What is the diagnosis?

Calcaneus fracture. 

• Pearl: This fracture is further characterized as a tongue type fracture. There are two fracture classification systems: 

  • Joint Depression Type - single vertical fracture line through the angle of Gissane

  • Tongue Type - Vertical fracture line as above with additional horizontal line creating a superior posterior fragment

  • Type I - one non displaced or minimally bony fragment

  • Type II - two bony fragments involving the posterior facet

  • Type III - three bony fragments including a depressed middle fragment

  • Type IV - four comminuted bony fragments 

• Essex-Lopresti

• Sanders

What is the mechanism of injury?

Calcaneal fractures are typically caused by significant force through the foot. Commonly seen in patients who jump or fall from a height and land on their feet. 

Which imaging modalities can be used?

Plain radiographs are the initial modality of choice, however CT scan can be obtained if there is concern for occult fracture on x-ray. CT scan may also be obtained for surgical planning or better classification of the fracture that is seen on x-ray.

• Pearl: There are two angles that should/can be measured to help evaluate for a calcaneal fracture. Bohler’s angle and Gissane’s angle, however Bohler’s is much more commonly used. 

• Bohler’s Angle: Angle between a line drawn from the highest point of the tuberosity and highest point of the posterior facet and a line drawn from the highest point of the anterior process and the highest point of the posterior facet. The angle between these two lines should be 25-40 degrees (Image 2) [1]. 

Image 2. Lateral x-ray of the foot demonstrating Bohler's angle. Case courtesy of Leonard Lustosa, radiopaedia.org, rID: 94702

What is the management in the ED?

If the fracture is nondisplaced with no significant articular involvement these will always be treated conservatively with immobilization, pain control, and outpatient follow up. However, in this case, there is articular involvement with a reduced Bohler’s angle (Image 3). Institutional practice will vary in obtaining an orthopedic consult versus urgent follow-up in the clinic.

• Pearl: If concern for fracture exists but is unclear based on Bohler’s angle, a contralateral film can be obtained and Bolher’s angle calculated to compare. 

Image 3. Bohler’s angle demonstrated on previous case image (Image 1). Bohler’s angle is less than 25° in this case. Annotation by Will Denq, MD. 

When do you consult Orthopedics?

Indications for surgical intervention and early orthopedic consultation include [1]: 

• Displaced tongue type fractures (as in this case)

• Joint depression with articular comminution or anterior process involvement

• Bohler angle <5 degrees

• Significant deformity of the joint/calcaneus

  • Pearl: Historically almost all calcaneal fractures were treated non-operatively due to relatively high (~11%) complication rate [3]. However, more recent studies have shown that functional outcome and anatomic alignment benefits outweigh the infection risk with surgical intervention [2] for fractures with above concerns.