Calcaneus fractures describe the fracture of the calcaneus bone in the heel of the foot. They are sometimes called Lover's fracture or the Don Juan fracture.
Patients usually present with a history of a fall from a significant height, a motor vehicle collision or injury subsequent to a similar scenario. A motor vehicle collision is especially suspicious for calcaneal fractures if the patient is sitting in the front because of a higher likelihood of contact with floorboards. Most patients suffer from intra-articular injuries and tend to be young males.
Other areas of pain should also be investigated. Sometimes the pain in the calcaneal region is so severe that the patient is not fully aware of other sources of pain or injuries. It is also important to look for vertebral compression fractures or compression fractures of the humerus which can occur in around 10% to 15% of all cases.
History taking should encompass past medical conditions such as cancer, peripheral vascular diseases or diabetes. Prior surgical history or placements of orthopedic hardware are especially important if they occurred close to the site of injury.
On physical exam, patients present with edema, ecchymosis, pain, heel and/or plantar arch deformities and difficulty bearing weight on the affected foot. Inspection of the injured area is important in detecting any open fractures, especially where lacerations can be found. Pain upon squeezing the heel in the palm of the hand is a characteristic feature of calcaneal fractures. The Mondor sign is another pathognomonic finding. It describes a specific pattern of ecchymosis that can be followed distally, to the sole of the affected foot. The physical exam should also target the vascular system, paying particular attention to distal capillary refill, dorsalis pedis and posterior tibial pulses. Pulses need to be compared on both sides. It is also important to rule out the development of compartment syndrome. The latter can be suspected by diminished pulses, swelling, pallor and sensory abnormalities (paresthesias).
The physical exam should also encompass the midfoot, the ankle and the knee. Positive findings should prompt imaging with X-ray to rule out any potential fractures. Other highly vulnerable areas that can be associated with calcaneal fractures are the malleoli (medial, posterior and lateral) and the base of the fifth metatarsal.
Up to 7% of all patients with calcaneal fractures may have bilateral fractures. This is perhaps not surprising given the associated mechanisms of injury, such as a fall from the height. It is important to thoroughly exam both sides in order to exclude bilateral injuries.
X-ray imaging is the principal diagnostic method. Generally, both lateral and axial views are taken. CT is sometimes done if the X-ray is inconclusive but clinical findings point to calcaneal fractures, if more detail about the fracture is necessary and if the Bohler angle is greater than 20°.
The Bohler angle is estimated by the intersection of two imaginary lines on lateral x-rays. The first line connects the superior part of the posterior calcaneal tuberosity with the superior subtalar articular surface. The second line links the superior subtalar articular surface with the superior part of the anterior calcaneal process. The Bohler angle normally measures between 20 and 40°. An angle smaller than 20° points to a calcaneal fracture.
Because calcaneal injuries can be associated with compression fractures of the spine, it is important to check for thoracolumbar injuries.
Surgery is necessary for the treatment of calcaneal fractures. It is usually an open surgery, in which the bone is pieced back together or the fracture is fixed utilizing plates and screws to rectify the alignment. Open surgery is performed by cutting over the lateral part of the heel in a hockey stick or "L" formation, enabling the displacement of critical tendons and nerves for better access. When plates and screws are used to hold the bone together, the process is named "internal fixation".
A "closed reduction" is sometimes applicable in the treatment of calcaneal fractures. This procedures entails making several small cuts around the heal and putting the bone fragments together with the help of imaging procedures such x-rays without having to directly visualize the fractured bone pieces. The final position is then held with screws fixed through the skin. Recent evidence suggests that minimally invasive surgery is associated with lower morbidity than open reduction or closed reduction with internal fixation  .
Both general and local anesthesia are utilized in surgeries relating to calcaneal fractures. Local anesthesia is administered in the form an injected regional nerve block. The latter helps in controlling pain 12 to 24 hours after the surgery is performed. The surgery can be either done on the same day of admission or planned within a longer hospital stay.
Placement of a tourniquet aids in minimizing bleeding as well as in improving the visualization of important structures while the procedure is underway. After incisions are made and the sural nerve and muscle tendons are displaced, the skin is retracted through the use of metal wires. This then gives full access for the surgeons to the bone fragments, which are subsequently re-instated in the correct position. Metal wires are also used to temporarily fix the bone fragments in place, before permanently adjusting the positions of the bones with plates and screws. At the end of the surgery, the skin is closed and a splint is applied.
Residual morbidity may be difficult to determine in the initial stages of the disease. It may take up to a year to accurately assess long-term damage subsequent to calcaneal fractures  .
Causes of calcaneal fractures can be divided into intra and extra-articular. Intra-articular fractures are usually the result of excessive axial loading with subsequent transmission of tension into the plantar tuberosity of the calcaneus, situated on the lateral side of the axis of the lower extremity. The more prevalent causes of increased axial loading that ultimately manifest with calcaneal fractures include fall from heights above 6 feet, traffic accidents, impact during running or jumping, overuse injuries and stress fractures in athletes.
Extra-articular fractures, on the other hand, usually occur after a strong twist to the hindfoot. They may also follow blunt-force injuries and avulsion injuries of the Achilles tendon.
Fractures of the calcaneus comprise 2% of all fractures that occur in adults. Around 30% are extra-articular and 30% are intra-articular, with young men being most commonly affected. The calcaneus is also the most commonly fractured tarsal bone, representing about 60% of all tarsal fractures  .
A calcaneal body fractures is the most frequent extra-articular fracture. Other extra-articular fractures include those targeting the anterior process, the superior tuberosity beak, the sustentaculum tali and avulsions. Anterior process fractures are the only fractures seen more commonly in women and make up about 10% to 15% of all extra-articular calcaneal injuries. Avulsions and superior tuberosity beak fractures represent 10-15% of extra-articular fractures. Sustentaculum tali injuries are not usually found in isolation.
Calcaneal fractures are mostly encountered as closed fractures and only 2% of all reported cases are open fractures.
Calcaneal fractures generally result from excessive axial load on the talus, with subsequent transmission of the force in a lateral direction from the talus onto the calcaneus. The fracture line starts from the angle of Gissane and courses in the posteromedial direction, drawing an oblique fracture line. Multiple secondary fractures may then subsequently form from the initial fracture line. In 75% of the cases, there is involvement of the subtalar joint.
Calcaneal fractures can be generally classified into two types: tongue-type and joint depression fractures . Tongue-type fractures are characterized by a secondary fracture line that extends in a direct posterior direction. The result is the formation of a posterior, superior and a lateral fragments. The inferior fragment completes the rest of the calcaneus. Joint depression fractures are more common and are characterized by a secondary fracture line that originates from the angle of Gissane and then courses in a posterior direction before exiting the bone on the posterior facet, after deviating dorsally. The major part of the posterior facet makes up the fracture fragment.
Calcaneal fractures result most frequently from a combination of factors. Compressive forces, shearing stress and a rotational component are all necessary for the fracture to occur . This takes place most commonly after a fall from a height, a motor vehicle incident or severe muscular tension that can ultimately result in trauma. It is important not to ignore chronic medical diseases such as osteoporosis and diabetes, that can also significantly increase the risk of calcaneal fractures.
There are very limited prevention measures that can be utilized in cases of motor vehicle accident and falls from a height. These usually correspond to common safety precautions. On the other hand, weight bearing and strength exercises can help prevent fractures that result from muscular tension and stress. The type of footwear worn can also have a significant impact on calcaneal fracture incidence. Inadequate footwear as well as the performance of intense sporting activities barefoot can increase the risk of stress fractures in general, and calcaneal fractures more specifically .
Calcaneal fractures represent 2% of all fractures in adults and 60% of tarsal fractures . They most commonly occur after a fall from a height, a motor vehicle accident, excessive muscular tension and trauma.
Calcaneal fractures can be generally divided into two subtypes: intra and extra-articular. Intra-articular fractures are more common and occur largely because of axial stress that is slightly displaced to the lateral side. Extra-articular fractures result from trauma, particularly after a twisting of the hindfoot or avulsion injuries of the Achilles tendon. Patients usually present with pain, edema, ecchymoses and swelling over the injured site. It is important to rule out compartment syndrome that usually manifests with paresthesias, decreased pulses, swelling and pallor. Pathognomonic signs on physical exam include tenderness when the heel is compressed in the palm of the hand and a distinctive pattern of ecchymosis named the Mondor sign. It is usually necessary to examine the spine and other joints during the physical exam, especially since the condition is commonly associated with other injuries, particularly compression fractures of the thoracolumbar spine.
Diagnosis is established with x-ray imaging and can be further validated with CT if more detail is sought for. Surgery is the principal treatment modality. The surgeon usually performs an open surgery and fixes the bone fragments after retracting the overlying tendons and nerves . A closed reduction may also be performed, with the help of imaging aids such x-ray. Calcaneal fracture surgery necessitates general anesthesia and a local nerve block that helps in limiting postoperative pain for up to 24 hours. Prognosis is variable, and morbidity can be properly assessed after a year from the date of the injury.
Calcaneal fractures are a type of bone fractures that affect a bone in the heel, called the calcaneus. They most commonly occur after a patient falls from a height above six feet, a motor vehicle accident in which the patient is sitting in front, due to excessive muscle strain or after direct trauma to the foot. Patients usually present with pain on the affected side, swelling and reddening of the skin around the location of the injury. The physician may perform a particular procedure during the physical exam, in which the heel is held in the palm of the hand and gently squeezed. The presence of pain on such a maneuver is a distinctive sign for calcaneal fractures. The condition is usually diagnosed with X-ray, although a CT can also be performed if more detail is needed. Treatment requires surgery, which can be done either by opening the skin, retracting the nerves and muscle tendons, and subsequently fixing the bone back together or by making small incisions in the skin and fixing the bone after visualizing it with X-ray. The doctor may need to administer both general anesthesia and a local nerve block. The latter helps in controlling the pain after the procedure is done. Prognosis is variable, and severity of the damage occurred may need a year to be accurately determined.