Define Calcaneal Fracture. Describe its clinical features, investigations and management.

Definition

The calcaneus is the most commonly fractured tarsal bone. The classic mechanism is a fall from a height onto the heels, driving the talus into the calcaneus (an axial compression injury). Fractures are intra-articular (involving the subtalar/posterior facet — the majority) or extra-articular.

Clinical Features

A painful, swollen, bruised heel that the patient cannot bear weight on; the heel may look broadened and shortened with the normal medial arch flattened. Watch for fracture blisters and compartment syndrome of the foot.

Böhler's angle on the lateral radiograph; flattening below ~20° indicates depression of the posterior facet.

Investigations

Lateral and axial (Harris) radiographs of the heel. Measure Böhler's angle (normal 20–40°; reduced in depression fractures) and Gissane's angle. CT is essential for intra-articular fractures to plan surgery (Sanders classification).

Management

Undisplaced / extra-articular fractures are treated conservatively — rest, elevation, no weight-bearing initially, then a period in a cast/boot with early ankle and subtalar movement. Displaced intra-articular fractures may be treated by open reduction and internal fixation to restore the joint surface, heel height and width, though management is debated and wound complications are common; primary subtalar arthrodesis is an option for severe comminution. Surgery is delayed until swelling settles (positive ‘wrinkle test’).

• Most common tarsal fracture; mechanism = axial load (fall onto heels).
• Always exclude spine, hip, tibial plateau and contralateral heel injuries.
• Böhler's angle (normal 20–40°) reduced in depression; CT for intra-articular planning.
• Undisplaced → conservative; displaced intra-articular → ORIF once swelling settles.