Professional edition active

Calcaneal Fractures

ByDanielle Campagne, MD, University of California, San Francisco
Reviewed/Revised Dec 2022
View Patient Education

Calcaneal (heel bone) fractures often result from great force. Diagnosis is by x-rays and, if needed, CT. Treatment requires orthopedic consultation and includes casting and sometimes surgery.

Topic Resources

(See also Overview of Fractures.)

Calcaneal fractures are serious but uncommon injuries; they account for only 1 to 2% of all fractures. However, if not diagnosed and treated promptly, they can result in long-term disability. Up to 10% of these fractures are missed at initial presentation in an emergency department.

Typically, these fractures result from a high-energy axial load to the foot (eg, a fall from a height onto the heels). Because these fractures require great force, they are often accompanied by other serious injuries; 10% of patients with a calcaneal fracture have a thoracolumbar compression fracture.

Stress fractures may also occur in the calcaneus, particularly in athletes, such as long-distance runners.

Calcaneal fractures may be intra-articular.

Symptoms and Signs of Calcaneal Fractures

Usually, the area around the heel and the hindfoot is tender and very swollen. Patients cannot put weight on their foot.

Acute compartment syndrome occurs in up to 10% of patients.

Diagnosis of Calcaneal Fractures

  • X-rays

  • Sometimes CT

If a calcaneal fracture is suspected, x-rays that include axial and lateral views should be taken.

CT is done if

  • X-rays are negative but clinical findings suggest a calcaneal fracture.

  • The Bohler angle is < 20°.

  • More detail about the fracture is needed.

Calcaneal Images
Bohler Angle
Bohler Angle

The Bohler angle is formed by the intersection of a line drawn from the superior aspect of the posterior calcaneal tuberosity to the superior subtalar articular surface and a line drawn from the superior subtalar articular surface to the superior aspect of the anterior calcaneal process. Normally, the angle is 20 to 40°. An angle of < 20° suggests a fracture.

... read more

Image courtesy of Danielle Campagne, MD.

Calcaneal Fracture
Calcaneal Fracture

This x-ray shows a comminuted fracture of the calcaneus.

Image courtesy of Danielle Campagne, MD.

The Bohler angle is determined on the lateral x-ray. This angle is formed by the intersection of a line drawn from the superior aspect of the posterior calcaneal tuberosity to the superior subtalar articular surface and a line drawn from the superior subtalar articular surface to the superior aspect of the anterior calcaneal process. Normally, the angle is 20 to 40°. An angle of < 20° suggests a fracture.

Pearls & Pitfalls

  • If patients have calcaneal swelling and tenderness after a high-energy axial load to the calcaneus, check the Bohler angle on x-ray, and check for thoracolumbar compression fracture and compartment syndrome.

Clinicians should also check for other injuries, such as thoracolumbar compression fractures and compartment syndrome.

Treatment of Calcaneal Fractures

  • Orthopedic consultation

  • Casting or possibly surgery, depending on the type of fracture

Orthopedic consultation is necessary.

Whether intra-articular calcaneal fractures should be treated surgically or nonsurgically is much debated.

Extra-articular calcaneal fractures are treated symptomatically with protection, rest (avoiding weight bearing), a compression dressing (which also provides protection), ice, and elevation (PRICE). When the swelling resolves, a cast is applied.

Key Points

  • If calcaneal fractures are not diagnosed and treated promptly, they can result in long-term disability.

  • Because these fractures usually result from a high-energy axial load to the foot, other injuries (eg, thoracolumbar compression fracture) are often also present; other complications include compartment syndrome (in up to 10%).

  • Diagnose based on x-rays and, if needed, CT.

  • Whether intra-articular calcaneal fractures should be treated surgically or nonsurgically is controversial.

  • When diagnosing a calcaneal fracture, always check for a thoracolumbar fracture.

  • Treat extra-articular calcaneal fractures symptomatically with PRICE, followed by casting.

quizzes_lightbulb_red
Test your KnowledgeTake a Quiz!
Download the free MSD Manual App iOS ANDROID
Download the free MSD Manual App iOS ANDROID
Download the free MSD Manual App iOS ANDROID