Calcaneus fractureMANAGEMENT

FOOT · 12 SECTIONS

⚲

498 items

☷ Legend

01Approach to the Critical Patient/attcp50

Initial priorities

›Limb threat screen

›Open fracture concern

›Visible bone

›Deep wound over heel

›Skin compromise

›Posterior heel skin blanching

›Tense fracture blistering

›Foot compartment syndrome concern

›Pain out of proportion

›Pain with passive toe motion

›Neurovascular compromise

›Cap refill delay

›Weak or absent DP pulse

›Weak or absent PT pulse

›ABCs and trauma context

›High-energy fall protocol

›Spine precautions when indicated

›Associated injury survey

›Hemodynamic instability pathway

›Polytrauma activation

›Massive transfusion protocol if indicated

›Immediate imaging and consultation triggers

›Heel deformity with high-energy axial load

›CT hindfoot for intra-articular pattern and surgical planning

›Early orthopedics consultation

›Posterior tuberosity displacement with threatened skin

›Emergent orthopedics notification

›Temporizing plantarflexion splint positioning

›Immobilization and analgesia early

›Bulky splinting strategy

›Posterior short leg splint

›Extra padding at heel

›Elevation strategy

›Above heart level

›Strict non-weight-bearing

Key concepts

›Calcaneus fracture pattern recognition

›Intra-articular

›Posterior facet involvement

›Subtalar joint injury risk

›Extra-articular

›Tuberosity avulsion

›Anterior process

›Sustentaculum tali

›Time-dependent soft tissue risk

›Swelling peak in first 24-72 hours

›Skin necrosis risk with displaced tuberosity fragment

›Frequent associated injuries with axial load

›Lumbar spine burst fracture risk

›Contralateral calcaneus fracture risk

›Tibial plateau fracture risk

02History/hx35

Injury context

›Mechanism and energy

›Fall from height

›Estimated height

›Feet-first landing

›Motor vehicle collision

›Pedal impact

›Ejection

›Low-energy twisting

›Avulsion pattern concern

›Osteoporosis context

›Timing

›Time since injury

›Time since swelling progression

›Symptoms and function

›Inability to bear weight

›Plantar heel pain

›Lateral hindfoot pain

›Neurovascular and compartment symptom cluster

›Numbness or tingling in sole

›Increasing tightness in foot

›Pain escalating despite analgesia

›Skin and wound context

›Laceration near heel

›Contamination concern

›Comorbidity and risk modifiers

›Diabetes mellitus

›Peripheral vascular disease

›Smoking history

›Chronic steroid use

›Medications and bleeding risk

›Anticoagulant use

›Antiplatelet use

›Baseline mobility

›Pre-injury walking status

›Assistive device use

03Physical Exam/exam50

Focused foot and ankle exam

›Inspection

›Hindfoot swelling

›Medial and lateral bulging

›Heel widening

›Skin integrity

›Posterior heel blanching

›Fracture blisters

›Open wound

›Alignment

›Hindfoot varus

›Hindfoot valgus

›Palpation and compartments

›Calcaneal tenderness

›Posterior tuberosity

›Lateral wall

›Anterior process

›Foot compartments

›Tense swelling

›Pain with passive toe extension

›Neurovascular

›Pulses

›Dorsalis pedis pulse

›Posterior tibial pulse

›Perfusion

›Capillary refill

›Skin temperature asymmetry

›Sensory

›Tibial nerve plantar sensation

›Sural nerve lateral foot sensation

›Superficial peroneal dorsal sensation

›Motor

›Great toe flexion

›Great toe extension

›Ankle dorsiflexion

›Tendon and adjacent structure screen

›Achilles insertion tenderness

›Peroneal tendon subluxation or crepitus

›Joint above and associated injury screen

›Ankle tenderness and instability

›Knee tenderness

›Lumbar spine tenderness

PITFALLS

›Normal-appearing initial radiographs with high clinical suspicion

›Persistent inability to bear weight

›High-energy axial load history

›Under-recognition of posterior tuberosity avulsion

›Skin necrosis risk

›Requires urgent fixation pathway

›Missed compartment syndrome of the foot

›Disproportionate pain despite splinting

›Escalation to compartment pressure measurement

04Differential Diagnosis/ddx23

Traumatic hindfoot and ankle conditions

›Calcaneus fracture intra-articular (ICD-10 S92.0-)

›Posterior facet depression

›Tongue-type fracture

›Calcaneus fracture extra-articular (ICD-10 S92.0-)

›Tuberosity avulsion

›Sustentaculum tali fracture

›Anterior process fracture

›Talar neck or body fracture (ICD-10 S92.1-)

›Subtalar joint pain predominance

›AVN risk context

›Ankle fracture (ICD-10 S82.8-)

›Malleolar tenderness pattern

›Syndesmotic injury

›Midfoot injury

›Lisfranc injury (ICD-10 S93.32-)

›Navicular fracture (ICD-10 S92.25-)

›Tendon injury mimic

›Achilles tendon rupture

›Thompson test abnormal

›Palpable gap

›Soft tissue injury without fracture

›Severe ankle sprain

›Calcaneal contusion

05Laboratory Tests/lt24

Indicated scenarios

›Baseline labs for operative pathway

›Complete blood count for anemia or infection concern

›Open fracture

›Polytrauma

›Electrolytes and creatinine for perioperative planning

›Contrast CT consideration

›Comorbidity burden

›Coagulation studies for anticoagulant use

›INR when warfarin use

›Anti-Xa level per local protocol when DOAC timing unclear

›Open fracture or infection concern

›Tetanus status verification

›Immunization history uncertainty

›High-risk wound contamination

›Compartment syndrome or crush concern

›Creatine kinase for rhabdomyolysis concern

›Prolonged entrapment

›Extensive soft tissue injury

›Creatinine for kidney injury risk

›Myoglobinuria concern

›Dehydration

Interpretation and pitfalls

›Normal labs do not exclude compartment syndrome

›Diagnosis remains clinical

›Pressure measurement pathway when uncertain

06Diagnostic Tests/dt76

Scoring Systems

›Classification and management mapping

›Sanders classification for intra-articular calcaneus fracture on CT

›Type I

›Nondisplaced posterior facet fragments

›Typical nonoperative pathway

›Type II

›Two-part posterior facet fracture

›ORIF consideration based on displacement and soft tissues

›Type III

›Three-part posterior facet fracture

›Higher risk subtalar arthritis

›ORIF or staged fixation consideration

›Type IV

›Comminuted posterior facet fracture

›Primary subtalar arthrodesis consideration

›Essex-Lopresti classification for tongue-type vs joint depression

›Tongue-type

›Posterior tuberosity fragment displacement

›Skin compromise risk

›Joint depression

›Posterior facet depression predominance

›Subtalar incongruity risk

›Gustilo-Anderson for open fracture

›Antibiotic breadth and timing pathway

›Operative urgency pathway

Radiographs

›Required views

›Foot series

›AP foot

›Lateral foot

›Oblique foot

›Calcaneus views when available

›Axial heel view

›Lateral calcaneus view

›Ankle series when tenderness present

›Mortise view

›Lateral ankle view

›Key radiographic measurements and signs

›Bohler angle on lateral

›Normal range 20-40 degrees

›Decrease suggests posterior facet depression

›Critical angle of Gissane

›Abnormal widening suggests calcaneal fracture

›Heel widening and lateral wall blowout

›Peroneal tendon impingement risk

›Subtalar joint line disruption

›Intra-articular involvement suspicion

›Post-reduction and post-splint imaging

›Neurovascular status documentation before and after immobilization

›Repeat radiographs if alignment changes

MRI

›Occult fracture pathway

›Persistent heel pain with negative radiographs

›Stress fracture consideration

›Bone marrow edema detection

›Soft tissue injury clarification

›Achilles insertion injury

›Peroneal tendon tear

›Contraindications and limitations

›Time sensitivity not ideal for acute surgical planning

›Metal hardware compatibility considerations

›Indications

›Suspected intra-articular calcaneus fracture

›Posterior facet displacement assessment

›Sanders classification assignment

›Surgical planning

›Comminution mapping

›Sustentaculum involvement

›Equivocal radiographs with high suspicion

›High-energy axial load

›Severe hindfoot swelling and pain

›Technique considerations

›Thin-cut hindfoot CT with multiplanar reconstructions

›Bilateral CT when contralateral injury concern

›CT pearls

›Posterior facet step-off measurement

›Subtalar joint congruity assessment

›Tuberosity fragment displacement quantification

07Disposition/dispo31

Site of care and follow-up timing

›Admission and transfer triggers

›Open fracture

›Immediate orthopedics consultation

›Transfer if no operative capability

›Threatened posterior heel skin

›Emergent orthopedics consultation

›Admission for urgent fixation pathway

›Neurovascular compromise

›Immediate escalation

›Vascular surgery involvement if indicated

›Foot compartment syndrome concern

›Emergent ortho evaluation

›Compartment pressure measurement pathway

›Polytrauma

›Trauma service admission

›Spine imaging pathway when indicated

›Discharge criteria

›Closed fracture

›Pain controlled on oral regimen

›Intact neurovascular exam after splint

›Reliable strict non-weight-bearing plan

›Safe mobility

›Crutches or walker training

›Home support confirmed

›Follow-up timing

›Orthopedics within 3-7 days

›Soft tissue swelling reassessment

›Operative candidacy reassessment

›Earlier review within 24-48 hours

›Increasing swelling

›Skin blister progression

08Treatment/t111

Immediate life-saving interventions

›Limb-threatening complications

›Open fracture pathway

›Antibiotics within 60 minutes when feasible

›Cefazolin IV 2 g

›Repeat dosing interval 8 hours

›If severe cephalosporin allergy

›Clindamycin IV 900 mg

›Repeat dosing interval 8 hours

›If gross contamination concern

›Add gentamicin IV 5 mg/kg

›Adjust for renal function

›Tetanus prophylaxis

›If unknown or incomplete immunization

›Tdap

›Tetanus immune globulin per local dosing

›Sterile dressing and splint

›Saline-moistened gauze

›Bulky padding

›Threatened posterior heel skin

›Plantarflexion splint positioning

›Heel offloading

›Compartment syndrome concern

›Remove constrictive wraps

›Emergent ortho consultation for fasciotomy consideration

Immobilization and Splinting

›Splint selection

›Posterior short leg splint

›Ankle neutral to slight plantarflexion

›Heel padding

›Bulky Jones dressing adjunct

›Swelling accommodation

›Skin protection

›Immobilization principles

›Non-circumferential immobilization during swelling phase

›Post-splint neurovascular reassessment

›Elevation and icing plan

›Weight-bearing status

›Strict non-weight-bearing

›Knee scooter caution with balance and falls

Reduction

›Indications for urgent realignment

›Posterior tuberosity avulsion with skin tenting

›Temporizing reduction attempt with plantarflexion positioning

›Immediate orthopedics involvement

›Fracture-dislocation of subtalar joint

›Reduction under sedation pathway

›Post-reduction CT for congruity

›Analgesia and anesthesia options

›Multimodal analgesia

›Acetaminophen PO 1000 mg

›Maximum 3000 mg per 24 hours when risk factors

›NSAID option when appropriate

›Ibuprofen PO 600 mg

›Maximum 2400 mg per 24 hours

›Opioid for breakthrough

›Hydromorphone PO 1-2 mg

›Re-dose interval 4-6 hours

›Regional anesthesia consideration

›Popliteal sciatic nerve block

›Ultrasound guidance when available

›Post-block neurovascular documentation

›Procedural sedation when required

›Monitoring

›Continuous pulse oximetry

›Capnography if available

›Cardiac monitoring

›Blood pressure cycling every 3-5 minutes

›Airway readiness

›Suction setup

›Bag-valve-mask at bedside

›Post-reduction requirements

›Immediate neurovascular re-check

›Post-reduction radiographs

›Re-splint in stable position

›Failed reduction pathway

›Persistent deformity with skin threat

›Emergent orthopedics escalation

›Worsening pain and tense swelling

›Compartment syndrome escalation

Open fracture medications and timing

›Antibiotic selection by contamination and severity

›Gustilo I-II suspicion

›Cefazolin IV 2 g

›Continue every 8 hours

›Typical duration 24 hours after debridement per local protocol

›Gustilo III suspicion

›Cefazolin IV 2 g

›Continue every 8 hours

›Add gram-negative coverage per local protocol

›Gentamicin IV 5 mg/kg

›Renal dosing adjustment

›Farm or fecal contamination concern

›Add anaerobic coverage per local protocol

›Metronidazole IV 500 mg

›Repeat dosing interval 8-12 hours

›Tetanus pathway

›Clean minor wound with immunization up to date

›No booster if last dose within 10 years

›Dirty wound or immunization uncertain

›Tdap booster if last dose more than 5 years

›Tetanus immune globulin when indicated

DVT prophylaxis when relevant

›Risk assessment for lower limb immobilization

›Prior venous thromboembolism history

›Active cancer

›Major trauma

›Prolonged non-weight-bearing

›Prophylaxis plan per local protocol

›Mechanical prophylaxis when inpatient

›Pharmacologic prophylaxis when indicated

›LMWH selection per local dosing

›Contraindications screening

›Documentation

›Risk-benefit discussion

›Follow-up plan for duration

09Special Populations/sp29

Pregnancy

›Maternal and fetal considerations

›Imaging with shielding when feasible

›Radiographs acceptable when clinically indicated

›CT when benefits outweigh risks

›Analgesia selection

›Acetaminophen preferred first-line

›NSAID avoidance in later pregnancy

›Disposition modifiers

›Lower threshold for obstetric consultation after trauma

›Fetal monitoring pathway per gestational age

Geriatric

›Fragility fracture context

›Low-energy mechanism still significant

›Osteoporosis evaluation and referral

›Soft tissue and healing risk

›Higher wound complication risk

›Vascular disease screening

›Functional disposition

›Admission threshold lower with mobility limitations

›PT and OT needs

Pediatrics

›Pattern differences

›Extra-articular patterns more common than adults in some ages

›Apophyseal avulsion consideration

›Imaging considerations

›Lower radiation strategy

›Radiographs first-line

›CT reserved for surgical planning or unclear diagnosis

›Immobilization and follow-up

›Weight-based analgesia

›Growth and remodeling considerations

10Background/b30

Epidemiology

›High-energy mechanism association

›Falls from height common mechanism

›Occupational injury association

›Bilateral injury prevalence

›Contralateral calcaneus evaluation importance

Pathophysiology

›Axial load transmission through talus

›Posterior facet depression mechanism

›Lateral wall blowout mechanism

›Tongue-type fracture mechanism

›Posterior tuberosity fragment hinging

›Achilles pull contributing to displacement

›Extra-articular fracture mechanisms

›Tuberosity avulsion from Achilles traction

›Anterior process from inversion and bifurcate ligament traction

Therapeutic Considerations

›Nonoperative vs operative decision drivers

›Articular displacement degree

›Posterior facet step-off relevance to subtalar arthritis risk

›Hindfoot alignment

›Varus malalignment functional impairment risk

›Soft tissue envelope status

›Surgery timing often delayed until swelling improves

›Wound complication risk factors

›Smoking

›Diabetes mellitus

›Severe swelling and blistering

›Common complications

›Subtalar post-traumatic arthritis

›Chronic heel widening and shoe-wear problems

›Peroneal tendon impingement

›Complex regional pain syndrome

11Patient Discharge Instructions/pdi28

Copy discharge instructions

›Calcaneus fracture care plan

›Strict non-weight-bearing until orthopedics clears

›Splint care

›Keep clean and dry

›Do not insert objects inside splint

›Elevation

›Above heart as much as possible for first 48-72 hours

›Ice

›15-20 minutes at a time

›Avoid wetting splint

›Pain control plan

›Acetaminophen as directed

›NSAID only if approved for you

›Opioid only for breakthrough pain

›Mobility and safety

›Crutches or walker use as taught

›Avoid falls

›Return to ED now for any of the following

›Increasing pain not controlled with medications

›New numbness or tingling in foot or toes

›Toes becoming cold, pale, or blue

›Increasing tightness or swelling in foot

›Wet, broken, or too-tight splint

›Fever or wound drainage

›Skin blistering that rapidly worsens

›Follow-up plan

›Orthopedics appointment within 3-7 days

›Earlier reassessment within 24-48 hours if swelling or skin changes worsen

12References/r11

Evidence-based sources and guidelines

›Reference set

›Orthopedic trauma texts and consensus guidance for calcaneus fracture evaluation and CT-based classification

›Sanders classification CT-based intra-articular stratification

›Essex-Lopresti tongue-type vs joint depression framework

›Open fracture management standards

›Gustilo-Anderson classification use for antibiotic and operative urgency pathways

›Tetanus prophylaxis standards for wound management

›Procedural sedation standards

›ACEP procedural sedation guidance Level B or Level C where applicable

›Continuous monitoring expectations during sedation

›Source template :contentReference[oaicite:0]{index=0}

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 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.