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From the EMDaily Archives: What’s the Diagnosis? By Dr. Rebecca Fieles

A 44 year old male presents for left 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, his left lower extremity is neurovascularly intact. He has swelling and marked bony tenderness of both the lateral and medial malleoli and heel. X-rays of the left foot is obtained and shown below. What’s the diagnosis?

Answer: Comminuted Calcaneal Fracture


  • Most commonly due to high axial load injuries such as fall from height or MVC
  • Most common tarsal fracture


  • 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


  • Plain radiographs of ankle/foot
  • Harris view: calcaneus in axial view
  • Non-contrast CT of foot/ankle is gold standard and assists with surgical planning
  • Sander’s Classification (based on CT)
    • Type I: All intra-articular fractures that have < 2 mm displacement, regardless of number of fracture lines or 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 Treatment

  • Analgesia, ice, elevation
  • Splinting, often with bulky Jones dressing
  • Orthopedics consultation
    • Most intra-articular fractures require surgical repair
    • Most extra-articular fractures can be managed conservatively with 10-12 weeks of casting and non-weight bearing


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

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