Calcaneus Fractures Clinical Presentation

Updated: Jul 10, 2020
  • Author: Scott Nicklebur, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS  more...
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A history of a fall from height, a motor vehicle accident (particularly with the patient sitting in the front of the vehicle, where contact with the floorboards is more likely), or a similar mechanism should suggest a possible injury to the hindfoot. Patients are more likely to be young male individuals with intra-articular injuries.

Inquire about other areas of injury or pain. The discomfort associated with a fracture of the calcaneus may be so distracting to the patient that other significant injuries are ignored. Compression fractures of the spine are common (seen in 10-15% of cases), as are compression-type injuries to other areas of the bony skeleton, such as the proximal femur.

Document chronic medical conditions such as diabetes, peripheral vascular disease, or malignancy. Ask about prior injuries or surgeries in the affected area. In case of prior injury or surgery, ask about any orthopedic hardware that might be present.

Determine current and recent medication use, and inquire as to social habits such as alcohol and tobacco consumption.


Physical Examination

Patients with a fracture of the calcaneus may present with the following:

  • Pain
  • Edema
  • Ecchymosis
  • Deformity of the heel or plantar arch
  • Inability to bear weight on the injured foot

Observe all areas for evidence of open injury, particularly areas with overlying lacerations.

Hold the heel of the patient's foot in the palm of the hand, and gently squeeze. Elicited pain suggests calcaneal fracture.

Examine closely for evidence of ecchymosis, particularly that which tracks distally to the sole of the foot. This particular pattern of ecchymosis, known as the Mondor sign, is pathognomonic for calcaneal fracture.

Check for posterior tibial and dorsalis pedis pulses, and compare these to the uninjured side. Ensure that distal capillary refill is 2 seconds or less.

Pay particular attention to the presence of any paresthesia, edema, pallor, diminished pulses, or severe pain with passive flexion of the toes that might suggest compartment syndrome of the foot.

Examine the knee, ankle, and midfoot for tenderness, ecchymosis, or swelling. Radiographs of the knee, ankle, and foot may be indicated if positive findings are noted.

Inspect and palpate other areas at high risk for fracture, such as the medial, lateral, and posterior malleoli, as well as the base of the fifth metatarsal.

As many as 7% of patients with a calcaneus fracture may have fracture of the contralateral heel. Given the appropriate mechanism of injury (ie, a fall from height), care must be taken to examine both lower extremities thoroughly to exclude the presence of bilateral injuries.