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

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

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

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

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

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

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

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

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

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

Evidence & Review