What's the Diagnosis? By Dr. Rebecca Fieles

A 44 yo M presents to the ED w/ L foot and ankle pain. He was running and stepped into a hole, stating he heard a "crack". He has been unable to bear weight since the injury. On exam, he has swelling and marked bony tenderness of both the lateral and medial malleoli and heel. Xrays of the L foot were obtained. What's the diagnosis? (scroll down for answer)



 Answer: Comminuted fracture of calcaneus

  • Etiology
    • Most commonly due to high axial load injuries such as fall from height or MVC
    • ** most common tarsal fracture
  • Presentation
    • Diffuse pain, swelling and ecchymosis after trauma
    • Often unable to bear weight
    • Deformity of heel or plantar arch on exam
    • Mondor's sign- ecchymosis/hematoma that tracks along sole of foot (pathognomonic for calcaneal fracture)
  • Diagnosis
    • Plain radiographs of ankle/foot
    • Harris view: calcaneus in axial view
    • Non-contrast CT of the foot/ankle is the gold standard and assists with surgical planning
  • Sander's Classification (based on CT)
    • Type I: all intra-articular fractures that have < 2mm displacement, regardless of # of fracture lines/fragments
    • Type II: two bony fragments involving posterior facet
    • Type III: three bony fragments including depressed middle fragment
    • Type IV: four comminuted bony fragments
  • ED management
    • assess NV status 
    • analgesia, ice, elevation
    • splinting, often with bulky Jones dressing
    • ortho consult
      • Most intra-articular fractures require surgical repair
      • Most extra-articular fractures can be treated conservatively with 10-12 weeks of casting; pt discharged from ED non-weightbearing




Jiménez-Almonte JH, King JD, Luo TD, Aneja A, Moghadamian E. Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. Clin. OrthopRelat. Res. 2019 Feb;477(2):467-471