Lateral x-ray of a woman’s right foot following a car accident
Sagittal computed tomography of the patient’s right foot
A 21-year-old woman presents to the emergency department with severe right ankle pain after being involved in a motor vehicle accident. X-ray and sagittal computed tomography images of the fracture were taken.
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The patient has a tongue-type calcaneus fracture with decreased Bohler angle. Bohler angle can be determined by drawing a line from the highest point of the anterior process to the highest point of the posterior facet and then drawing a line from the posterior facet to the superior aspect of the posterior tuberosity.1 The intersecting lines should form an angle measuring between 20 and 40 degrees. An angle less than 20 degrees indicates collapse of the weight-bearing posterior facet.
Intra-articular calcaneus fractures are often described in two types of fracture patterns: tongue-type and joint depression-type.2 A tongue-type fracture occurs when the articular fragment remains attached to the tuberosity fragment. The secondary fracture line in a tongue-type fracture appears beneath the posterior facet and exits posteriorly through the tuberosity. A joint depression-type fracture occurs when the articular fragment separates from the adjacent tuberosity. The secondary fracture line in a joint depression-type fracture exits just behind the posterior facet.
The goals of surgical treatment for intra-articular tongue-type fractures include restoring the articulation of the subtalar and calcaneocuboid joints, restoring the Bohler angle, reestablishing the normal width and height of the calcaneus, and correcting the varus deformity of the fracture. A calcaneal body fracture is a true extra-articular fracture not involving the subtalar joint, and an anterior process fracture occurs along the calcaneocuboid joint.
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Wheeless CR III. Bohler’s angle. In: Wheeless CR III, Nunley JA II, Urbaniak JR, eds. Wheeless’ Textbook of Orthopaedics. http://www.wheelessonline.com/ortho/bohlers_angle. Updated September 5, 2012. Accessed February 16, 2016.
- Clare MP, Sanders RW. Fractures and dislocations of the calcaneus. In: Bucholz RW, Court-Brown C, Heckman JD. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:2293-2336.