Calcaneal fracture

Fractures of the calcaneus are caused by acute trauma or chronic load-bearing on the foot. Fractures may be extraarticular (e.g., avulsion of the calcaneal process) but more commonly involve an intraarticular surface (e.g., the subtalar joint). Acute calcaneal fractures are typically caused by a high-energy impact to the heel (e.g., fall from a significant height, motor vehicle accident); a low-energy impact may cause a fracture in an osteoporotic or diseased bone. Clinical manifestations of an acute fracture include heel pain and plantar ecchymosis. X-rays typically confirm the diagnosis, but a CT should be obtained if clinical suspicion for an acute fracture is high and the initial x-ray findings are negative. Orthopedics should be consulted early, and the affected extremity should be elevated and placed in a bulky dressing. Surgical treatment may be required for displaced or intraarticular fractures.

For details about stress fractures in the calcaneus, see “Calcaneal stress fractures.”

• Calcaneal fracture: a fracture of the body of the calcaneus
• Intraarticular calcaneal fracture (most common): subtalar joint involved
• Extraarticular calcaneal fracture
  • Subtalar joint not involved
  • Usually an avulsion of the anterior process, sustenatculum tali, or calcaneal tuberosity

• High-energy axial impact on normal bone (most common) ^[1][2]
• Low-energy axial impact on osteoporotic or diseased bone ^[3]

• Heel pain and tenderness
• Swelling and deformity of the foot ^[1][4]
• Plantar ecchymosis (Mondor sign)
• Fracture blisters
• Other significant coincident injuries ^[2]
  • Additional lower extremity fractures
  • Vertebral fracture
  • Nonorthopedic injury (e.g., intracranial injury, pneumothorax, abdominal organ trauma)

Over 75% of patients with an acute calcaneal fracture have another significant injury. ^[2]

Symptoms of a calcaneal fracture may be overshadowed by symptoms from other larger injuries. ^[1]

• X-ray: initial test for all patients with heel pain after trauma
  • Obtain AP, lateral, and Harris axial views. ^[5]
  • Radiographic fracture signs may be subtle (e.g., loss of calcaneal height, depressed articular surface, and/or small avulsion). ^[6]
  • A Bohler angle < 20° suggests compression fracture.
• CT: indicated when ^[4]
  • Fracture is visible on x-ray
  • Suspicion remains high despite normal x-ray

Initial management ^[1][3][5]

• Assess for associated injuries.
• Assess for signs of compartment syndrome. ^[7]
• Provide pain control: See “Pain management in the emergency department.”
• Apply bulky compressive dressing and/or posterior ankle splint.
• Reduce inflammation by elevating the leg and applying ice.
• Obtain orthopedic consultation.
  • Emergent: compartment syndrome, intraarticular fractures, tongue-type fracture
  • Early (within 48 hours): nondisplaced extraarticular fractures
• Admit patients if there is significant edema and/or concern for compartment syndrome.

Definitive treatment ^[1][3][5]

• Extraarticular fractures
  • Usually conservative management
  • Avoidance of weight-bearing activities for 4–8 weeks
• Intraarticular fractures: conservative treatment or surgical repair, depending on fracture characteristics

• Compartment syndrome ^[1]
• Entrapment neuropathy
• Posttraumatic arthritis ^[4]
• Chronic pain
• Loss of limb ^[8]

Intraarticular fractures have the highest risk of long-term disability. ^[1][3]

We list the most important complications. The selection is not exhaustive.