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Calcaneus Fractures Workup

  • Author: Scott Nicklebur, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
 
Updated: May 02, 2016
 

Laboratory Studies

The need for preoperative, or screening, laboratory studies usually depends on the extent of other injuries and the presence of comorbid medical conditions. A complete blood count (CBC), blood typing, coagulation profile evaluation, and electrocardiography (ECG) are reasonable preoperative studies in calcaneus injuries. Additional studies, if warranted, are selected on a patient-by-patient basis and are usually ordered at the discretion of the physician performing the preoperative clearance examination.

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Imaging Studies

Advances in imaging have allowed practitioners to carefully classify and select the subset of injuries that are particularly amenable to operative intervention.

Plain radiography

Plain radiographs of the foot are indicated for any suspected calcaneus injury. Also, consider imaging the contralateral ankle and foot for comparative purposes. Images should include anteroposterior (AP), lateral, oblique, axial, and Broden views.

AP radiographs are needed to evaluate calcaneocuboid joint involvement, talonavicular subluxation, and lateral wall widening. AP views of the ankle are used to assess subfibular impingement as a result of lateral displacement of the lateral wall of the calcaneus.

Lateral radiographs of the foot are needed to evaluate the Bohler angle. This angle is defined by two intersecting lines: one drawn from the anterior process of the calcaneus to the peak of the posterior articular surface and a second drawn from the peak of the posterior articular surface to the peak of the posterior tuberosity. The average Bohler angle is 25-40°. In severe fractures with subtalar joint involvement, this angle may decrease or become negative. (See the image below.)

Calcaneus fractures. Comminuted fracture of calcan Calcaneus fractures. Comminuted fracture of calcaneus sustained in motorcycle accident. Note loss of Bohler angle.

Oblique views show the degree of displacement of the primary fracture line and the lesser facets.

Axial views depict the primary fracture line, varus malposition, posterior facet stepoff, lateral-wall displacement, and fibular abutment. (See the image below.)

Calcaneus fractures. Axial radiograph reveals comm Calcaneus fractures. Axial radiograph reveals comminuted fracture of calcaneal body.

Broden views of the foot are obtained by internally rotating the leg 45° with the ankle in neutral position. The beam may then be directed toward the lateral malleolus and advanced cephalad at intervals of 10°, 20°, 30°, and 40° to fully evaluate the posterior facet.[26]

Computed tomography

Computed tomography (CT) has revolutionized the diagnosis, treatment, and ability to render accurate prognoses of fractures of the calcaneus. CT results also form the basis of many of the current systems for classifying calcaneus fractures. CT-based classifications categorize intra-articular injuries according to the comminution and displacement of the posterior facet. (See the image below.)

Calcaneus fractures. Bilateral calcaneus fractures Calcaneus fractures. Bilateral calcaneus fractures sustained in motor vehicle collision. Compare minimally displaced calcaneal tuberosity fracture on patient's left side with comminuted intra-articular (Sanders type III) fracture on right.

The patient should be positioned on the imaging table with his or her hips and knees flexed. Axial and coronal sectional images are then obtained with a minimum interval of 2 mm. Axial views enable good visualization of the talonavicular and calcaneocuboid joints, the anteroinferior aspect of the posterior facet, the sustentaculum tali, and the lateral calcaneal wall. Coronal views are then oriented perpendicular to the posterior facet. These views are important for distinguishing injury to the posterior facet.

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Contributor Information and Disclosures
Author

Scott Nicklebur, MD Assistant Professor of Emergency Medicine, Texas A&M Health Science Center College of Medicine

Scott Nicklebur, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Robert A Probe, MD Associate Professor of Orthopedic Surgery, Texas A&M University Health Science Center; Chairman, Department of Orthopedic Surgery, Scott and White Clinic and Memorial Hospital

Robert A Probe, MD is a member of the following medical societies: American Medical Association, Texas Medical Association, AO Foundation, American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association

Disclosure: Received consulting fee from Stryker Orthopaedics for consulting.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinod K Panchbhavi, MD, FACS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

James K DeOrio, MD Associate Professor of Orthopedic Surgery, Duke University School of Medicine

James K DeOrio, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society

Disclosure: Received royalty from Merete for other; Received royalty from SBi for other; Received royalty from BioPro for other; Received honoraria from Acumed, LLC for speaking and teaching; Received honoraria from Wright Medical Technology, Inc for speaking and teaching; Received honoraria from SBI for speaking and teaching; Received honoraria from Integra for speaking and teaching; Received honoraria from Datatrace Publishing for speaking and teaching; Received honoraria from Exactech, Inc for speaking a.

Acknowledgements

Timothy B Dixon, MD Staff Physician, Department of Surgery, Division of Orthopedic Surgery, Scott and White Memorial Hospital

Disclosure: Nothing to disclose.

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Calcaneus fractures. Comminuted fracture of calcaneus sustained in motorcycle accident. Note loss of Bohler angle.
Calcaneus fractures. Axial radiograph reveals comminuted fracture of calcaneal body.
Calcaneus fractures. Avulsion-type fracture of calcaneus, sustained when patient fell 6 ft from ladder onto solid ground. Because of distraction of fracture fragments, injury was treated with open reduction and internal fixation.
Calcaneus fractures. Status post open reduction and internal fixation.
Calcaneus fractures. Bilateral calcaneus fractures sustained in motor vehicle collision. Compare minimally displaced calcaneal tuberosity fracture on patient's left side with comminuted intra-articular (Sanders type III) fracture on right.
 
 
 
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