Lover’s Fracture

A 35-year-old construction worker was brought in by the ambulance to the Emergency Department. He was reported to have fallen from scaffolding at the height of approximately 4 meters and landed onto the concrete floor below feet first. He was found conscious by paramedics but in obvious pain, holding his right leg. Upon initial examination in the ED, the patient remains vitally stable but complains of severe, persistent pain in his right ankle and heel. After adequate analgesia, an X-ray of the right ankle and foot revealed signs of a calcaneal "Lover’s" fracture (Figure 1).

Figure 1
Figure 1: Image courtesy of Annelies van der Plas, and J.L. Bloem - http://www.startradiology.com/internships/general-surgery/ankle/x-ankle/

Calcaneal Fractures

Before we begin our discussion on calcaneal fractures, it is important to highlight the major anatomical structures visible on a standard X-ray of the ankle and foot.

Figure 2
calcaneus and foot anatomy

Figure 2 shows a lateral x-ray of the right ankle, demonstrating the calcaneus as the bone – commonly referred to as the heel – that makes up the majority of the hindfoot.

As would be expected, the size and position of the calcaneus predispose the bone to various forms of injury. A calcaneal fracture is most often sustained after a road traffic accident or a fall from significant height onto the feet as was the case with our patient. Due to the mechanism of injury, it is often colloquially dubbed as “Lover’s fracture” or the “Don Juan fracture”(1).

Epidemiology

Among fractures of the hindfoot, calcaneal fractures comprise 50-60% of all tarsal bone fractures (2). These fractures are usually intra-articular (3) and occur more commonly in young men aged between 20 and 40 years. Diseases which decrease bone density, such as osteoporosis, invariably increase the risk for development of the fracture when injury occurs.

Patient evaluation

Patients with calcaneal fractures will often present in severe pain, though they may not always be able to localize the exact source for their pain. Swelling at the ankle or heel along with bruising (ecchymosis) can also be expected. Due to the mechanism of fall, injury usually occurs bilaterally. Most patients are unable to bear any weight onto the affected limb.

The lower extremity or extremities in question should undergo a thorough neurovascular exam, as diminished pulses distal to the injury (dorsalis pedis) could indicate arterial compromise and mandate aggressive investigation with angiography or Doppler scanning. Though the gold standard for diagnosing calcaneal fractures remains a CT scan, a plain film X-ray is usually obtained first which should include an Antero-Posterior (AP), a lateral, and an oblique view.

Bohler’s Angle and Critical Angle of Gissane

Historically, physicians would measure Bohler’s angle and the critical angle of Gissane in cases where a calcaneal fracture was not clearly evident on a plain X-ray. Outlined in Figure 3, a calcaneal fracture would be suspected if Bohler’s angle was below 20 degrees or the critical angle of Gissane was noted to be more than 140 degrees. Bohler’s angle was found to be a lot more diagnostically reliable when compared to the critical angle of Gissane (4). However, both these methods of diagnosis are now considered obsolete and the same research that studied that utility of the angles found that Emergency Physicians were able to accurately identify calcaneal fractures approximately 98% of the time without the measurement of either angle.

Figure 3
853 - bohler angle - calcaneus
854 - Gissane angle- calcaneus

Figure 3- Bohler’s Angle and Critical angle of Gissane

Management

The goal of initial management in the Emergency Department is centered on adequate pain relief, immobilization and wound care (including antibiotics when there are signs of a contaminated wound). [See the link for open fractures and antibiotic choices.]

An important point to note is that the mechanism of injury in calcaneal fractures (namely fall from height) is a form of axial loading. The energy from landing on the ground will often be transmitted up through the body, usually to the spine causing compression fractures of the vertebrae. The patient, however, may not complain about pain in other areas due to the overwhelming and distracting pain in the calcaneus. Therefore, all calcaneal fractures should be managed with a high index of suspicion for associated injuries.

Other potential complications include compartment syndrome, wound infection, malunion and osteomyelitis. All patients diagnosed to have calcaneal fractures should be managed by a multidisciplinary team that includes an Orthopedic Surgeon to ensure definitive management and repair of the fracture.

Take Home Points

  • High energy impact with axial loading, usually from a road traffic accident or a fall from height should raise suspicion of a calcaneal fracture.

  • Perform a thorough evaluation of the site of injury and suspect associated injuries (check the spine and remember to check the other foot for concomitant injury).

  • Maintain adequate analgesia (these fractures hurt!) and involve the Orthopedic Surgeon as soon as the diagnosis is made.

References and Further Reading

  1. Lee P, Hunter TB, Taljanovic M. Musculoskeletal colloquialisms: how did we come up with these names? Radiographics. 2004;24 (4): 1009-27. doi:10.1148/rg.244045015
  2. Davis D, Newton EJ. Calcaneus Fractures. [Updated 2019 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan
  3. Jiménez-Almonte JH, King JD, Luo TD, Aneja A, Moghadamian E. Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. Clin. Orthop. Relat. Res. 2019 Feb;477(2):467-471
  4. Jason R. K., Eric A. G., Gail H. B., Curt B. H. & Frank L. Boehler’s angle and the critical angle of gissane are of limited use in diagnosing calcaneus fractures in the ED. American Journal of Emergency Medicine. 24, 423–427 (2006)

A 28-year-old man presents to the ED with left ankle pain

by Stacey Chamberlain

A 28-year-old man presents to the ED with left ankle pain after twisting his ankle playing basketball. He is able to bear weight and notes pain and swelling to the lateral aspect of the ankle (he points to just below the lateral malleolus). He denies weakness, numbness, or tingling and has no other injuries. On exam, he is neurovascularly intact. Edema and tenderness are noted slightly anterior and inferior to the lateral malleolus. There is no point tenderness to the distal posterior malleoli bilaterally.

Should you get an X-ray to rule out fracture?

Ottawa Ankle Rule

Pain in the malleolar zone and any one of the following:

  • Bone tenderness along the distal 6 cm of the posterior edge or tip of the tibia (medial malleolus), OR
  • Bone tenderness along the distal 6 cm of the posterior edge or tip of the fibula (lateral malleolus), OR
  • An inability to bear weight both immediately after the trauma and in the ED for four steps.

Ottawa Foot Rule

Pain in the midfoot zone and any one of the following:

  • Bone tenderness at the base of the fifth metatarsal, OR
  • Bone tenderness at the navicular bone, OR
  • An inability to bear weight both immediately after the trauma and in the ED for four steps.

Case Discussion

In the above case, using either CDR, an X-ray is unnecessary.

Open fracture! Antibiotic choice.

ERic Motorcycle accident

A 20-year-old male presents to your ED with a 5 cm wound after he fell off his motorbike. On physical exam, the wound overlays a fractured left tibia but does not show extensive soft tissue damage nor any signs of periosteal stripping or vascular injury. 

Which antibiotic should you give to this patient?

To learn more about it, read chapters below.

Read "Scores" Chapter
Read "Lower Extremity Injuries" Chapter

Quick Read

Gustilo-Anderson Classification

Gustilo-Anderson classification is used for fractures with open wounds and antibiotic coverage.

Gustilo-Anderson Classification

TypeDefinition
Type IOpen fracture, clean wound, wound <1cm in length
Type IIOpen fracture, wound >1cm in length without extensive soft tissue damage, flaps, avulsions
Type IIIOpen fracture with extensive soft tissue laceration, damage, or loss or an open segmental fracture. This type also includes open fractures caused by farm injuries, fractures requiring vascular repair, or fractures that have been open for 8 hours prior to treatment.
Type III AType III fracture with adequate periosteal coverage of the fractured bone despite extensive soft tissue laceration or damage
Type III BType III fracture with extensive soft tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination. It will often need further soft tissue coverage procedure (i.e. free or rotational flap).
Type III CType III fracture associated with arterial injury requiring repair, irrespective of degree of soft tissue injury

According to the above classification, each class should receive the following antibiotics:

  • Type I: 1st generation cephalosporin
  • Type II: 1st generation Cephalosporin +/- Gentamycin
  • Type III: 1st generation Cephalosporin + Gentamycin +/- Penicillin

To learn more about it, read chapters below.

Read "Scores" Chapter
Read "Lower Extremity Injuries" Chapter

Selected Orthopaedic Problems and Injuries section is added.

Selected Orthopaedic Problems and Injuries

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What is your opinion about below x-ray? I, II, III, IV or V?

Please give your answer at the comment box below.

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iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

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iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

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iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!