Fractures of the calcaneus account for 2 percent of all fractures.

The calcaneus is the most frequently fractured tarsal bone and accounts for 60 percent of all tarsal fractures.

A total of 90 percent of these fractures occur in men 21 to 45 years old, the majority of which are industrial workers.^{1, 2, 3, 5, 6}

The anterior portion of the calcaneus is the body.

The posterior portion of the calcaneus is the tuberosity.

The principal articulation is with the talus, forming the subtalar joint.

Calcaneus fractures may be intra- or extra-articular. Approximately 75 percent of calcaneus fractures are intra-articular, and of these 75 percent are depressed.¹

Axial loading.

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  Falls from height drive the talus down into calcaneus and cause most intra-articular fractures.

Generally falls of greater than 8 feet are required unless osteoporosis is present.

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  Motor vehicle accidents (MVAs) account for the remainder of these fractures, in which the accelerator or brake pedal impacts the plantar surface of the foot.

  
  
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  Twisting of the foot is the cause of most extra-articular fractures.

Tuberosity fractures in diabetics typically occur via avulsion by the Achilles tendon.

The patient will present with moderate to severe heel pain after a mechanism as described earlier.

The foot will appear swollen with ecchymosis extending to the arch of the foot.

There may be widening and shortening of heel, with tenderness to palpation.

Fracture blisters may be present if presentation is delayed, as these develop within twenty-four to forty-eight hours.

It is important to assess for compartment syndrome as this occurs in 10 percent of calcaneus fractures.

Radiography (X-ray): anteroposterior (AP), lateral, and Harris axial views along with a full ankle series are required (Figures 8.7 and 8.8).

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  X-ray should be reviewed and Bohler’s angle should be assessed.

  
  
  
  
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    Bohler’s angle is composed of a line drawn from the highest point of the anterior process of the calcaneus to the highest point of the posterior facet and a line drawn tangential from the posterior facet to the superior edge of the tuberosity.

    
    
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    Normal angle is between 20 and 40° (Figure 8.9).

    
    
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    Any angle less than this indicates collapse of the posterior facet. However, this angle may be normal in the presence of fracture, and therefore this measurement cannot be used to exclude fracture. The most important function of this measurement is for prognosis, as fractures with a decreased Bohler’s angle have worse outcomes. If the diagnosis is in question, a comparison X-ray of the opposite foot may be useful.

  
  
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  The Gissane angle may also be used to assess for fractures of the calcaneus. It is formed by the downard and upward slopes of the superior surface of the calcaneus. It is best evaluated on the lateral view.

  
  
  
  
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    Normal angle is between 105 and 135°.

    
    
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    An increase in this angle indicates collapse of the posterior facet.²

CT is useful in determining the extent of the fracture and for preoperative planning.

Open fractures of any kind require immediate orthopedic consultation in the ED.

Calcaneal body fractures.

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  These require immobilization with a bulky, well-padded posterior splint. As with all splints, adequate padding will help to prevent fracture blisters and skin injury. Often a stirrup slab is used to increase stability and immobilization.

  
  
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  The patient should be kept on strict non-weight bearing status (NWBS). Crutches, with instructions on their use, should be provided.

  
  
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  Ice and elevation are recommended to prevent or minimize swelling.

  
  
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  Adequate analgesia should be provided.

Most patients may be discharged safely from the ED. However, if there is significant swelling and there is concern for the development of compartment syndrome, the patient should be admitted to the hospital.

For intra-articular fractures of the calcaneal body, orthopedic referral should be made and the patient should be seen within twenty-four hours.

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  Definitive management depends on the degree of displacement. Nondisplaced fractures may be managed nonoperatively with NWBS for six to eight weeks. This may be followed with a gradual increase in activity. Management of displaced fractures varies from conservative (nonoperative) to surgical repair. Thus urgent orthopedic consult is recommended.

For all other extra-articular fractures, orthopedic or sports medicine referral should be made and the patient should be seen within two weeks.

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  Nondisplaced fractures are managed with NWBS for four to six weeks with gradual return to activity.

  
  
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  Displaced fractures may be managed nonoperatively or with surgical repair, so early orthopedic consult is recommended.

Posttraumatic arthritis is the most frequent complication. Typically, patients will present with stiffness and chronic pain.

Compartment syndrome may occur in 10 percent of calcaneus fractures.

Wound dehiscence, if surgical intervention required.

Calcaneal osteomyelitis

Increased heel width.

Loss of subtalar motion.

Peroneal tendonitis

Sural nerve injury.

Calcaneus fractures in children rarely occur and typically involve children older than 9 years old.

Most occur secondary to a fall or jump from heights similar to those of adults; however, the mechanism requires less energy than adults.

Initial injury is missed in 45–55 percent of pediatric cases.

Nonoperative management is recommended for extra-articular fractures and intra-articular fractures with less than 4-mm displacement. Children are typically made non-weight bearing for six weeks.

Operative management is recommended for displaced intra-articular fractures².

More than 50 percent of calcaneus fractures are associated with additional injuries.

A total of 26 percent of calcaneus fractures are associated with additional lower extremity injuries.

Calcaneus fractures are bilateral in 7 percent of cases.

Compression fractures of the thoracolumbar spine occur in 10 percent of cases.

Compartment syndrome develops in 10 percent of calcaneus fractures.

Bohler’s angle may be used to assess for subtle fractures.

Intra-articular fractures typically carry a worse prognosis than extra-articular fractures.^{1, 2, 3, 5, 6}

Fracture of the talus is the second most common tarsal fracture.

The incidence ranges from 0.1–0.85 percent of all fractures and 5–7 percent foot injuries.

The most common talus fractures involve the neck of the talus. Of these, 14–26 percent have associated medial malleolus fractures.

Fractures of the lateral process of the talus account for 2.3 percent of all snowboarding injuries and 15 percent of all ankle injuries.

Fractures of the talar head are rare, accounting for only 3–5 percent of all talus fractures.^{1, 2, 3, 6}

The talus is divided into three segments, the head, neck, and body.

Fractures of the talus are divided into major fractures, those involving the head, neck, or central portion of the body, and minor fractures, those that do not involve the central portion of the bone.

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  Minor fractures include the posterior process, lateral process, and osteochondral talar dome fractures.

A total of 60 percent of the surface of the talus is covered by articular cartilage.

There are no tendinous muscle insertions and the bone itself is held in place by ligaments.

Vascular supply does not penetrate cartilage but is delivered by surrounding ligaments. This predisposes the talus to avascular necrosis, especially in the cases of proximal talus fractures.

Talar head fractures are typically the result of direct impact such as a fall from height onto a dorsiflexed foot.

Talar neck fractures are also typically the result of falls from heights onto a dorsiflexed foot or following an MVA with the foot in a dorsiflexed position.

Talar body fractures are the result of acute hyperextension of the foot.

Lateral process fractures are the result of axial loading, dorsiflexion, eversion, and external rotation. Typically these are seen after falls, MVAs, or snowboarding injuries.

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  Fractures of the lateral process are often termed “snowboarder’s ankle.”

Posterior process fractures are often the result of extreme plantarflexion.

Patients typically present with ankle pain after mechanisms as described earlier.

Generally edema, ecchymosis, and tenderness are present.

ROM is typically limited by pain.

Palpation may elicit crepitus.

Specific aspects of the physical exam may provide clues to determine what portions of the talus may be involved.

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  Talar head fractures are associated with tenderness concentrated over the talar head and talonavicular joint. Typically ankle motion is normal, but inverting the foot exacerbates pain over the talonavicular joint.

  
  
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  Talar neck fractures present with the foot in hyperextension if an associated dislocation is present.

  
  
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  Lateral process fractures cause pain and swelling over the lateral malleolus with point tenderness anteroinferior to the lateral malleolus.

  
  
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  Posterior process fractures present with posterolateral tenderness and edema. Pain is exacerbated by plantarflexion. Dorsiflexion of the great toe may exacerbate pain as the flexor hallucis longus tendon slides along the bone.

X-ray: Full evaluation requires multiple views of the foot and ankle. Views of the ankle should include AP, mortise, and lateral views while AP, lateral, and oblique views of the foot should be obtained (Figure 8.10).

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  Talar neck fractures are best seen on lateral views.

  
  
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  The Canale view provides optimum evaluation of the talar neck, but due to the manipulation of the foot and ankle required to obtain the view may be difficult to obtain in the acute setting.

CT may be necessary as some fractures may not be adequately visualized using only X-ray.

CT may help further characterize the fracture pattern and assess any articular involvement.

Open fractures of any kind require immediate orthopedic consultation in the ED.

Talus fractures require immobilization with a bulky, well-padded posterior splint. A stirrup slab may be placed to increase stability.

The patient should be kept on strict NWBS. Crutches, with instructions on their use, should be provided.

Ice and elevation are recommended to prevent or minimize swelling.

Adequate analgesia should be provided.

Most talus fractures may be safely discharged home, with the exception of open fractures and those with neurovascular compromise. These injuries require orthopedic consultation in the ED.

Major fractures of the talus require immediate orthopedic referral, with follow-up within twenty-four hours.

Minor fractures of the talus require early orthopedic or sports medicine referral, with follow-up within two weeks.

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  The posterior splint for lateral process fractures should maintain the ankle in a neutral position while the splint for a posterior process fracture should maintain the foot in 15° of plantarflexion.

Return to activity largely depends on the approach to treatment.

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  Talar head fractures are treated in a non-weight bearing cast for six to eight weeks. However, open reduction with internal fixation (ORIF) is recommended if there is instability of the talonavicular joint, there is an articular step-off, or if the fracture involves more than 50 percent of the articular surface.

  
  
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  Talar neck fractures are definitively managed with a short-leg non-walking cast for six weeks followed by three weeks of partial weight-bearing. Displaced fractures require surgical intervention and anatomic reduction.

  
  
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  Talar body fractures that are nondisplaced are treated definitively with a short-leg non-walking cast for six to eight weeks. Displaced or comminuted fractures require surgical intervention for anatomic reduction.

  
  
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  Lateral process fractures are typically managed nonoperatively with immobilization in a non-weight bearing short-leg cast for four weeks and an additional two weeks of partial weight-bearing. ORIF is indicated for large fragments or for more than 2-mm of displacement.

  
  
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  Posterior process fractures are managed similarly to lateral process fractures. ORIF is indicated for large fragments or fractures with a large degree of displacement.

Talar head fractures may lead to talonavicular osteoarthritis or chondromalacia.

Talar neck fractures may lead to peroneal tendon dislocations, avascular necrosis, or delayed union.

Displaced or comminuted talar body fractures may lead to avascular necrosis.

Lateral process fractures may lead to malunion or nonunion.

Avascular necrosis may develop in any case of fracture dislocation.

Fractures of the talus are extremely rare in children and the talar neck is most often involved.

These fractures are typically managed in a long-leg cast with non-weight bearing for six to eight weeks followed by progressive weight-bearing for an additional two-three weeks.

Operative management is indicated if there is more than 5-mm displacement or more than 5° malalignment of fracture fragments on AP radiograph.²

Talar fractures, especially to of the neck, are predisposed to avascular necrosis, so diagnosis, management, and appropriate referral are essential to preventing this complication.^{1, 2, 3, 6}

The navicular bone is the most commonly fractured bone of the midfoot.¹

Fractures are classified as dorsal avulsion (most common), tuberosity fractures, body fractures, or compression fractures.

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  Body and compression fractures are the rarest of these types.

Typically these fractures are the result of a direct blow or axial loading. In the case of axial loading, the force may be directly along the long axis of the foot or in an oblique orientation.

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  Dorsal avulsion fractures often have a component of foot inversion while tuberosity fractures often follow an acute eversion force.

  
  
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  Navicular stress fractures may occur as a result of overuse, most commonly in sports which require explosive movements and sudden changes in direction (e.g., soccer, basketball, high jumpers).

Patients present with pain and swelling over the dorsal medial aspect of the foot.

Dorsal navicular fractures have tenderness to palpation over the dorsal medical aspect of the foot.

Tuberosity fractures have tenderness to palpation distal to the medial malleolus. In the case of this fracture, eversion of the foot elicits pain.

It is important to palpate all bony structures of the foot and ankle as navicular fractures often involve concomitant injuries.

X-ray: AP, lateral, medial oblique, and lateral oblique views often demonstrate these injuries.

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  If possible, these should be done with patient weight-bearing.

  
  
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  Comparison views of the unaffected foot may be required.

Subtle, nondisplaced fractures may not be visualized with X-ray, so CT may be required if suspicion is high.

Navicular fractures require immobilization with a bulky, well-padded posterior splint.

The patient should be kept on NWBS. Crutches, with instructions on their use, should be provided.

Ice and elevation are recommended to prevent or minimize swelling.

Adequate analgesia should be provided.

Most navicular fractures may be safely discharged to home, with the exception of open fractures and those with neurovascular compromise. These injuries require orthopedic consultation in the ED.

Displaced fractures of the navicular require immediate orthopedic referral, with follow-up within twenty-four hours.

Nondisplaced fractures of the navicular require early orthopedic or sports medicine referral, with follow-up within two weeks.

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  These fractures require repeat X-ray in ten to fourteen days.

  
  
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  If joint instability or associated injuries are seen on the follow-up X-ray, then surgical intervention is often required.

Nonoperative management involves a short-leg cast with gradual weight-bearing over the course of six to eight weeks.

Operative management requires a patient to be non-weight bearing in a short-leg cast for a period of twelve weeks from the time of surgical intervention.

Avascular necrosis may develop after body fractures.

Nonunion is often seen with tuberosity fractures.

Arthritis

Loss of normal foot alignment.

Late instability of the foot.

It is important to adequately evaluate all associated and surrounding structures when navicular fractures are found as there is a high rate of associated injury.

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  Dorsal avulsion fractures are often seen with associated lateral malleolar ligament injuries.

  
  
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  Tuberosity fractures are often seen with associated fractures of the cuboid.

Injury to the cuboid may be isolated but is often seen with associated injuries of surrounding midfoot structures.^{1, 2, 3}

The cuboid articulates with the calcaneus, navicular, and lateral cuneiform as well as the fourth and fifth metatarsals.

Indirect trauma accounts for the majority of cuboid fractures. This involves a torsional stress or plantarflexion with abduction of the foot.

Direct trauma may also cause a cuboid fracture and this typically involves a crush injury with a force applied to the dorsolateral aspect of the foot.²

Patients present with pain and swelling following a traumatic mechanism as described earlier.

There is swelling and tenderness to palpation of the dorsolateral aspect of the foot.

Motion of the midfoot exacerbates the pain.

All bony structures should be palpated to detect any associated injuries.^{1, 3}

X-ray: AP, lateral, and oblique views may demonstrate these injuries.

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  If possible, xrays should be performed with patient weight-bearing.

  
  
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  Comparison views of the unaffected foot may be required.

CT imaging may be required to further assess the extent of the fracture and any instability.

Cuboid fractures require immobilization with a bulky, well-padded posterior splint.

The patient should be kept on strict NWBS. Crutches, with instructions on their use, should be provided.

Ice and elevation are recommended to prevent or minimize swelling.

Adequate analgesia should be provided.

Most cuboid fractures may be safely discharged to home, with the exception of open fractures and those with neurovascular compromise. These injuries require orthopedic consultation in the ED.

Cuboid fractures require early orthopedic or sports medicine referral with follow-up within two weeks.

Displaced or severely comminuted fractures or those fractures with more than 2-mm joint surface disruption will require ORIF; however, these do not require immediate (i.e., twenty-four hours) orthopedic follow-up.

Nondisplaced fractures managed nonoperatively should be treated with a short-leg cast for six to eight weeks. During this time patients are NWBS. Patients are then able to begin a gradual return to activity.

Nonunion may occur in fractures with significant displacement or inadequate immobilization.

Osteonecrosis may be seen following severely displaced or comminuted fractures.

Posttraumatic osteoarthritis

Foot instability

Cuboid fractures are often associated with other soft tissue injuries.

In the case of a fracture to the distal portion of the cuboid, a tarsometatarsal dislocation should be assumed present until proven otherwise.

Cuboid fractures are often seen with concomitant calcaneus and metatarsal fractures.^{1, 2, 3}

Isolated injuries to the cuneiforms are very rare. Most often they coexist with other injuries.

The cuneiforms articulate with the navicular, metatarsals, and the cuboid (lateral cuneiform).

Often occur after axial loading.

Patients present with pain and swelling over the involved area.

There is localized tenderness to palpation over the cuneiform region.

If the patient is able to bear weight, pain is elicited in the midfoot.

Motion of the midfoot exacerbates the pain.

X-ray: AP, lateral, and oblique may demonstrate these injuries.

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  If possible, these should be done with patient weight-bearing.

CT imaging may be required to further assess the extent of the fracture and any instability.

Cuneiform fractures require immobilization with a bulky, well-padded posterior splint.

The patient should be kept on strict NWBS. Crutches, with instructions on their use, should be provided.

Ice and elevation are recommended to prevent or minimize swelling.

Adequate analgesia should be provided.

Most cuneiform fractures may be safely discharged home, with the exception of open fractures and those with neurovascular compromise. These injuries require orthopedic consultation in the ED.

Cuneiform fractures require early orthopedic or sports medicine referral with follow-up within two weeks.

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  Fractures of the medial cuneiform may require surgical intervention.

Nondisplaced fractures managed nonoperatively should be treated with a short-leg cast for six to eight weeks. During this time patients are on NWBS. Patients are then able to begin a gradual return to activity.

Similar to those seen with cuboid fractures.

As with cuboid fractures, associated injuries are common, so it is imperative to adequately assess for these injuries.^{1, 2, 3}

Lisfranc injuries involve a spectrum of injuries from stable sprains to unstable fracture-dislocations.

The unstable fracture-dislocation (Figure 8.11) is rare and accounts for only 0.2 percent of all fractures.

Approximately 20 percent of these injuries are missed initially.

These are becoming increasingly more common as the result of sports injuries, specifically soccer and football^{1, 2, 3, 6, 7}.

The Lisfranc joint marks the articulation between the midfoot and forefoot (Figure 8.12).

The cuneiforms articulate with the first three metatarsals while the cuboid aligns with the fourth and fifth metatarsals.

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  The articulation between the second metatarsal and the middle cuneiform is recessed, providing additional stability.

In addition to the bony articulations, inherent to this joint’s stability are the multiple ligamentous connections.

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  Tarsometatarsal ligaments connect the metatarsal bones to bones of the midfoot.

  
  
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  Transverse intertarsal ligaments connect the metatarsals, with the exception of the first and second metatarsals, which do not have ligamentous connection.

  
  
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  The intertarsal ligaments have a weaker dorsal component, making dorsal dislocations more likely.

  
  
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  The Lisfranc ligament extends obliquely from the plantar surface of the medial cuneiform to the plantar surface of the base of the second metatarsal, providing the primary stabilizing force of this joint (Figure 8.12).

The dorsalis pedis artery dives between the first and second metatarsals, placing it at risk for compromise during injury.

MVAs, falls, and athletics (football, soccer, and equestrian) account for the majority of these injuries, with MVCs accounting for 45 percent. ^{1, 6}

High-energy mechanisms (MVAs) lead to the more severe fracture-dislocations, while lower-energy mechanisms typically cause ligamentous injuries.

Direct blows to the dorsum of the foot may cause significant soft tissue injury.

Indirect trauma involves an axial load or a rotational force applied to a plantarflexed foot.

Depending on the extent of the injury, the patient may present ambulatory with minimal pain and swelling, or be unable to bear weight with significant pain and extreme swelling.

The foot may have gross deformity or may appear relatively normal, depending on the injury.

Edema and ecchymosis to the dorsum and/or plantar surface^{1, 7} of the midfoot may be present.

There will likely be tenderness to palpation over the area of the Lisfranc joint.

Passive plantar and dorsiflexion of the foot may elicit pain, and this should heighten suspicion of injury and prompt further evaluation.

Passive abduction and pronation of the forefoot with the hindfoot held fixed may exacerbate pain and is suggestive of injury.

Passive movement of the metatarsal heads may produce pain at the tarsometatarsal joint.

Passive dorsiflexion of the toes may elicit pain, suggesting the possibility of associated compartment syndrome.

Although rare, vascular injury may occur, so pulses should be assessed.