The Case:
A 16-year-old male presented to the ED 3 days after slipping on ice and landing on his right heal with significant impact. On examination he is neurovascularly intact, however, has significant tenderness to palpation over the right heal, and the rest of his lower extremity exam is limited secondary to pain.
Interpretation:
Comminuted mildly displaced tongue-type calcaneal fracture.
Why it Matters
Calcaneus fractures represent 60% of all tarsal bone fractures and are the most diagnosed tarsal bone fractures in emergency medicine. Tongue-type calcaneus fractures (TTCF) are longitudinal fractures that exit the calcaneal tuberosity posteriorly with involvement of a portion of the articular surface. The typical mechanism of injury in younger individuals is a high-energy injury with an axial load applied to the heel. There is separation of the calcaneal tuberosity into superior and inferior fragments, with the superior fragment being displaced posteriorly and superiorly because of the pull of the calf muscles.
This displacement pattern can result in catastrophic secondary soft tissue injury overlying the fracture as the tongue fragment leads to increased pressure of the soft tissue, in turn compromising its blood supply. On clinical evaluation, particular attention should be paid to the skin overlying the calcaneal area to look for persistent skin blanching or skin tenting indicative of vascular compromise.
Early recognition by the emergency physician and prompt orthopedic consultant involvement is imperative in these cases. If there are no signs of skin tenting or blanching, then the affected extremity may be splinted with emphasis on offloading the posterior calcaneus and minimizing pressure on the skin (ie, ankle plantarflexion and padded, bulky dressing). On the other hand, urgent fracture reduction should be performed if there are any clinical signs of soft tissue compromise. A delay or error in diagnosis and treatment can result in a closed fracture becoming an open fracture which can lead to increased patient morbidity.
References:
Chhabra N, Sherman SC, Szatkowski JP. Tongue-type calcaneus fractures: a threat to skin. Am J Emerg Med. 2013 Jul;31(7):1151.e3-4. doi: 10.1016/j.ajem.2013.02.029. Epub 2013 Apr 10. PMID: 23583117.
Vilabril F, Costa JV, Dias JV, Cândido RM, Machado I (2021) Tongue-Type Calcaneal Fracture due to a Low-Energy Injury. Trauma Cases Rev 7:088. doi.org/10.23937/2469-5777/1510088
Written By:
Dr. Vishal Mittal, MD
Emergency Medicine, PGY-1
Cook County Health
Reviewed By:
Dr. Scott Sherman, MD
Associate Program Director
Cook County Health