Cite This Article

What is the diagnosis?

Comminuted, intra-articular fracture of the calcaneus. 

Image 2. Lateral and oblique plain films demonstrating fracture line. Author’s own images and annotations. 

What is the mechanism of injury?

Typically a component of axial loading from fall from height or jumping, usually higher energy mechanism. Often seen in high impact MVCs as well. 

What physical exam findings are expected?

Heel/hindfoot pain, worse with ambulation. If there is concern for bilateral calcaneal fractures, make sure to evaluate for spinal injury given high risk for concomitant spinal fracture [1]. 

Which imaging modalities can be used?

X-rays are typically used for first line imaging.  Böhler’s angle can be used to assist in identifying subtle intra-articular fractures on X-ray imaging in the appropriate clinical context though a normal angle does not preclude a fracture.

Image 3. Image courtesy of radiopaedia.com, case by Leonardo Lustosa; rID: 94702

On a lateral foot X-ray, at its highest point, it is the angle measured between two lines drawn: anterior process of the calcaneus and posterior articular facet crossed by the posterior articular facet and the calcaneal tuberosity.

CT scans are used for surgical planning and often based on the Sanders Classification which describes severity of fracture with increasing fracture fragments [2]. 

Image 4. CT scan, author’s own images. Intraarticular calcaneal fracture demonstrated on lateral CT imaging.

What is the management in the ED/when should you consult orthopedics?

Most calcaneal fractures are non-operative and can be placed in a posterior leg splint with outpatient follow up. Even when indicated, operative repair is often delayed until swelling has improved. 

• Pearl: Be sure to put plenty of padding over the heel as there is a high incidence of skin breakdown with these fractures. 

There are some specific circumstances to emergently consult orthopedic surgery including open fractures which require urgent washout and certain calcaneal tuberosity fractures, also known as tongue type fractures. Tongue fractures are an avulsion injury of the Achilles tendon at its insertion site on the calcaneus and with major displacement there is risk of pressure injury to nearby soft tissue. This injury should be taken seriously as if missed and splinted, can result in skin necrosis [3]. Though rare, there has been some evidence that has demonstrated risk of compartment syndrome as a complication of calcaneal fractures [4]. 

Overall, this should be evaluated by orthopedic surgery in some capacity depending on its severity. Some studies have demonstrated improved functional outcomes after surgery despite post-operative complications [5].