01Approach to the Critical Patient/attcp40

Emergent threats

›Time-critical limb and life threats

›Open fracture

›2-3% of calcaneal fractures

›Emergent irrigation, debridement, IV antibiotics, tetanus prophylaxis

›Orthopedic surgery consult immediately

›Compartment syndrome of the foot

›Occurs in up to 10% of calcaneal fractures

›Sanders type IV is strongest predictor (OR 21.67)

›Tense plantar swelling, pain out of proportion, pain with passive toe dorsiflexion

›Emergent fasciotomy if diagnosed

›Skin compromise from tongue-type or tuberosity fracture

›Risk of full-thickness skin necrosis within hours

›Splint in plantarflexion and emergent orthopedic consultation

Stabilization priorities

›Initial management sequence

›Elevate limb and apply ice immediately

›Jones dressing or bulky posterior splint

›Strict non-weight-bearing

›Multimodal analgesia initiated

›Neurovascular status documented serially

Monitoring and escalation

›Monitoring targets

›Compartment pressure if clinical concern

›Stryker device measurement

›Pressure >30 mmHg or within 30 mmHg of diastolic warrants fasciotomy

›Skin integrity over posterior heel

›Reassess every 1-2 hours if tongue-type or tuberosity pattern

02History/hx45

Mechanism and presentation

›Mechanism of injury

›Fall from height — most common mechanism

›Height of fall and landing surface

›Axial loading pattern

›Motor vehicle accident or crush injury

›High-impact athletic landing

›Stress fracture — gradual onset with repetitive loading

›Symptom characterization

›Severe heel pain with acute onset at time of injury

›Inability to bear weight

›Diffuse rearfoot pain suggesting intra-articular involvement

›Focal pain suggesting extra-articular pattern

›Numbness or tingling in the plantar foot — compartment syndrome concern

Associated injuries and alarm symptoms

›Concomitant injury screen

›Back pain — lumbar spine fracture in 7-22% of calcaneal fracture cases

›Bilateral heel pain — bilateral fractures in 8% of cases

›Contralateral extremity pain

›Knee or hip pain from associated trauma

›Alarm features

›Skin tenting or blanching over posterior heel — tongue-type fracture emergency

›Worsening pain out of proportion — compartment syndrome

›Loss of sensation or motor function — neurologic compromise

Risk factors

›High-risk patient profile

›Young working-age male — highest demographic incidence

›Occupational exposure — construction, manual labor

03Physical Exam/exam43

Vitals and general

›Vital signs

›Hemodynamic stability in polytrauma context

›Heart rate and blood pressure — shock from associated injuries

›General appearance

›Pain severity and functional status

›Ability to mobilize or bear weight

Lower extremity and foot exam

›Inspection

›Significant heel swelling and ecchymosis

›Ecchymosis along heel and arch — pathognomonic for calcaneal fracture

›Skin blistering suggesting significant swelling

›Widened heel and loss of heel height

›Skin tenting or blanching posteriorly — tongue-type emergency

›Palpation

›Diffuse calcaneal tenderness

›Calcaneal squeeze test

›Medial-lateral compression of calcaneus

›Positive if reproduces pain

›Plantar compartment firmness

›Neurovascular exam

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill of toes

›Sensation in sural, tibial, and deep peroneal nerve distributions

›Compartment assessment

›Tense plantar swelling

›Pain with passive toe dorsiflexion

04Differential Diagnosis/ddx51

Life-threatening and urgent diagnoses

›Emergent conditions requiring immediate action

›Compartment syndrome of the foot

›ICD-10 M79.3 compartment syndrome

›Tense swelling, pain out of proportion, pain with passive stretch

›Differentiated by compartment pressure measurement >30 mmHg

›Open calcaneal fracture

›ICD-10 S92.001A open fracture designation

›Visible bone, wound communicating with fracture

›Associated lumbar spine fracture

›ICD-10 S32.009A vertebral fracture

›Back tenderness, neurologic deficit in lower extremities

Calcaneal fracture subtypes

›Intra-articular fractures (~70-75%)

›ICD-10 S92.001 calcaneus fracture

›Involves posterior facet of subtalar joint

›Sanders classification guides management

›Higher morbidity and surgical complexity

›SNOMED CT calcaneus fracture disorder

›Extra-articular fractures (~25-30%)

›Anterior process fractures

›Calcaneocuboid joint involvement threshold >25%

›Generally better prognosis

›Tuberosity fractures

›Skin tenting risk from posterior displacement

›Emergent reduction if skin at risk

›Sustentaculum tali fractures

›Body fractures without subtalar joint involvement

05Laboratory Tests/lt30

Routine labs

›Standard injury labs

›Complete blood count

›Baseline hemoglobin if surgical intervention planned

›Leukocytosis in open fracture or polytrauma

›Basic metabolic panel

›Renal function for antibiotic dosing in open fracture

›Electrolytes for perioperative planning

›Coagulation studies

›PT/INR if anticoagulated

›Preoperative requirement

Metabolic and bone health labs

›Bone metabolism assessment

›Serum calcium

›Baseline in suspected metabolic bone disease

›Hypocalcemia in osteoporosis workup

›Vitamin D level (25-OH vitamin D)

›Relevant in stress fractures and osteoporotic pattern

›Deficiency impairs fracture healing

›Parathyroid hormone

›If hyperparathyroidism suspected as underlying cause

Specific clinical contexts

›Open fracture labs

›Blood cultures — if systemic infection signs

›Wound culture at time of debridement

›Tetanus immune status verification

›Polytrauma labs

›Lactate — perfusion assessment

06Diagnostic Tests/dt88

Scoring Systems

›Sanders classification (CT-based)

›Type I — nondisplaced fracture (<2 mm displacement) regardless of fragment number

›Conservative management standard

›Best prognosis

›Type II — two-part fracture of posterior facet

›Subtypes A, B, C based on location of primary fracture line

›Surgical vs. conservative management debated

›Type III — three-part fracture of posterior facet

›Higher complication rate

›Surgical candidates if medically fit

›Type IV — comminuted fracture with ≥4 fragments

›Worst prognosis

›Strongest predictor of compartment syndrome (OR 21.67)

›Subtalar arthrodesis may be preferred over ORIF

›Essex-Lopresti classification (radiograph-based)

›Tongue-type fracture

›Horizontal fracture line

›Skin tenting risk if posteriorly displaced

›Reduction in plantarflexion position

›Joint-depression type fracture

›Separate posterior facet fragment depressed into body

›More amenable to ORIF

›Bohler's angle measurement

›Measured on lateral radiograph

›Normal range 25-40 degrees

›Angle ≤20 degrees highly accurate for calcaneal fracture diagnosis

›Sensitivity 99%, specificity 99% at ≤20 degrees threshold

›Angle of Gissane (normal 120-145 degrees)

›Less reliable than Bohler's angle in the ED

›Assessed at critical angle between posterior facet and anterior process

MRI

›MRI indications for calcaneal fracture

›Stress fracture diagnosis

›Preferred modality when radiographs are negative

›Detects fracture within days of injury onset

›Radiographs may remain negative for weeks

›Protocol and findings

›T1-weighted sequences — cortical disruption

›STIR or T2 fat-suppressed — bone marrow edema

›Stress fracture appears as linear low T1 signal with surrounding edema

›Additional indications

›Soft tissue injury assessment — Achilles tendon, plantar fascia

›Subtalar joint cartilage assessment when CT equivocal

›Suspected occult fracture with negative CT

CT

›CT scan — gold standard for fracture characterization

›Indications

›All suspected intra-articular fractures

›Surgical planning for all displaced fractures

›When radiographs are positive or clinical suspicion high despite negative X-ray

›Protocol

›Axial, coronal, and sagittal reconstructions

›Thin-slice (1-1.5 mm) through hindfoot

›Bilateral CT when bilateral fracture suspected

›Findings and measurement

›Number of fracture fragments and displacement

›Posterior facet comminution and depression

›Bohler's angle on CT

›Calcaneocuboid joint involvement

›Sanders classification assignment

›Associated imaging

›Lumbar spine CT or radiographs for all falls from height

›Concomitant vertebral fractures in 7-22% of calcaneal fracture cases

›ACR Appropriateness Criteria

›CT foot/heel appropriate after positive radiograph for surgical planning

›CT lumbar spine appropriate with calcaneal fracture from fall

Ultrasound

›Ultrasound for calcaneal fracture

›Limited primary diagnostic role

›Not standard for fracture characterization

›CT and radiograph remain primary modalities

›Potential adjunct uses

›Soft tissue assessment — hematoma, blistering

›Vascular assessment — posterior tibial and dorsalis pedis Doppler

›Guided nerve block — posterior tibial nerve block for analgesia

›Compartment syndrome assessment

›Ultrasound cannot reliably replace compartment pressure measurement

›Soft tissue edema pattern assessment only

Plain radiographs

›Standard radiographic series

›Lateral foot radiograph — first-line for all heel injuries

›Bohler's angle measurement

›Essex-Lopresti classification

›AP foot radiograph

›Calcaneocuboid joint assessment

›Anterior process fracture visualization

›Harris axial (hindfoot axial) view

›Foot in dorsiflexion, beam angled 45 degrees cephalad

›Heel width assessment

›Varus or valgus alignment evaluation

›Medial and lateral wall comminution

›Bilateral views if bilateral injury suspected

07Disposition/dispo28

Admission criteria

›Inpatient admission indications

›Open calcaneal fracture

›IV antibiotics, surgical planning, debridement

›Compartment syndrome of the foot — diagnosed or evolving

›Emergent fasciotomy

›Tongue-type or tuberosity fracture with skin compromise

›Emergent orthopedic reduction

›Associated spinal fracture

›Spinal precautions and further workup

›Bilateral calcaneal fractures

›Non-ambulatory, require rehabilitation planning

›Planned urgent or emergent surgical intervention

Discharge criteria

›Safe discharge criteria

›Closed, nondisplaced extra-articular fracture

›No signs of compartment syndrome

›Adequate pain control achieved

›Able to use crutches safely and demonstrate non-weight-bearing compliance

›Reliable orthopedic follow-up arranged within 5-7 days

›Patient understands return precautions

Transfer criteria

›Transfer indications

›Open fracture requiring operative debridement — transfer to orthopedic center if unavailable

›Compartment syndrome requiring emergent fasciotomy — transfer if surgical capability absent

›Complex polytrauma — trauma center transfer

Follow-up requirements

›Orthopedic follow-up timeline

08Treatment/t86

Immediate ED management

›Initial stabilization

›Elevation of limb above heart level

›Ice application — 20 minutes on, 20 minutes off

›Posterior splint application

›Tongue-type and tuberosity fractures — splint in plantarflexion

›All other fractures — posterior splint in neutral position

›Strict non-weight-bearing with crutches

›Compartment checks at regular intervals

Analgesia

›Multimodal analgesia protocol

›Acetaminophen

›1 g orally or IV every 6 hours

›Safe for most patients

›First-line non-opioid

›NSAIDs

›Ibuprofen 400-600 mg orally every 6-8 hours

›Theoretical concern about bone healing — controversial

›Avoid if renal impairment or planned surgery soon

›Opioids for severe pain

›Oxycodone 5-10 mg orally every 4-6 hours as needed

›Morphine 2-4 mg IV titrated for severe acute pain

›Short course only — limit to acute ED and post-operative period

›Regional analgesia

›Posterior tibial nerve block

›High-volume local anesthetic injection at medial ankle

›Bupivacaine 0.25-0.5% 5-10 mL

›Effective for plantar foot analgesia

›Ankle block

›Combination of five nerve blocks around the ankle

›Provides comprehensive foot analgesia without motor block

›Ultrasound-guided technique preferred

Open fracture management

›Open fracture protocol

›Wound irrigation with normal saline

›Sterile dressing application

›Antibiotics — initiate within 1 hour of presentation

›Gustilo type I and II

›Cefazolin 2 g IV every 8 hours (first-generation cephalosporin)

›Penicillin allergy — clindamycin 900 mg IV every 8 hours

›Gustilo type III

›Cefazolin 2 g IV every 8 hours plus

›Gentamicin 5 mg/kg IV once daily

›Add penicillin G if contaminated wound or farm injury

›Tetanus prophylaxis

›Tetanus toxoid if vaccination not up to date

›Tetanus immune globulin if unvaccinated or unknown status

Nonsurgical management

›Conservative treatment protocol

›Indications

›Nondisplaced fractures (Sanders type I)

›Extra-articular fractures without skin compromise

›Less than 25% calcaneocuboid joint involvement

›Medical comorbidities precluding surgery

›Immobilization

›Short leg non-weight-bearing cast or controlled ankle motion boot for 4-6 weeks

›Transition to removable boot at 4-6 weeks

›Rehabilitation

›Early subtalar range-of-motion exercises when pain allows

›Progressive weight-bearing after 6 weeks if union confirmed

›Physical therapy for functional recovery

Surgical management

›ORIF indications

›Displaced intra-articular fractures (Sanders type II-III)

›Calcaneocuboid joint involvement >25%

›Significant heel widening causing impingement

›Surgical timing

›Delay surgery 7-14 days until soft tissue swelling resolves

›Wrinkle test positive — skin pliable enough to close

›Tongue-type with skin compromise — may require emergent reduction

›Surgical approaches

›Extensile lateral approach — traditional gold standard

›Full exposure of posterior facet and lateral wall

›Higher wound complication rate

›Sinus tarsi approach (minimally invasive)

›Smaller incision, lower wound complication rate

›Increasing evidence supporting equivalent outcomes

›Evidence base

›UK HeFT RCT — no significant functional difference between ORIF and nonoperative at 2 and 5 years

›Higher wound complications in surgical group

›Operative treatment may improve return-to-work rates (91% vs. 72%)

›Subtalar arthrodesis

›Sanders type IV fractures — primary arthrodesis may be preferred

›Severe comminution where ORIF not reconstructable

›Post-traumatic subtalar arthritis as delayed salvage

DVT prophylaxis

›Venous thromboembolism prevention

›Low molecular weight heparin for prolonged non-weight-bearing

›Enoxaparin 40 mg subcutaneously once daily

›Renal adjustment required if creatinine clearance <30 mL/min

›Mechanical prophylaxis — compression stockings on contralateral limb

›Duration — continue until full weight-bearing restored or 6 weeks

09Special Populations/sp64

Pregnancy

›Pregnancy-specific considerations

›Mechanism and imaging

›Falls are most common mechanism in pregnancy — altered center of gravity

›Radiographs — two views acceptable with abdominal shielding

›CT — limit slices; fetal radiation exposure 1-3 mGy for foot CT well below threshold

›MRI preferred over CT when alternative to radiograph needed

›Pain management in pregnancy

›Acetaminophen — safe throughout pregnancy; preferred analgesic

›NSAIDs — avoid after 20 weeks; premature ductus arteriosus closure risk

›Opioids — limit duration; neonatal opioid withdrawal syndrome risk

›Regional nerve blocks — preferred; local anesthetics generally safe

›DVT prophylaxis

›Pregnancy is an independent VTE risk factor

›LMWH preferred over unfractionated heparin for extended prophylaxis

›Warfarin — avoid; crosses placenta and causes embryopathy

›Surgical considerations

›Surgery generally deferred until after delivery if possible

›Second trimester safest period if surgery required

›Multidisciplinary team — orthopedics, obstetrics, anesthesia

Geriatric

›Geriatric-specific considerations

›Fracture pattern differences

›Lower-energy mechanism — osteoporotic calcaneus

›Extra-articular fractures more common in elderly

›Associated fractures — wrist, hip, spine

›Surgical risk assessment

›Higher wound complication and medical complication rates

›Diabetes, peripheral vascular disease more prevalent

›Nonoperative management often preferred in elderly with comorbidities

›Bone health optimization

›Calcium supplementation — 1000-1200 mg/day

›Vitamin D supplementation — 800-1000 IU/day

›Osteoporosis workup if mechanism suggests low bone density

›Bisphosphonate therapy consideration for secondary fracture prevention

›Fall prevention and rehabilitation

›Multidisciplinary fall risk assessment

›Prolonged non-weight-bearing may not be feasible for frail patients

›Walking aid assessment and home safety evaluation

›Pain management

›Increased opioid sensitivity — lower starting doses

›NSAIDs — caution for GI bleeding, renal impairment, fluid retention

›Acetaminophen — preferred; dose 500-750 mg every 6 hours

Pediatrics

›Pediatric-specific considerations

›Epidemiology and fracture patterns

›Calcaneal fractures are rare in children — <1% of pediatric fractures

›Non-accidental trauma must be considered — any skeletal fracture in young child

›Calcaneal apophysitis (Sever disease) is more common mimic

›Growth plate considerations

›Calcaneal apophysis appears at 6-8 years

›Fusion complete by 14-16 years

›Growth plate (physis) involvement affects surgical planning and healing

›Salter-Harris classification applied to physeal fractures

›Fracture characteristics

›More plastic and less comminuted than adult fractures

›Extra-articular pattern more common in children

›Stress fractures — consider repetitive activity, RED-S in adolescent athletes

›Imaging in pediatrics

›Radiograph first-line — compare with contralateral heel if uncertain

›CT with minimal dose protocol if fracture complex

›MRI preferred for stress fractures and growth plate assessment

›Management

›Conservative management preferred — children heal more reliably than adults

›Short leg non-weight-bearing cast for 4-6 weeks for most fractures

›Surgical indications — severely displaced intra-articular fractures

›Weight-based analgesia — acetaminophen 15 mg/kg every 4-6 hours

10Background/b69

Epidemiology

›Incidence and demographics

›Most commonly fractured tarsal bone

›Accounts for 1-2% of all fractures

›Represents 60% of all tarsal fractures

›Predominantly affects younger working-age males

›Peak incidence in males aged 30-50 years

›Male predominance — roughly 70-80% of cases

›Bilateral fractures in 8% of cases

›Associated spinal fractures in 7-22% of cases from falls

›Mechanism distribution

›Falls from height — most common mechanism

›Motor vehicle accidents

›Industrial crush injuries

›Athletic injuries and stress fractures — minority

›Morbidity and outcomes

›Significant long-term morbidity — patients incapacitated up to 3 years

›Long-term complications include subtalar arthritis, chronic heel pain, difficulty with shoe wear

›Return to work often delayed in manual laborers

›Operative treatment may improve return-to-work rates (91% vs 72% nonoperative)

›Wound complication rates up to 25% with extensile lateral approach in high-risk patients

Pathophysiology

›Fracture mechanism

›Axial loading — primary mechanism

›Talus driven downward into calcaneus with high axial force

›Body weight plus fall energy transmitted through heel

›Shear forces produce primary fracture line through posterior facet

›Secondary fracture lines

›Primary fracture line in coronal plane — posterior facet medial and lateral portions

›Secondary lines propagate anteriorly or superiorly

›Fragment number and displacement determines Sanders classification

›Compartment syndrome mechanism

›Intraosseous bleeding and soft tissue hemorrhage into closed foot compartments

›Foot has 4-9 compartments (variable by description)

›Medial, central, lateral, and interosseous compartments

›Calcaneal (hindfoot) compartment — critical in calcaneal fractures

›Elevated compartment pressure impairs perfusion

›Risk highest with Sanders type IV fractures

›Skin necrosis mechanism in tongue-type fracture

›Posterior fragment displaces superiorly

›Achilles tendon pulls fragment further posterior and superior

›Skin overlying posterior heel stretched acutely — tent-like deformity

›Pressure necrosis can occur within hours without reduction

›Post-traumatic arthritis mechanism

›Articular cartilage damage at time of injury

›Imperfect reduction of posterior facet leads to joint incongruity

›Subtalar joint incongruity — progressive arthritis even with anatomical reduction

Therapeutic Considerations

›Operative versus nonoperative evidence

›HeFT randomized controlled trial (Griffin et al., BMJ 2014)

›No significant functional difference between ORIF and nonoperative at 2 years

›Cochrane Review 2023 confirms uncertain functional benefit of surgery

›Higher wound complication rates in surgical group

›Subgroup: younger patients and workers may benefit more from surgery

›Minimally invasive approaches

›Sinus tarsi approach demonstrates lower wound complication rates

›Comparable radiographic and functional outcomes to extensile approach

›Trend toward minimally invasive techniques in literature

›Surgical timing evidence

›Delayed surgery (7-14 days) allows soft tissue recovery

›Premature surgery significantly increases wound complication risk

›Wrinkle sign — positive (skin pliable) indicates appropriate timing

›Conservative management evidence

›Nondisplaced fractures — conservative management is standard of care

›Extra-articular fractures — generally managed conservatively

›Early mobilization reduces stiffness and improves functional outcomes

›Functional bracing allows earlier weight-bearing than cast in some protocols

›Bone healing optimization

›Smoking cessation — significantly reduces wound and nonunion complications

›Nutritional optimization — protein, calcium, vitamin D

›Diabetes management — tight glycemic control reduces surgical complications

›DVT prophylaxis — LMWH for prolonged non-weight-bearing period

11Patient Discharge Instructions/pdi29

copy discharge instructions

›You have been diagnosed with a calcaneal (heel bone) fracture

›This is a serious injury that requires careful follow-up with an orthopedic surgeon

›Recovery typically takes 6-12 months; some patients experience residual symptoms for longer

›Activity restrictions

›Do not put any weight on the injured foot — use crutches at all times

›Keep the injured foot elevated above the level of your heart as much as possible

›Apply ice wrapped in a cloth to the splint or boot area for 20 minutes at a time

›Do not remove or modify the splint or boot without orthopedic instruction

›Your follow-up appointment

›Orthopedic surgeon visit within 5-7 days — do not miss this appointment

›Bring this discharge paperwork to your follow-up visit

›Further imaging (CT scan) may be needed to plan treatment

›Pain management

›Take pain medication as prescribed — do not exceed recommended doses

›Acetaminophen (Tylenol) 500-1000 mg every 6 hours as needed for pain

›NSAIDs (ibuprofen, naproxen) may be prescribed — take with food

›Wound and splint care

›Keep the splint or boot dry at all times

›Do not insert objects into the splint to scratch

›Report any foul odor or discharge from a wound

›Return to the emergency department immediately if you experience

›Increasing pain that is not controlled by prescribed medication

›Numbness or tingling in your toes or foot

›Toes turning white, blue, or cold

›Inability to move your toes

›Worsening swelling

›Skin breakdown or blistering over the back of the heel

12References/r28

Guidelines and key sources

›Silver S, Williams E, Plunkett ML — Common Foot Fractures, American Family Physician 2024

›PMID 38393796

›Comprehensive review of calcaneal fracture diagnosis and management

›Lewis SR, Pritchard MW, et al — Surgical Versus Non-Surgical Interventions for Displaced Intra-Articular Calcaneal Fractures, Cochrane Database 2023

›Cochrane systematic review — uncertain functional benefit of surgery over conservative care

›Griffin D, Parsons N, Shaw E et al — Operative Versus Non-Operative Treatment for Closed, Displaced Intra-Articular Calcaneal Fractures: HeFT RCT, BMJ 2014

›PMID 25059747

›Landmark trial — no significant functional difference at 2 years

›Dickenson EJ, Parsons N, Griffin DR — Long-term Follow-Up From HeFT RCT, Bone Joint J 2021

›PMID 34058883

›5-year follow-up confirms no significant functional difference

›Park YH et al — Predictors of Compartment Syndrome After Calcaneal Fracture, Bone Joint J 2018

›PMID 29589492

›Sanders type IV — OR 21.67 for compartment syndrome

›Snoap T et al — Calcaneus Fractures: A Possible Musculoskeletal Emergency, J Emergency Med 2017

›PMID 27658550

›Bohler's angle sensitivity 99%, specificity 99% at ≤20 degrees threshold

›Badillo K et al — Multidetector CT Evaluation of Calcaneal Fractures, Radiographics 2011

›PMID 21257934

›CT protocol and Sanders classification review

›Smith SE et al — ACR Appropriateness Criteria Acute Trauma to the Ankle, JACR 2020

›ACR imaging guidelines for calcaneal fracture evaluation

›Walters JL et al — Association of Calcaneal and Spinal Fractures, J Foot Ankle Surg 2014

›PMID 24618246

›7-22% concomitant vertebral fracture rate with calcaneal fractures from falls

›Myerson M, Manoli A — Compartment Syndromes of the Foot After Calcaneal Fractures, Clin Orthop 1993

›PMID 8472441

Evidence & Review

Evidence & Review