Calcaneus Fractures

HPI:
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.

Exam:
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.

Images:
Tongue type:

(Credits: South Florida Institute of Sports Medicine)

Bohler’s angle (normal):

Bohler’s angle (reduced):

(Radiopedia.org)

Management:
#Initial ED
-       Obtain AP, Lateral, oblique foot plain film images at minimum.
-       Often Broden, Harris views will be requested for complete visualization.
#Non-operative
-       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
#Operative
-       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

Discussion:
-       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

Key Points:
-       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

References:
http://www.orthobullets.com/trauma/1051/calcaneus-fractures