**5. Clinical evaluation/presentation**

A thorough history and physical exam are essential for diagnosing calcaneus fractures. Important considerations of the patient's medical history, toxic habits, and daily activities (work status) are crucial as they affect outcomes. Pain and swelling are usually the first sign that a calcaneus fracture is present. Patients with these fractures may have other associated injuries that cause pain, which can lead to a delay in identifying calcaneus fractures. Although a rare occurrence in the authors' experiences, it has been reported that up to 10% of calcaneus fractures can lead to compartment syndrome [33]. Key components of the physical exam include visual inspection, neurovascular examination, and tendon function. Examination should include palpation and range of motion of the entire ipsilateral extremity and spine.

During visual inspection, ecchymosis and swelling of the heel, open skin lesions, or fracture blisters may be present. Tenting or ecchymosis may be visible in tuberosity fractures of the posterior calcaneus (**Figure 6**). Urgent surgical reduction is required if these findings are present to prevent posterior heel skin necrosis. Open skin lesions can present with calcaneus fractures (**Figure 7**). Urgent intravenous antibiotics, tetanus vaccination, and bedside irrigation are performed when open fracture is identified. After these urgent measures are taken, operative irrigation and debridement should be performed within 24 hours with concurrent temporary fixation with percutaneous pins, splinting, or definitive fixation with ORIF (described later in the chapter). Wound complications resulting from calcaneus fractures can be devastating and may require a free flap or amputation. Poor splinting techniques can contribute to posterior heel wounds. Therefore, to reduce the risk of splint/cast-related wounds, equinus can be allowed, and abundant heel padding is helpful.

Palpation typically elicits diffuse tenderness; in beak fractures, there will be a lack of posterior heel blanching. In avulsion fractures, there will be a heel cord continuity disruption. The neurovascular exam should include a comparison of the dorsalis pedis and posterior tibial pulses to the contralateral leg. Evidence of vascular insufficiency in the foot may require angiography or Doppler scanning. The primary targets when assessing tendon function should be the Achilles tendon and flexor hallucis longus (FHL). Decreased ankle plantarflexion strength occurs with avulsion of the posterior tuberosity, and weak flexion of the great toe points toward a displaced fracture entrapping the FHL.

Patients may also present with undiagnosed heel pain at times with negative radiographs. Concern for stress fractures should be present, especially in at-risk

#### **Figure 6.**

*Ecchymosis and fracture blisters due to tongue-type fracture. (a) Fracture blister and ecchymosis of the heel. (b) Ecchymosis of the heel due to a tongue-type fracture. (c) Radiograph of tongue-type fracture causing skin problems in (a).*

#### **Figure 7.** *Open calcaneal fractures. (a)-(c)-open skin lesions due to calcaneal fractures.*

populations, including those with sudden increased physical activity, osteoporosis, or female athlete triad (menstrual dysfunction, low energy availability, and low bone mineral density).

**Figure 8.** *Radiograph showing Böhler's angle and the critical angle of Gissane.*
