The calcaneus is one of the thicker bones in the body. To fracture it takes a lot of force. The main mechanism that causes this fracture is a fall from a significant height, which delivers an axial load that can travel up the body and cause significant associated injuries.
- Vertebral fractures – cervical, thoracic, lumbar. In particular crush fractures of the thoraco-lumbar spine
- Other lower limb fractures: tibia, fibula, femur
- Pelvic and acetabular fractures
- Fracture of the contralateral calcaneum (always check both feet!)
- Compartment syndrome of the foot
- Fracture blisters (blistering of the skin due to oedema/swelling – can lead to soft tissue infection/osteomyelitis)
- Soft tissue injury – ligamentous instability
Conventional X-ray will diagnose most calcaneal fractures, however you must maintain a high index of suspicion in anyone with a suggestive history, who is unable to bear weight on their heel. A “normal” x-ray does not exclude a calcaneal fracture, and CT will often reveal occult fractures.
Why is this? Watch my video on “Calcaneal Crunchie” for the explanation:
There are other X-ray signs including Bohler’s angle and the ominous sounding Critical Angle of Gissane, which you need to know for exams, but can’t be relied on to exclude calcaneal fracture. Personally I never use them. If there is any doubt, just get a CT.
Some patients without a fracture still have significant pain from heel bruising and the aforementioned soft tissue injury, and may require a backslab, strict elevation, and followup in Orthopaedic outpatients to ensure there’s no hidden ligamentous injury. The management of those with a fracture is Orthopaedically complex, both from a surgical point of view, and due the many potential complications associated with this injury.
So there you go – some pearls on crunched up calcanei. Got any other tips on diagnosis of calcaneal fractures? Leave us a comment!
And much like a Crunchie, calcaneal fractures can really “change the colour of your day” – for the 80’s tragics out there, a bit of nostalgia: