A 42-year-old construction worker lands hard from a ladder, and the back of his left foot hits the concrete with a sound he describes as “a wet crack.” His heel is rapidly swelling inside a dusty work boot, and the skin over the hindfoot is tight and pale. He can wiggle his toes but cannot bear weight. The radiographs are not yet on the screen, and the next move has not been made.

— What’s your move? Read on.

Before you read
  • Which associated injury must be actively sought even when the heel dominates the presentation?
  • When is CT necessary, and when is outpatient care unsafe?

When to Think of It

Think of a calcaneal fracture after axial loading: fall from height, motor-vehicle crash, or forceful landing. Findings include heel ecchymosis, plantar bruising, swelling, inability to bear weight, decreased heel height, and tenderness over the calcaneus. Obtain foot radiographs—lateral, AP, and oblique; Harris axial view can help—and CT for intra-articular fracture definition or operative planning.

Sick or Not Sick

Sick versus not sick hinges on the skin and neurovascular examination: threatened skin, open fracture, compartment syndrome, vascular compromise, or neurologic deficit demands immediate orthopedic involvement. The single call that matters most is whether this is a limb-threatening injury requiring urgent decompression or operative management rather than routine immobilization.

The First Fifteen Minutes

  • Remove constrictive footwear and reassess skin, pulses, capillary refill, sensation, and motor function; document findings before and after splinting.
  • If severe pain: fentanyl 50–100 mcg IV, repeated by 25–50 mcg every 5 minutes as needed, because rapid titration provides analgesia without delaying assessment. Alternatively, morphine 0.05–0.1 mg/kg IV slowly, with respiratory monitoring.
  • Add acetaminophen 1,000 mg PO or IV if appropriate, because multimodal analgesia reduces opioid requirements.
  • If open fracture or gross contamination: cefazolin 2 g IV now; add gentamicin 5 mg/kg IV for severe type III contamination per local protocol, and use vancomycin 15–20 mg/kg IV when severe beta-lactam allergy or MRSA coverage is indicated—verify institutional open-fracture protocol.
  • Cover an open wound with sterile saline-moistened dressing, elevate, apply a well-padded posterior short-leg splint, and keep strictly non-weight-bearing. Do not repeatedly manipulate a closed fracture.

Definitive Care & Disposition

Urgent orthopedic consultation is required for open fracture, threatened skin, compartment syndrome, dislocation, neurovascular injury, or markedly displaced fracture. CT defines subtalar and calcaneocuboid involvement and is usually obtained after initial radiographs. Admit or transfer patients with open injuries, unsafe swelling, compartment concerns, polytrauma, or inability to manage strict non-weight-bearing. Selected closed, neurovascularly intact fractures may be discharged in a splint with elevation, analgesia, urgent orthopedic follow-up, and explicit return precautions; definitive fixation is often delayed until swelling and skin wrinkles return.

How This One Kills

The classic failure is placing a swollen heel into a circumferential cast, worsening pressure on compromised skin and precipitating necrosis or compartment syndrome. A second miss is failing to image the spine after a fall from height.
The Differential — What Else Looks Like This
  • Ankle fracture — malleolar tenderness and fracture pattern rather than maximal heel compression pain; confusing them can miss subtalar injury.
  • Achilles rupture — palpable tendon defect and positive Thompson test; treating as an isolated rupture misses a high-energy calcaneal injury.
  • Heel contusion — preserved heel architecture and ability to bear weight; false reassurance delays fracture care.
  • Lisfranc injury — midfoot plantar ecchymosis and tarsometatarsal tenderness; missed Lisfranc instability causes chronic midfoot collapse.

The Second-Day Story

Older adults, patients with neuropathy, and those with low-energy falls may have limited pain despite major displacement. Plantar ecchymosis, inability to bear weight, heel widening, or focal calcaneal tenderness should override a benign pain score. In an intoxicated or polytrauma patient, examine the heel and spine systematically rather than waiting for a reliable history.
Back to Our Patient
Back to the 42-year-old worker: the axial-load mechanism, heel swelling, plantar ecchymosis, and inability to bear weight make a calcaneus fracture the leading diagnosis. His pulses and sensation are intact, but the skin is tense, so the key risk-stratification task is serial skin and compartment assessment while examining him for thoracolumbar injury. He receives IV fentanyl, acetaminophen, elevation, and a padded posterior splint, remains non-weight-bearing, and undergoes foot radiographs followed by CT showing an intra-articular fracture without open injury or neurovascular compromise. Orthopedics arranges urgent follow-up and delayed fixation planning; he is discharged only after pain control, safe crutch use, and return precautions are confirmed.
Patient Presentation to Attending
How you’d present this patient on the floor — tight, pertinent positives and negatives, no rambling
“This is a 42-year-old construction worker with severe left heel pain and inability to bear weight after landing from a ladder, concerning for an axial-load calcaneus fracture. He has rapid swelling, plantar ecchymosis, and maximal tenderness over the heel, without an open wound, paresthesias, or back pain. The foot is warm with palpable pulses, intact toe motor and sensation, but the hindfoot skin is tense. I’m obtaining calcaneal and foot radiographs with CT for intra-articular definition, maintaining strict non-weight-bearing, elevating and splinting the extremity, and providing multimodal analgesia. I’ll involve orthopedics urgently if the skin worsens, compartment findings develop, or imaging shows displacement requiring operative care; otherwise, after safe ambulation training and reliable follow-up, he can be discharged for close orthopedic management.”

Study Directive

  • Draw the calcaneus and subtalar joint, then label where CT changes management.
  • Practice and document a complete hindfoot neurovascular/compartment examination.
  • Review your local open-fracture antibiotic and tetanus protocol.
  • Work through three cases deciding: discharge, admission, transfer, or immediate orthopedic intervention.

Recent Literature

  • Review or guideline Current Controversies in Management of Calcaneus Fractures
    Gotha HE, Zide JR · Orthop Clin North Am, 2017 · PMID 27886687 · cited 36×
    Reviews operative versus nonoperative decision-making for calcaneus fractures, including how fracture pattern, soft-tissue condition, and patient factors guide management and timing.