A 35-year-old otherwise healthy man was descending from a roof when he fell. He reported landing on his feet and then falling backwards. He did not lose consciousness or hit his head. He reported immediate right ankle and foot pain that was persistent. The exam was normal except for severe pain and swelling to the right hind foot and ankle. The lateral radiograph of the right ankle is shown.
What is the diagnosis? How is it treated? What associated injuries and complications are of concern?
Find the diagnosis and case discussion on p. 16.
Diagnosis: Calcaneal Fracture
Calcaneal fractures are uncommon injuries, and account for only about two percent of all fractures, but they make up approximately 60 percent of tarsal bone fractures. Calcaneal fractures are most common in 30- to 50-year-old men and frequently are work-related (falls from ladders, etc.). Unfortunately, they are associated with high rates of morbidity even with optimal management and can cause significant amounts of disability in this patient population. (Am J Emerg Med 2004;22:607.)
Anatomically, the calcaneus makes up a major weight-bearing surface of the hind foot, and is flanked by a few important structures. A clinically significant distinction is between the intra- and extraarticular surfaces. The intraarticular surface is made up three superior facets that articulate with the talus and form the subtalar joint. The extraarticular surfaces are primarily sites of tendon attachment, and these are subsequently associated with avulsion-type injuries.
Adjacent structures at risk for concurrent injury with calcaneal fractures include the peroneus brevis and the longus and neurovascular bundles. The peroneus brevis and longus run just posterior to the lateral malleolus and along the lateral aspect of the calcaneus. These are at particular risk for injury or dislocation with lateral displacement of fracture fragments. The neurovascular bundles run along the medial and lateral sides of the calcaneus. On physical exam, injury to these bundles can result in decreased sensation or blood flow to the lateral or medial aspect of the forefoot, respectively. You can also see isolated weakness of toe flexion of the affected foot.
Calcaneal fractures are typically the result of high-energy trauma, including landing on one's feet from a height, or high-speed motor vehicle collisions where the feet compress against the floorboard. Because of these high-energy injuries, it is important to remember that nine percent of patients have bilateral calcaneal fractures, up to 50 percent of patients have other concurrent injuries, and 10 percent have spinal injuries. (Am J Emerg Med 2004;22:609.) A high index of suspicion for associated injury needs to be maintained.
Calcaneal fractures typically present with significant pain and swelling to the heel and ankle. In addition to inspection and palpation, a thorough neurovascular exam should be done to evaluate for deficits. The lateral radiograph is usually diagnostic, but the axial, or Harris view, of the calcaneus can reveal a subtle fracture or delineate direction of displacement of fragments. Böhler's angle can be measured on the lateral radiograph to evaluate for occult calcaneal fracture. To measure Böhler's angle, one line is drawn from the apex of the posterior facet to the anterior process, and the second line is from the apex of the posterior facet to the anterior tubercle. (Image.)
Traditionally, it has been taught that a “normal” Böhler's angle is 20°-40°, and standard practice has been to compare the radiographs of the injured and uninjured feet. Authors of a recent Journal of Emergency Medicine article found the average Böhler's angle without injury to be 29.4°. They concluded that an angle less than 25° was moderately predictive of injury, and an angle less than 23° was highly predictive of injury. (2013;45:879.) Because there is not a clear cut-off, current recommendations include obtaining a CT scan to evaluate definitively for injury if there is concern without obvious fracture. Because of the high rate of complications associated specifically with intraarticular fractures, CT is also recommended for any calcaneal fracture where intraarticular involvement is not clear.
Emergency department management of calcaneal fractures includes pain control, splinting, orthopedic consult, and evaluation for early complications. All calcaneal fractures need orthopedic follow-up. Those requiring emergent consult include open fractures, fractures with neurologic or vascular compromise, the development of compartment syndrome (approximately 10% of intraarticular fractures), or fractures at risk of skin necrosis from tenting by fracture fragments. Uncomplicated, comminuted, or displaced intraarticular fractures are suitable for urgent orthopedic follow-up. All calcaneal fractures should be placed in a bulky posterior slab splint, and the patient should be non-weight-bearing until evaluated by an orthopedic surgeon.
Treatment of extraarticular fractures is usually nonsurgical and associated with relatively good outcomes. Treatment of intraarticular calcaneal fractures is variable and associated with rates of complication approaching 50 percent whether treated surgically or nonsurgically. (Injury 2004;35[Suppl 2]:SB64.) Late complications include nonunion or malunion, skin necrosis of surgical flaps, osteomyelitis, and complex regional pain syndrome.
The patient was diagnosed with a comminuted fracture of the calcaneus with possible avulsion fracture fragment of the navicular. He had negative radiographs of the lumbar spine as well as tibia/fibula films. He underwent surgery 10 days later with open reduction and internal fixation of the right calcaneus. This patient's course was complicated weeks later with poor wound healing and ultimately with osteomyelitis. Five months postoperative, the patient was finally cleared for weight-bearing and able to start more aggressive physical therapy.