Diagnosis

• Mondor's Sign - Hematoma or bruising which extends from the heel to the arch of the foot
• Injured side often wider than unaffected side - heel can appear flatter, wider and in a varus/valgus postition when compared to contralateral side
• Tenderness on both medial and lateral calcaneus with extreme pain on ROM of STJ
• Ankle joint ROM generally not painful
• Hoffa sign - loss of plantarflexion strength of the tendo achilles in severely comminuted fractures.
• Most cannot bear weight on heel
• Children may present with knee flexion and ankle equinus to avoid weight bearing
• Typically edema develops quickly after injury
• 10% of calcaneal fractures have compartment syndrome present - Manoli and Myerson
• Fracture blisters may be present
• Always evaluated other areas, particularly the lumbar and cervical spine, head, wrists, knees, and hips, for potential injuries
• Neurovascular - always evaluate neurovascular status, especially along course of sural nerve and posterior tibial artery
• Radiographs - DP of foot, Lateral of foot and ankle, Calcaneal axial. It may be difficult to appreciate the fracture as the architecture of calcaneus may mask the appearance of fractures.

• • Lateral - best to assess Böhler's angle and crucial angle of Gissane
    • Böhler's angle - typically 25-40° - angle formed by intersection of lines from highest point of anterior process to highest point of posterior articular surface, and other line from same point on posterior articular surface to the most superior point of calcaneal tuberosity.
      • Angle decreases or even reversed with severe fractures
    • Crucial angle of Gissane - between 125-140° - created by subchondral bone of posterior facet and subchondral bone of middle and anterior facet
    • Angle increased to greater than 180° with displacement of posterior facet in joint depression fractures
  • The goal of adequate reduction are the recreation of both angles and restoration of the subtalar joint
  • Medial oblique - used to visualize the involvement of the calcaneocuboid joint
  • Broden I and II and the Isherwood II - used to evaluate the subtalar joint, especially the posterior facet - rarely used due to availability of CT scan

• • Lumbar spine - essential for patients who suffered a fall or patients who complain of back pain and have tenderness on physical exam of spine.
• CT scan - vital for evaluating extent of articular involvement