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Calcaneus fracture
Shoulder & Clavicle
AC separation
Biceps tendon rupture
Clavicle fracture
Humerus proximal fracture
Rotator cuff tear
Scapular fractures
Shoulder dislocations
SLAP tear
Sternoclavicular dislocation
Arm & Elbow
Compartment syndrome (anterior, lateral, deep - superficial posterior)
Coronoid process fracture
Elbow dislocations
Epicondylar fracture
Humeral shaft fracture
Intercondylar and condylar region fracture
Olecranon fracture
Radial head fracture (Mason I-IV)
Supracondylar fracture (pediatric and adult)
Triceps tendon rupture
Forearm, Wrist & Hand
Carpal bones fractures
Carpal dislocations and ligament injuries
Distal radius and ulna fracture
Fight bite (human bite over MCP)
Finger dislocations by joint
Finger open fractures - amputations
Forearm fractures
Hand and finger tendon and ligament injuries
Hand tendon injuries
Metacarpal fractures
Nail bed injuries
Phalangeal fractures
Tuft fracture
Spine
Cervical spine fracture (C1-C7)
Cord syndromes
Sacrum and coccyx fracture
Thoracic and lumbar spine fracture
Pelvis & Hip
Acetabular fractures
Hip dislocations
Pelvis fractures
Proximal femur fractures
Thigh & Knee
Distal femur fractures
Femoral shaft fractures
Knee dislocation
Knee ligament injuries
Patellar dislocation
Patellar fracture
Patellar tendon rupture
Pes anserine bursitis
Prepatellar bursitis
Quadriceps tendon rupture
Tibial plateau fracture
Tibial spine fracture
Tibial tubercle fracture
Leg & Shin
Achilles tendon rupture
Fibular shaft fracture
Proximal fibula fracture
Stress fracture (tibia-fibula)
Tibial and Fibular shaft fracture
Tibial shaft fracture
Toddler's fracture
Ankle
Ankle dislocation
Ankle fractures
Ankle sprain
Maisonneuve fracture (proximal fibula and syndesmosis)
Peroneal tendon dislocation or tear
Peroneal tendon tear or dislocation
Subtalar dislocation
Syndesmotic injury (high ankle sprain)
Foot
Calcaneus fracture
Cuboid fracture
Cuneiform fractures
Dancer's fracture (5th MT spiral shaft)
Jones fracture (5th MT base - metadiaphyseal junction)
Lisfranc injury (tarsometatarsal dislocation)
March fracture (metatarsal stress fracture)
Metatarsal fractures (1st-5th)
Navicular fracture
Plantar fascia rupture
Talus fracture
Tibialis posterior tendon dysfunction
Toe dislocations
Calcaneus fracture
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Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
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
History
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
Physical Exam
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
Differential Diagnosis
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
Laboratory Tests
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
Diagnostic Tests
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
CT
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
Disposition
Site of care and follow-up timing
Copy
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
Treatment
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
Special Populations
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
Background
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
Patient Discharge Instructions
Copy discharge instructions
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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
References
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
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Orthopedic Injuries
Calcaneus fracture