Calcaneus Fractures Workup

Updated: Jul 10, 2020
  • Author: Scott Nicklebur, MD; Chief Editor: Vinod K Panchbhavi, MD, FACS, FAOA, FABOS, FAAOS  more...
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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.


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. [27]


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.