35 yo male construction worker falls from 15 feet off of a ladder complaining of severe R foot/ankle pain as well as lower back pain.
Obvious swelling and ecchymosis of the R ankle and heel with associated tenderness. No deformity or tenderness to the L foot/ankle. Midline lumbar tenderness. Patient has palpable PT/DP pulses bilaterally with no noted sensory deficits.
(Credits: South Florida Institute of Sports Medicine)
Bohler’s angle (normal):
Bohler’s angle (reduced):
- Obtain AP, Lateral, oblique foot plain film images at minimum.
- Often Broden, Harris views will be requested for complete visualization.
- Extra-articular fractures with minimal displacement and intact Achilles tendon.
- Sanders Type I fractures
- Bulky cast with extra padding around the heel and ankle.
- Requires EXTENDED non-weightbearing status. Often approaches 12 weeks.
- All require referral to orthopedic surgery
- Prompt recognition of Tongue-type fractures as illustrated above.
- Orthopedic EMERGENCY as skin overlying the fracture has a high instance of compromised vascularity and death/necrosis.
- Displaced intraarticular fractures
- Sanders type II-IV
- Common in males aged 35-45, often work related
- Due to extended non-weightbearing requirement these injuries have large socioeconomic impact on patients
- High complication rate if not recognised early
- Contralateral calcaneus and spine have a 10% concomitant injury rate.
- Look for reduced Bohler angle and increased angle of Gissane
- Be vigilant as secondary injuries very common
- Most commonly the spine and contralateral calcaneus
- Recognise tongue-type fractures early and prompt notification of orthopedic surgery
- Don’t forget the spine in axial load type injuries
CMC ER Residents
Disclaimer: All images and x-rays included on this blog are the sole property of CMC EM Residency and cannot be used or reproduced without written permission. Patient identifiers have been redacted/changed or patient consent has been obtained. Information contained in this blog is the opinion of the author and application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.