A 42-year-old patient is brought in by EMS after jumping off of a two-story building. The primary survey is intact and the secondary survey demonstrates swelling, ecchymosis, and tenderness to the right heel. You obtain foot x-rays and see the following images (Image 1. Lateral view of the right foot. Author’s own images).
- Pearl: The calcaneus is the most commonly fractured tarsal bone [1,2]. It is associated with a high degree of morbidity if not adequately diagnosed and treated. Overall, it makes up 2% of all fractures. Approximately 75% are intra-articular. Males have more than double the incidence of calcaneal fractures than females [2].
Obtain AP, lateral, and oblique plain films of the foot. A Harris view is a specialized view that allows for isolated images of the calcaneus [1,3]. Böhler angle is formed by drawing two lines tangential to the anterior and posterior aspects of the superior calcaneus on the lateral radiograph (Figure 2) [1,4]. A normal Böhler angle is between 20-40 degrees, and an angle of less than 20 degrees is pathologic [4]. Obtain CT imaging if there is high clinical suspicion despite equivocal x-rays [1].
Figure 2. Böhler Angle. Author’s own images and illustrations.
Associated injuries include concurrent Achilles tendon injuries, lower extremity fractures, talar dislocations, and bilateral calcaneal fractures [1-3]. In addition, studies have shown that 7-10% of calcaneal fractures are associated with a concomitant vertebral fracture, including compression or burst fractures, especially with high energy mechanisms such as a fall from height [1,2,5].
- Pearl: Vertebral compression fractures are typically stable because they only involve the anterior column. Burst fractures result from a higher axial load and involve both the anterior and posterior columns. Neurologic deficits may occur from retropulsion of the posterior vertebral body into the spinal canal. Surgical indications depend on the location and severity of the fracture, neurologic injury, and stability of the posterior column [6].
Figure 3. CT images of the lumbar spine that demonstrate an acute vertebral burst fracture of L2. Author’s own images.
Provide pain control and perform frequent neurovascular exams because 10% of patients may develop compartment syndrome, especially in displaced fractures [1]. Orthopedic consultation should be obtained for compartment syndrome, open fractures, displaced fractures, intra-articular fractures, and fracture-dislocations. This injury can be immobilized with a bulky compressive dressing and posterior leg splint [1,3]. If discharging with outpatient orthopedic follow-up, advise non-weight bearing on the affected extremity.
Resources & References:
Check out ALiEM’s EMRAD post to brush up on other can’t miss adult foot and ankle injuries.
- Germann CA, Perron AD, Miller MD, Powell SM, Brady WJ. Orthopedic pitfalls in the ED: calcaneal fractures. Am J Emerg Med. 2004 Nov;22(7):607-11. PMID: 15666272.
- Mitchell MJ, McKinley JC, Robinson CM. The epidemiology of calcaneal fractures. Foot (Edinb). 2009 Dec;19(4):197-200. PMID: 20307476.
- Davis D, Seaman TJ, Newton EJ. Calcaneus Fractures. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 8, 2020
- Loucks C, Buckley R. Bohlers angle: Correlation with outcome in displaced intra-articular calcaneal Fractures. Journal of Orthopaedic Trauma. 1999;13(8):554-558. PMID: 10714782.
- Walters JL, Gangopadhyay P, Malay DS. Association of calcaneal and spinal fractures. The Journal of Foot and Ankle Surgery. 2014;53(3):279-281. PMID: 24618246.
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