The calcaneus is the most frequently fractured tarsal bone. Patients present with severe heel pain in association with soft tissue swelling and ecchymosis extending to the arch. The normal contour of the heel can be distorted. Radiographs should include AP and lateral views of the foot and a Harris axial view if possible. Fractures can involve the tuberosities, the sustentaculum, or the body and are classified as intra-articular or extra-articular. Bohler angle should be calculated for all fractures involving the body to rule out a depression, as this will change management. The angle is normally between 20 and 40 degrees; if approaching or less than 20 degrees, a depressed fracture should be suspected.
Calcaneus Fracture: Bohler Angle. The Bohler angle is formed by the intersection of lines drawn tangentially to the anterior (A) and posterior (B) elements of the superior surface of the calcaneus (C). A normal angle is approximately 20 to 40 degrees.
Calcaneus Fracture. This patient fell from a ladder and struck his heel. A cortical step-off is seen on the inferior aspect of the calcaneus. The Bohler angle has been calculated at approximately 22 degrees. (Photo contributor: Alan B. Storrow, MD.)
Management and Disposition
CT scans should be obtained to further delineate fracture patterns and rule out involvement of the subtalar joint. Intra-articular fractures require orthopedic consultation; open reduction and internal fixation are usually needed. Nondisplaced extra-articular fractures generally heal well with bulky compressive dressings, rest, ice, elevation, and non–weight bearing for 8 weeks. Orthopedic referral is necessary since some may require open reduction. Complications include fracture blisters, nonunion, and chronic pain.
Calcaneal fracture warrants a diligent search for associated injuries. Twenty percent are associated with spinal fractures, 7% contralateral calcaneal fractures, and 10% compartment syndromes. The subtalar joint is disrupted in 50% of cases. A high index of suspicion for thoracic aortic rupture and renal vascular pedicle disruption must be maintained.
Minimally displaced fractures of the anterior calcaneus are easily missed and should be suspected in a patient who does not recover appropriately from a lateral ankle sprain.
CT scanning is the optimal imaging technique for characterizing fracture dislocations, while MRI may be used to evaluate ligamentous injury.
Bilateral Calcaneal Fracture. A fall from a ladder caused bilateral calcaneal fractures. Note swelling and ecchymosis. (Photo contributor: Lawrence B. Stack, MD.)