Calcaneus fractureMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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418 items

☷ Legend

01Approach to the Critical Patient/attcp41

Immediate priorities

›Stabilization priorities

›ABCs with trauma activation for high-energy mechanism

›Hemorrhage concern triggers

›Hypotension

›Tachycardia

›Limb threat screening

›Open fracture

›Gross contamination

›Bone protrusion

›Skin compromise over heel

›Tenting

›Threatened posterior skin in tongue-type pattern

›Compartment syndrome concern

›Escalating pain despite analgesia

›Pain with passive toe motion

›Analgesia early

›Multimodal plan

›Acetaminophen

›NSAID if no contraindication

›Opioid for severe pain

›Regional block with trained provider

Immobilization and limb protection

›Early limb care

›Posterior short leg splint with bulky padding

›Neutral ankle position if tolerated

›Avoid circumferential cast acutely due to swelling

›Strict elevation

›Heel offloading

›Ice as tolerated

›Non-weight-bearing

›Crutches or walker

›Wheelchair if bilateral injuries

Key associated injury checks

›Associated injuries

›Bilateral calcaneus fractures

›Contralateral foot and ankle imaging threshold low

›Axial load trauma pattern

›Lumbar spine fracture screening

›Pelvic injury screening

›Polytrauma triggers

›Fall from height

›Motor vehicle collision

›Altered mental status

02History/hx34

Mechanism and timeline

›Mechanism details

›Axial load mechanism

›Fall from height

›Jump landing

›Motor vehicle collision with floorboard intrusion

›Time since injury

›Immediate inability to bear weight

›Progressive swelling

›Energy level estimate

›Height of fall

›Surface landed on

Symptoms and function

›Symptom profile

›Heel pain location

›Plantar heel

›Lateral hindfoot

›Weight-bearing ability

›Unable

›Limited with antalgic gait

›Neurologic symptoms

›Numbness plantar foot

›Paresthesia toes

Risk modifiers

›Patient factors

›Diabetes

›Wound risk

›Neuropathy baseline

›Smoking

›Delayed healing

›Peripheral vascular disease

›Skin and wound risk

›Anticoagulant or antiplatelet use

›Hematoma risk

›Compartment syndrome risk

›Prior hindfoot surgery or deformity

›Baseline alignment

03Physical Exam/exam40

Foot and ankle exam

›Hindfoot assessment

›Swelling distribution

›Hindfoot edema

›Ankle edema

›Ecchymosis patterns

›Plantar ecchymosis sign

›Suggests calcaneus fracture with significant injury

›Skin integrity

›Blisters

›Fracture blisters as surgery-timing limiter

›Tenting

›Open wound location

›Heel pad status

›Alignment and position

›Tenderness and mobility

›Deformity

›Heel widening

›Varus malalignment

Neurovascular

›Perfusion and nerve function

›Pulses

›Dorsalis pedis

›Posterior tibial

›Capillary refill

›Delayed refill concern

›Sensation

›Tibial nerve distribution

›Sural nerve distribution

›Superficial peroneal distribution

›Deep peroneal distribution

›Motor

›Toe flexion and extension

›Ankle dorsiflexion and plantarflexion as tolerated

Compartment syndrome and tendon checks

›Time-sensitive threats

›Foot compartment syndrome features

›Pain out of proportion

›Tense compartments

›Pain with passive toe stretch

›Achilles tendon status

›Posterior heel tenderness

›Thompson test if concern

04Differential Diagnosis/ddx28

Traumatic hindfoot and ankle

›Hindfoot differentials

›Calcaneus fracture

›Intra-articular

›Extra-articular

›Talus fracture

›Talar neck

›Talar body

›Subtalar dislocation

›Medial

›Lateral

›Ankle fracture

›Malleolar fractures

›Syndesmotic injury

›Midfoot injury

›Lisfranc injury

›Cuboid fracture

Soft tissue and overuse mimics

›Nonfracture considerations

›Severe ankle sprain

›Plantar fascia rupture

›Achilles tendon rupture

›Contusion with heel pad injury

High-energy associated conditions

›Polytrauma related

›Lumbar compression fracture

›ICD-10 S32.0-

›Pelvic ring injury

›ICD-10 S32.8-

›Calcaneal compartment syndrome

›SNOMED CT compartment syndrome of foot

05Laboratory Tests/lt16

Trauma and pre-op supportive labs

›Lab strategy

›High-energy trauma pathway labs

›Complete blood count for hemorrhage concern

›Hemoglobin trend if ongoing bleeding concern

›Electrolytes and renal function for analgesic planning

›NSAID safety context

›Coagulation studies for anticoagulant use or operative planning

›INR interpretation for warfarin

›Type and screen for anticipated surgery or major trauma

›Crossmatch trigger with hemodynamic instability

Infection and open fracture

›Open fracture support

›Wound contamination assessment

›Tetanus status

›Booster thresholds per immunization history

›Glucose in diabetes for wound risk context

›mmol/L documentation

06Diagnostic Tests/dt46

Scoring Systems

›Classification and decision support

›Sanders classification for intra-articular calcaneus fractures on CT

›Based on number and location of posterior facet fracture lines

›Type I nondisplaced

›Type II two-part

›Type III three-part

›Type IV comminuted

›Essex-Lopresti pattern description for calcaneus

›Tongue-type fracture

›Posterior tuberosity fragment risks skin compromise

›Joint-depression fracture

›Posterior facet depressed fragment

›Böhler angle on lateral radiograph

›Decreased angle suggests calcaneus fracture and loss of height

›Markedly decreased angle suggests intra-articular involvement

›Gissane angle on lateral radiograph

›Abnormal angle supports fracture pattern recognition

MRI

›MRI role

›Occult fracture concern with negative radiographs and persistent focal pain

›Bone marrow edema pattern

›Stress injury differentiation

›Soft tissue evaluation

›Achilles insertion injury

›Peroneal tendon injury

›Limited acute ED role

›CT preferred for fracture mapping and operative planning

›CT indications and pearls

›CT hindfoot for suspected intra-articular calcaneus fracture

›Posterior facet involvement

›Subtalar joint step-off estimation

›Preoperative planning utility

›Fragment mapping

›Sanders classification assignment

›Bilateral injuries or complex hindfoot trauma

›CT both hindfeet if bilateral pain and swelling

›Radiation considerations

›Pregnancy imaging minimization with shielding when possible

Ultrasound (or US)

›Ultrasound applications

›Limited fracture detection role

›Cortical disruption detection in skilled hands

›Not definitive for operative planning

›Achilles evaluation when tendon rupture concern

›Tendon discontinuity

›Hematoma at insertion

›POCUS for trauma adjuncts

›FAST in polytrauma context

07Disposition/dispo30

Consult and level of care

›Disposition pathways

›Emergent orthopedic consultation triggers

›Open calcaneus fracture

›Immediate antibiotics

›Operative irrigation and debridement planning

›Threatened posterior skin

›Tongue-type with skin tenting

›Urgent reduction or fixation consideration

›Neurovascular compromise

›Diminished pulses

›Progressive sensory loss

›Compartment syndrome concern

›Emergent fasciotomy pathway

›Admission considerations

›Polytrauma requiring imaging and monitoring

›Bilateral calcaneus fractures with mobility failure

›Uncontrolled pain despite ED regimen

›Unsafe discharge environment

Discharge criteria and follow-up

›Outpatient management criteria

›Closed fracture

›Stable soft tissues

›No neurovascular deficit

›Pain controlled with oral regimen

›Ambulation plan with non-weight-bearing support

›Reliable follow-up

›Orthopedics within 3 to 7 days typical

›Earlier if significant swelling or skin risk

›Imaging complete

›Radiographs obtained

›CT arranged or completed when needed

08Treatment/t78

Initial nonoperative ED management

›Core management

›Immobilization

›Bulky posterior short leg splint

›Heel padding

›Toe exposure for neurovascular reassessment

›Edema control

›Elevation above heart level

›Continuous first 48 to 72 hours when feasible

›Ice intermittently

›Skin protection barrier

›Activity restriction

›Strict non-weight-bearing

›Explicit no heel strike

Analgesia protocols

›Pain control regimen

›Acetaminophen

›1000 mg PO every 6 to 8 hours

›Maximum 3000 mg per day if liver risk

›Ibuprofen

›400 mg PO every 6 to 8 hours

›Avoid in CKD, active GI bleed, high bleeding risk

›Naproxen

›500 mg PO initial

›250 to 500 mg PO every 12 hours

›Hydromorphone

›1 to 2 mg PO every 4 to 6 hours as needed

›Sedation and respiratory depression precautions

›Morphine

›0.05 to 0.1 mg/kg IV for severe pain

›Titration every 10 to 15 minutes to comfort

›Ketorolac

›15 mg IV single dose option

›Avoid in CKD and high bleeding risk

›Regional anesthesia option

›Popliteal sciatic block by trained clinician

›Neurovascular reassessment plan after block

Open fracture management

›Open fracture bundle

›Antibiotics

›Cefazolin 2 g IV

›Repeat every 8 hours if ongoing coverage needed

›If severe cephalosporin allergy

›Clindamycin 900 mg IV

›If heavy contamination or farm injury

›Add gentamicin 5 mg/kg IV

›Add metronidazole 500 mg IV if anaerobe concern

›Tetanus prophylaxis

›Tdap booster if indicated

›Tetanus immune globulin for unknown or incomplete immunization with dirty wound

›Wound care

›Sterile saline irrigation

›Cover with sterile dressing

›Avoid aggressive ED debridement of deep tissues

Operative versus nonoperative guidance

›Treatment selection concepts

›Nonoperative candidates

›Nondisplaced extra-articular fractures

›Minimal displacement intra-articular in select cases

›High surgical risk

›Severe peripheral vascular disease

›Poor soft tissues

›Operative consideration triggers

›Displaced intra-articular fractures

›Posterior facet step-off

›Significant heel widening or varus

›Tongue-type with skin compromise

›Urgent reduction or fixation to prevent necrosis

›Open fractures

›Soft tissue timing principle

›Definitive fixation often delayed until swelling improves

›Skin wrinkling sign as readiness marker

VTE and mobility considerations

›Thrombosis risk management

›Immobilization risk discussion

›Individualized pharmacologic prophylaxis decision

›High-risk features

›Prior VTE

›Active cancer

›Prolonged immobility

›Mobility plan

›Crutch training

›Stair safety assessment

09Special Populations/sp37

Pregnancy

›Pregnancy considerations

›Imaging strategy

›Radiographs with shielding when appropriate

›Maternal stabilization priority

›CT only when benefits outweigh risks

›Orthopedic planning necessity

›Analgesia safety

›Acetaminophen preferred

›NSAID avoidance in later pregnancy

›Opioid short course if severe pain

›VTE risk

›Pregnancy hypercoagulability

›Lower threshold for obstetric input if prophylaxis considered

Geriatric

›Geriatric considerations

›Low energy mechanism with fracture

›Osteoporosis context

›Fragility fracture workup planning

›Skin risk

›Higher blister and wound risk

›Splint padding optimization

›Medication safety

›NSAID renal and GI risk

›Opioid delirium and fall risk

Pediatrics

›Pediatric considerations

›Growth plate evaluation

›Calcaneal apophysis considerations

›Salter-Harris patterns if adjacent physes involved

›Imaging

›Comparison views sometimes helpful

›Contralateral radiograph in equivocal cases

›Analgesia dosing

›Weight-based acetaminophen

›15 mg/kg PO every 6 hours

›Weight-based ibuprofen

›10 mg/kg PO every 6 to 8 hours

›Nonaccidental trauma awareness in atypical history

›Developmentally inconsistent mechanism

10Background/b34

Epidemiology

›Epidemiology highlights

›Common mechanism

›Fall from height with axial load

›Occupational and recreational risks

›Construction falls

›Ladder falls

›Bilaterality frequency

›Meaningful rate of bilateral fractures in high-energy axial load

Pathophysiology

›Injury mechanics

›Axial compression through talus into calcaneus

›Posterior facet disruption

›Heel widening from lateral wall blowout

›Fracture types

›Intra-articular

›Subtalar joint involvement

›Extra-articular

›Tuberosity

›Sustentaculum tali

›Anterior process

›Soft tissue injury burden

›Fracture blisters

›Skin necrosis risk with tongue-type displacement

Therapeutic Considerations

›Treatment principles

›Soft tissue first strategy

›Swelling control before definitive surgery

›Anatomy driven outcomes

›Posterior facet congruity linked to subtalar arthritis risk

›Evidence framing

›Operative versus nonoperative outcomes vary by fracture pattern and patient factors

›Shared decision-making emphasis for borderline indications

›Guideline language

›Class I recommendation for emergent antibiotics in open fractures

›Class I recommendation for urgent management of threatened skin

›ACEP Level C support for early immobilization and elevation in closed fractures

11Patient Discharge Instructions/pdi26

copy discharge instructions

›Discharge instructions

›Diagnosis and expectations

›Heel bone fracture with significant swelling risk

›Healing time commonly weeks to months

›Activity

›No weight on injured foot

›Use crutches or walker at all times

›Splint care

›Keep splint clean and dry

›Do not insert objects inside splint

›Elevate foot above heart as much as possible for 48 to 72 hours

›Pain control

›Acetaminophen as directed

›NSAID only if safe for you

›Opioid only as prescribed

›Follow-up

›Orthopedics appointment as instructed

›CT appointment if arranged

›Return to ED now for red flags

›Increasing pain not controlled by medication

›Numbness or tingling in toes

›Toes turning blue or cold

›New inability to move toes

›Splint feels too tight with worsening swelling

›Fever or wound drainage

›New blistering or skin darkening over the heel

12References/r8

Guidelines and key sources

›Core references

›Orthopaedic Trauma Association educational resources on calcaneus fractures

›Classification and management principles

›AAOS patient and clinician education materials on calcaneus fracture care

›Nonoperative care principles

›Open fracture management guidance

›Antibiotic timing and tetanus prophylaxis standards

›Source file

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.