Urgent message: Prognosis for patients with calcaneal fractures can be significantly improved if the injury is recognized promptly and treated properly.

Author: Samina Yunus, MD, MPH, and Donna Goetsch, MSN, CNP

Author Information: Samina Yunus, MD, MPH, is Assistant Professor of Family Medicine at Cleveland Clinic Lerner College of Medicine and Donna Goetsch, MSN, CNP, is a Family Nurse Practitioner at Cleveland Clinic Chagrin Falls Family Health Center and Urgent Care in Chagrin Falls, Ohio.

Calcaneal fractures are high-impact fractures usually seen after a high-energy injury, such as a fall from a height or a motor vehicle accident. They constitute 60% of tarsal fractures and 2% of fractures overall, occur predominantly in men in their working years, and can lead to severe and prolonged disability.

Correct diagnosis and treatment of this injury and recognition of its unique characteristics on initial presentation can significantly improve the prognosis.

Case Presentation

A 53-year-old white male presented to the urgent care clinic with complaints of right foot and ankle pain for the past hour after jumping off a 4- foot fence and landing awkwardly on a jutting rock. The patient twisted his ankle as he fell to the ground and had not been able to bear weight on that foot since the injury. He rated the pain in his foot and ankle an 8 on the pain scale and denied pain at any other site. He had no dizziness, loss of consciousness or abdominal pain. The patient’s past medical history included hypertension, dyslipidemia, and coronary artery disease with quadruple bypass in 1997. His medication included valsartan, amlodipine, niacin, metoprolol, baby aspirin, and a multivitamin.

Pertinent Physical Exam

On examination the patient was alert, oriented, and in moderate pain. His vital signs included a BP of 134/74 mmhg, pulse 82 bpm and temperature 97.7 °F. He was in a wheelchair and unable to bear weight on his right foot.

The initial local exam revealed edema overlying bilateral malleoli and tenderness to palpation of the right heel and ankle. Neither ecchymoses nor blisters were noted and the overlying skin was intact. Assessing the patient’s range of motion was difficult because of his severe pain, but he was able to plantar flex his toes. Pedal pulses were strong and symmetrical.

Observations and Findings

Cardiovascular, respiratory, and abdominal exams were normal. The patient had no tenderness of the contralateral ankle or foot or bilaterally in his knees, hips, wrists or spine.

X-ray of the patient’s right foot and ankle showed a comminuted slightly impacted fracture through the posterior body of the right calcaneus with suspicion of intraarticular extension (Figure 1). Overlying soft tissue swelling was present.

An x-ray of the lumbar spine did not show any fracture.

Computed tomographic (CT) scan of the foot confirmed a comminuted fracture of the calcaneus with extension to the articular surface of the subtalar joint.

Disposition

A bulky dressing with a posterior splint was applied and the patient was advised to ice and elevate his foot. The orthopedic surgeon on call was consulted and the decision was made to delay repair until the swelling subsided.

The patient subsequently had open reduction and internal fixation of the fracture, but his postoperative recovery was complicated by wound infection.

Nine months after surgery, the patient is doing well. His wound is completely healed and he has been increasing his weight bearing. He has good range of motion in his right ankle with mild restriction of subtalar motion. X-ray shows that the shape and alignment of the calcaneus is maintained, with evidence of disuse osteopenia. The patient continues to wear a boot with increasing activity.

Discussion

The calcaneus is the largest tarsal bone, and along with the talus, constitutes the hind foot. The subtalar talocalcaneal joint transmits the entire weight of the body to the calcaneus during normal gait.

Anatomically the calcaneal structure consists of cancellous bone surrounded by thicker cortical bone. Although the cortical bone immediately underlying the subtalar joint is of higher density, underlying it is the neutral triangle with very sparse trabeculae. That is the most vulnerable site on the bone. The transmission of the body’s axial load through the talus results in fractures most commonly through this area.

Patients with calcaneal fractures initially seek help because of severe pain and inability to bear weight. On exam, moderate swelling is noted around the heel, which appears wide and shortened compared to the unaffected foot. Ecchymosis in the sole of the foot is specific for calcaneal fractures and patients have severe pain to palpation over the calcaneus and Achilles tendon.

Because of the high energy involved in calcaneal fractures, it is very important to rule out associated traumatic injuries as well as local soft-tissue complications.

Frequently associated injuries include contralateral calcaneal fracture in 5% to 9% of cases, compression fracture of the lumbar spine in 10%, and other lower-extremity injuries in 25% of cases.

Early soft-tissue complications include intense edema, which can progress to compartment syndrome in 10% of cases. (Recent studies indicate the rate may be lower—approximately 1%.) Long-term complications of compartment syndrome include chronic pain, stiffness, and clawing of toes.

Fracture blisters are an acute complication that results from shearing forces at the dermoepidermal junction. They usually present 1 to 2 days after injury.

Imaging

On imaging, fractures can be classified as intraarticular (75%), which usually need surgical treatment and lead to higher morbidity, or extraarticular (25%), which can usually be treated conservatively.

Initial lateral view on standard foot x-rays can reveal a fracture, but measurement of the Boehler’s angle or an axial (Harris) view may be necessary. The Boehler’s angle measures the angle between a line connecting the posterior tuberosity and the apex of the posterior facet and between the apex of the posterior facet and the anterior process.

The normal range is 25 to 40 degrees. An angle less than 20 degrees is sugggestive of a compression fracture. Comparison with the contralateral side may be useful.

An axial or Harris view can be done if standard x-rays are unrevealing but suspicion for calcaneal fracture is high. Better visualization of calcaneal tuberosity, subtalar joint and sustentacular joints is possible with this view.

CT scan is the test of choice because of better anatomical mapping, which assists with surgical treatment.

Treatment in urgent care

Initial treatment of calcaneal fracture consists of pain control and appropriate management of soft-tissue injuries. Open fractures can have a postoperative osteomyelitis rate of up to 27% and early irrigation, debridement, and stabilization are recommended. Compartment syndrome should be recognized and urgent surgical management is recommended. Bulky posterior dressing with splint should be applied, combined with ice, elevation, and non-weight bearing.

Early orthopedic evaluation is necessary. If surgery is not done within 6 to 8 hours after injury, it needs to be delayed for 10 to 14 days until swelling
resolves. The goal of surgery is to restore the anatomy of the articular surfaces. Various factors influence healing and the development of complications, therefore, the decision regarding surgery needs to be individualized. Infection is the most common immediate complication. Recovery time is prolonged, ranging from 12 to 18 months. Long-term complications include the frequent need for delayed surgery to remove hardware or arthrodesis.

Points to remember

  • Diagnosis or suspicion of a calcaneal fractures mandates the search for associated injuries.
  • Boehler’s angle and Harris view can be used to help with diagnosis in subtle cases.
  • Differentiation into intra and extrarticular fractures is imperative, along with prompt orthopedic evaluation for intrarticular or any displaced fracture.
  • Soft-tissue injury should be rapidly treated with elevation, ice, and non-weight bearing to minimize the development of compartment syndrome or fracture blisters.

Bibliography

  1. Germann CA, Perron AD, Miller MD, Powell S, Brady WJ. Orthopedic pitfalls in the ED: Calcaneal fractures. Am J Emerg Med. 2004: 22: 607-611.
  2. Ramirez EG. Management of calcaneus fractures in emergency care. Advanced Emerg Nursing J. 2008: 30(3);201-208.
  3. Palmersheim BS, et al. Calcaneal fractures: update on current treatments. Clin Podiatr Med Surg. 2012: 29(2);205-220.
Recognizing and Managing Calcaneal Fractures in Urgent Care
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