Case:
A 33-year-old man presented to the ED after falling 15 feet from a scaffolding, landing on his right heel. He complained of severe right heel pain, but other than some mild pain in the right arm, he denied any other injuries. Examination revealed swelling and tenderness of the heel with a normal neurovascular exam. Palpation of the thoracic and lumbar spinous processes did not reveal any tenderness.
Radiograph Interpretation: Right foot demonstrated a depressed comminuted calcaneus fracture
While awaiting admission, he complained of some back pain when he sat up to use the urinal. Imaging of the spine was obtained.
CT interpretation: A compression fracture of T12 with 4 mm of retropulsion into the spinal canal.
Why it matters:
Calcaneal fractures are commonly due to an axial loading mechanism. As such, a classic associated injury is compression fracture of the spine, reported as frequently as 10-20% of cases. This case was interesting because despite a negative initial assessment of the spine on history and physical, the patient later complained of pain and was found to have a significant spinal injury. This case drives home the point that the clinician should carry a low threshold to obtain radiographs of the spine in a patient with a significant axial load mechanism with a potentially distracting amount of pain due to a calcaneus fracture. Routine screening spinal radiographs in this scenario should be considered.
Written by:
Ibrahim Mansour, MD
Chief Resident, Cook County Health
William Haufe, MD
PGY - 1, Cook County Health
Reviewed by:
Dr. Scott Sherman, MD
Associate Program Director, Cook County Health
References:
Walters JL, Gangopdhyay P, Scot Malay D. Association of calcaneal and spinal fractures. J Foot Ankle Surg. May-Jun 2014;53(3):279-81.
Bohl DD, Ondeck NT, et al. Demographics, mechanism of injury, and concurrent injuries associated with calcaneus fractures: A study of 14516 patients in the American College of Surgeons National Trauma Data Bank. Foot Ankle Spec. 2017 Oct;10(5):402-10.
Germann CA, Perron AD et al. Orthopedic pitfall in the ED: calcaneal fractures. Am J Emerg Med. 2004 Nov. 22(7):607-11.