Calcaneus Fracture: The Lover’s Fracture
Written by Vidhi Rao, MD; Edited by Timothy Khowong, MD
Calcaneal fractures are, as the name suggests, fractures of the calcaneus. Suspect a calcaneal fracture in a patient complaining of ankle/foot pain with an appropriate mechanism of axial loading onto the feet/heels. This can occur during an MVC or when landing onto the heel of a foot from a height, such as falling off of a ladder, leaping over a fence, or jumping out of a window… while chased by your lover’s spouse or by police during a gambling raid.
Anatomy of the Foot and Calcaneus
The calcaneus is the most commonly fractured tarsal bone. Subtypes include intra-articular (75%) or extra-articular (most commonly involving the anterior process; calcaneal tuberosity fractures are more commonly seen in association with osteoporosis. 17% of calcaneal fractures are open and associated with increased risk of wound complications.
Image: RSNA
Symptoms include pain, edema, ecchymosis (particularly Mondor’s sign), tenderness to palpation especially when squeezing heel or axial loading the foot.
Plantar ecchymosis, also known as Mondor’s sign, is pathognomonic for calcaneal fractures.
Evaluation
XR ankle lateral and AP views are the mainstay of diagnosis. Boehler’s angle (20-40 degrees) is formed between two lines: superior-most point of the calcaneal tuberosity and the posterior articular facet, and posterior articular facet and anterior articular facet. Decreased Boehler’s angle may be the only evidence of a fracture in the absence of cortical disruption and sclerotic lines. If abnormal, compare to the contralateral side to account for anatomic variation.
Image: EM in 5
A.Normal Boehler’s angle. B. Abnormally decreased Boehler’s angle.
The angle of Gissane (120-145 degrees), formed between the lines drawn along the surfaces of the posterior facet and the anterior process, may also be used to evaluate for collapse of the posterior facet.
Image: radiologykey
The Harris XR view allows for better characterization of the lateral and medial aspects of the calcaneal tuberosity. This is obtained with a 45 degree XR beam directed toward the heel with the foot in maximal dorsiflexion.
CT is considered the gold standard and is usually used for operative planning.
Include and document a careful neurovascular exam, as compartment syndrome of the foot is seen in 10% of patients. Additionally, be sure to evaluate for other traumatic injuries! It takes a large amount of force to fracture a calcaneus and the mechanism usually leads to a secondary axial loading injury. Concomitant injuries are seen in about 50% of patients with calcaneal fractures!
Bilateral calcaneal fracture - 7%
Other lower extremity - 26%
Thoracic/Lumbar spine - 10%
Management
Calcaneal fractures are generally managed with pain control, immobilization in posterior ankle splint/short-leg cast, and instructions to keep extremity non-weight-bearing and elevated to minimize swelling and development of compartment syndrome. Extra-articular fractures are stable for close outpatient orthopedic follow up, but intra-articular fractures require emergent orthopedic consultation.
Open fractures require immediate IV antibiotics and surgical washout. Otherwise, operative management is usually reserved for displaced fractures.
References
Wikem: https://wikem.org/wiki/Calcaneus_fracture
Orthobullets https://www.orthobullets.com/trauma/1051/calcaneus-fractures
Radiology key: https://radiologykey.com/lower-limb-iii-ankle-and-foot-2/
Radiopaedia https://radiopaedia.org/articles/calcaneus
Radiopaedia https://radiopaedia.org/articles/gissane-angle
EMin5 https://youtu.be/ExkQ7ZWVqOU
RSNA https://pubs.rsna.org/doi/full/10.1148/rg.311105036