What is the diagnosis?

Right comminuted calcaneal fracture Image 1(a) and 1(b) with annotations to show the findings (red arrows).

Left comminuted and displaced fractures of the calcaneus (red arrows) and talus (yellow arrow) with at least subluxation at the subtalar joints (red circle), Image 1(c) and 1(d).

• Pearl: Bohler’s angle helps determine if there is a calcaneus fracture. An angle less than <20 degrees is highly accurate in determining the presence of a calcaneus fracture [1].

Image 2. Image courtesy of EBM Consult, LLC

What is the mechanism of injury?

High energy impact of the heel on a hard surface.  Examples include a fall from a 2nd story building  or a high-energy motor vehicle collision.

• Pearl: Fun fact - injury is also coined the “lovers fracture” due to it occurring when a suitor jumps off a balcony to prevent being caught [2]. 

What physical exam findings are expected?

On examination, calcaneus fractures will present with pain, edema, and ecchymoses at the site. The patient is unable to bear weight. Suspicion should be raised significantly if there is plantar ecchymosis through the plantar arch of the foot [2]. Look for skin tenting, blistering, and skin breakdown at the heel, for this may be an indication of a tongue-type fracture. 

• Pearl: A tongue-type fracture is when there is a fracture with a secondary fracture line below the level of the Achilles tendon insertion site [3]. 

Which imaging modalities can be used?

Plain radiographs of the heel, lateral, and axial views.

Computed tomography (CT) scan to provide better visualization of subtalar joint and assess fracture pattern and injuries [4]. It can accurately evaluate fracture lines, dislocation, and comminution, utilizing multiplanar reformation [5]. CT also gives improved visualizations of the surrounding tissues and can show tendon entrapment or dislocation [3].

• Pearl: Mondor's Sign is a hematoma identified on CT.  It extends along the sole and is considered pathognomonic for a calcaneal fracture [2].

What is the management in the ED?

Immobilization with a splint, usually with a bulky dressing. The patient should be non-weight-bearing.

• Pearl: If a tongue-type fracture is found, you can place a removable posterior splint in plantarflexion until definitive treatment, making sure to monitor for skin tenting [2]. 

When do you consult Orthopedics?

Emergent Orthopedics consultation is needed for intra-articular and displaced fractures. Tongue-type fractures must be seen in HOURS of initial injury due to complications from skin tenting [6].

Outpatient Orthopedic follow-up (after compressive dressing and casting) for extra-articular fractures [6].