Fracture, calcaneus

• Heel fracture
• Lover’s fracture
• Don Juan fracture

• 825.0 Fracture of calcaneus closed
• 825.1 Fracture of calcaneus open

• S92.009A Unspecified fracture of unspecified calcaneus, initial encounter for closed fracture
• S92.009B Unspecified fracture of unspecified calcaneus, initial encounter for open fracture

• 4G: Impaired Joint Mobility, Muscle Performance, and Range of Motion Associated With Fracture1

Description

• Fracture
• Any defect in continuity of the calcaneus
• Displaced (calcaneus is moved on either side of fracture) or non-displaced (calcaneus has not moved)
• Closed (skin is intact)
• Open (skin is breached)
• Extra-articular calcaneal fracture
  • Involvement of the calcaneus anterior (type A), middle (type B), posterior (type C)
• Intra-articular calcaneal fracture
  • More common
  • Posterior talar articular facet of the calcaneus
  • Sanders system of classification categorizes into 4 types based on location at posterior articular surface

Essentials of Diagnosis

• Diagnosis usually made by clinical examination
• May not be fracture but plantar fasciitis or heel spur
• Böhler's angle (Tuber Angle)
  • Vertex between a line from the top of the posterior articular facet to the top of the posterior tuberosity and a line from the top of the posterior tuberosity to the top of the anterior articular facet.
  • Angle < 20 degrees suggests drop of the posterior facet and possible calcaneal fracture
• Angle of Gissane (Critical Angle)
  • Downward and upward slope of the calcaneal superior surface
  • Angle > 130 degrees suggests fracture of the posterior subtalar joint surface

General Considerations

• Occurs most often during high-energy collisions (fall from height, motor vehicle accident)
• Most frequently fractured tarsal bone
• May effect leg length with compression of the fracture

Signs and Symptoms

• Pain with weight bearing
• Point tenderness
• Increased pain on weight bearing
• Edema
• Redness
• Ecchymosis
• Fracture blister
• Loss of general function
• Loss of active mobility
• Muscle guarding with passive movement
• Heel deformity
• Mondor sign: hematoma going to the bottom of the foot

Functional Implications

• Pain with standing
• Antalgic gait
• Inability to bear weight on injured lower extremity
• Pain with open or closed chain ankle movements (driving)

Possible Contributing Causes

• History of high-impact activities
• Trauma
• History of falls
• Osteoporosis

Differential Diagnosis

• Stress fracture
• Heel spur
• Plantar fasciitis
• Achilles tendonitis

Imaging

• X-ray for fracture, often limited view
• CT scan for detailed imaging
• Bone scan if stress fracture is suspected

Diagnostic Procedures

• Calcaneal squeeze test to produce heel pain

• Hop-to gait sequence or decreased stance time on injured lower extremity secondary to pain
• Exposed bone in cases of open and displaced fracture
• Integumentary deformity over underlying fracture
• If vascular structures involved, foot will appear cool and pale
• If neurologic structures involved, patient will report numbness and decreased ability to move the foot and toes

• To radiology for imaging, ...