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
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
Disposition
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
Treatment
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
Special Populations
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
Background
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
Patient Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.