture

1. See Also
   1. Calcaneus Stress Fracture
   2. Calcaneus Anterior Process Fracture
2. Epidemiology
   1. Most commonly Fractured tarsal bone
   2. Approximately two thirds of Calcaneal Fractures are intra-articular
3. 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
4. Associated Injuries: Fall from height
   1. Lower thoracic or Lumbar Fracture (10% of Calcaneus Fracture)
   2. Palvic 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
5. Signs
   1. Swelling, pain, and Ecchymosis at Calcaneus
   2. Evaluate distal circulation, motor function and sensation (risk of Compartment Syndrome)
6. Imaging: Foot
   1. Foot XRay
      1. Standard Foot Anteroposterior and lateral views
      2. Obtain calcaneal views (with Harris axial heel view)
      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
            3. Draw one line tangent to the posterior aspect of the superior 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 <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
   2. CT Foot (or less commonly MRI Foot)
      1. Often needed to guide surgical management
7. Imaging: Other
   1. Consider thoracolumbar imaging (esp. lumbar imaging)
8. Management: Acute
   1. Evaluate for surgical emergencies (see below)
      1. Compartment Syndrome
      2. Tongue-Type (extra-articular Fracture)
   2. Splinting
      1. Bulky Bobby Jones splint with both sugar tong and posterior splint applied
      2. Copious padding should be applied (especially at heel) to prevent ulcers
      3. Avoid trapping the fifth toe under the fourth (risk of ulcer)
   3. Other measures
      1. Close interval follow-up and evaluation for possible surgical repair
      2. DVT Prophylaxis (e.g. Lovenox 40 mg SQ daily)
      3. Non-weight bearing for 6-8 weeks
      4. Elevate the leg
9. Management: Surgical Management
   1. Emergent Surgery Indications
      1. Compartment Syndrome
      2. Tongue-Type (extra-articular Fracture)
         1. Risk of skin necrosis from ankle tendons (gastrocnemius, achilles tendon) that pulls Calcaneus proximally
         2. Optimal repair time is within 1-2 hours of Fracture
   2. Subtalar fusion indications (and risk factors)
      1. Bohler's Angle <0 degrees
      2. Sanders Type 4 Fracture
      3. Workers compensation claim
      4. Male gender
   3. Other surgical indications
      1. May be necessary to Restore accurate anatomy
   4. Indications for non-surgical, conservative management
      1. Small, extraarticular Fractures (without achilles tendon involvement)
      2. Small anterior process Fracture
      3. Calcaneal Stress Fracture
10. 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