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
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CMC ER Residents
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