Calcaneal Fractures

Case: 27 year old Male s/p MVC with multiple open RLE fractures.  Complains of severe pain at the BL ankles, unwilling to allow any further testing in the trauma bay.  Plain films of single ankle below:

Calcaneal Fractures:
-        Mechanism: Generally result from an axial load to the lower extremity. Typically either a fall from height while landing on one’s feet –or- from an MVC.
-        Presentation: Patients may have a shortened and widened heel with varus deformity.  Patients also may have “Mondor’s sign” which is ecchymoses of the foot extending into the heel.

Diagnosis:

• Plain flims: Obtain AP/lateral/oblique views.
• Findings: reduced Bohler Angle.  (<25 degrees …normal is ~ 25-40)

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CT Scans:

• Plain films are fairly limited in the diagnosis and characterization of calcaneal fractures. 
• CT is gold standard. 
• Have a fairly low threshold for obtaining CT for further characterization of any suspected calcaneal fracture.

Classification: There are multiple levels of classification, but the most important delineation is between intra-articular and extra-articular fractures. 

• Approximately 75% are intra-articular. 
• Most classification systems are based on findings from CT scan. Sanders classification is generally used for intra-articular fractures:
  

As stated before -> Calcaneal fractures are associated with significant axial load so always consider other injuries including hip/pelvis, or lumbar spine fractures.

Treatment:
o   For most extra-articular and type I intra-articular fractures: Immobilization with short-leg splint, strict non weight-bearing status, elevation, pain control. Patient will need ortho follow-up ASAP.
o   For more severe fractures: Surgical fixation, if pursued, will vary depending on the patient’s comorbidities and the preference of the surgeon.

Important complications:
o   Poor wound healing (particularly in smokers and diabetics)
o   Compartment syndrome
o   Arthritis