Fracture: Calcaneus

Radiographic findings may include:

  • a linear or curvilinear decreased density dividing a bone into two or more segments
  • ill-defined increased density

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Here are presentations of calcaneal fracture (with *interpretations):

  • Case 1
  • *Case 1
  • Case 2a
  • *Case 2a
  • *Case 2b
  • *Case 2c
  • Case 3
  • *Case 3
  • Case 4
  • *Case 4
  • Case 5
  • *Case 5
  • Case 6
  • *Case 6
  • Case 7
  • *Case 7
  • Case 8
  • *Case 8
  • Case 9
  • *Case 9
stress fracture
stress fracture marked

Lateral view.
A vertically-oriented, ill-defined, and curvilinear increased density (arrows) presents in the superoposterior aspect of the calcaneal body.
Diagnosis: calcaneal stress fracture.

anterior beak fracture
anterior beak fracture marked

Lateral view.
The superoanterior "beak" of the anterior calcaneus is separate from the remainder of the body.
Diagnosis: anterior beak fracture (Rowe Type 1C) versus os calcaneus secundarius.

a dp view b lateral oblique view

Dorsoplantar (a) and lateral oblique (b) views.
An irregular-shaped ossicle (F) presents along the superolateral aspect of the calcaneal anterior process.
Diagnosis: avulsion fracture of the dorsolateral calcaneocuboid ligament enthesis (Rowe Type 1C).

Os Calcaneus secundarius

Medial oblique view.
A well-defined ossicle is seen between the calcaneus, talus, navicular, and cuboid bones. It is closely apposed to the superomedial aspect of the anterior calcaneus (arrowhead).
Diagnosis: os calcaneus secundarius.

Rowe
Rowe 5b marked

Lateral view.
A curvilinear, ill-defined decreased density (arrows) runs superoinferiorly through the anterior half of the calcaneal body, at the level of the middle talocalcaneal joint. A second curvilinear mixed increased and decreased density (arrowhead) runs parallel and inferior to the posterior talocalcaneal joint. Bohler's angle is 0 degrees.
Diagnosis: comminuted calcaneal body fracture, intra-articular (Rowe type 5, Essex-Lopresti type 2B).

Rowe 1a
Rowe 1a marked

Calcaneal axial view.
The medial aspect of the medial tuberosity (F) is separated from the body. Additionally, an ill-defined decreased density (arrows) runs superoinferiorly through the plantar-posterior aspect of the calcaneus.
Diagnosis: Comminuted fracture of the calcaneal medial tuberosity (Rowe type 1A, Essex-Lopresti 1B).

Rowe 1b
Rowe 2a

Lateral view.
An irregular shaped portion of the bursal projecttion (white arrows, aka the posterior calcaneal "beak") is separated from the body. The black arrow identifies an area of decreased density from which the "beak" originated.
Diagnosis: Fracture of calcaneal bursal projection (Rowe type 2A)

Rowe 2a marked
Rowe 1d

Dorsoplantar view.
A curvilinear decreased density (arrows) separates the anterolateral aspect of the calcaneus from the body. It enters the calcaneocuboid joint.
Diagnosis: Intra-articular fracture of the anterolateral calcaneus (Schmidt and Weiner type 1D).

Rowe 1d marked
Rowe 1b

Lateral view.
The sustentaculum tali (ST) is seaprated from the calcaneal body. There also are curvilinear decreased densities runnning through the midportion of the calcaneal body superoinferiorly and parallel to the posterior talocaneal joint, the latter mixed with ill-defined increased density. Bohler's angle is decreased.
Diagnosis: Comminuted, intra-articular fracture of the calcaneus (Rowe types 1B & 4/5?, Essex-Lopresti type 1C/2B?; this example does not exhibit obvious joint depression therefore the ???).

Rowe 4
Rowe 4 marked

Lateral view.
An obliquely-oriented decrased density separates the calcaneal body into at least two large segments. One discontinuity enters the posterior talocalcaneal joint (arrows), and another forms a tongue-like fragment posteriorly that is angulated superiorly. Bohler's angle is 0 degrees.
Diagnosis: Intra-articular, comminuted calcaneal fracture (Rowe type 5, Essex-Lopresti type 2A/B???).

Rowe 5b
Rowe 5b

Lateral view.
A vertically-oriented decreased density (arrows) separates the anterior aspect of the calcaneus from the remainder of the body. A mixed increased and decreased density (lines) run parallel to the posterior and middle talocalcaneqal joints.Bohler's angle is nearly 0 degrees.
Diagnosis: Intra-articular, comminuted calcaneal fracture (Rowe type 5, Schmidt & Weiner type 5B, Essex-Lopresti type 2B).

defect nonunion markled

Dorsoplantar view.
This patient had a portion of the distal one-third diaphysis removed many years prior to this image. The margins of bone are well-defined. There is no evidence of bone production; in fact, the bone ends are tapered and separated from one another.
Diagnosis: atrophic, defect nonunion.

Should a radiographic study be ordered to assess a suspected calcaneal fracture?

Definitely yes.

What are the best views to order?

Because of the complexity and subtle nature of calcaneal fracture visibility, I recommend ordering DP, medial oblique, lateral oblique, calcaneal axial (40 degrees), and lateral views.

CT is often necessary for further evaluation once fracture is confirmed, especially for preoperative planning.

Other information

Bone scintigraphy is valuable for assessing calcaneal stress fracture, which may take between four to eight weeks before visible on plain films.

References:

  1. Christman RA: Foot and Ankle Radiology, 2nd edition, Lippincott Williams & Wilkins, 2015.