X-ray Quiz: Foot pain

Your patient is a 35yo male who presents to the ER with the complaint of foot pain.  You learn that the patient sustained a fall from 10 feet landing upright.  On exam you note that the patient has pain over the calcaneous.  The X-ray is shown above.  Do you notice the abnormality?

Take a look now at an axial view of the calcaneous.  Do you see the abnormality now?

It’s pretty obvious from the above X-ray that this patient sustained a calcaneal fracture from the fall.  Is there any way you could have easily picked up on this when you first looked at the lateral view?

In fact, there is a measurement that could have been made which can pick up on calcaneal fractures.  Anytime you are reviewing an X-ray of a patient with pain over the calcaneous, you should measure Bohler’s angle.  An illustration of this angle is below:

As you can see above, in order to measure this angle, a line is drawn from the tuberosity to the most superior part of the posterior facet.  Another line is drawn from the most superior part of the facet to the anterior process.  Normally the angle created is between 20 and 40 degrees.  If the angle is less than 20 degrees, this indicates depressed fracture.  If you measure Bohler’s angle in the initial X-ray, you will in fact find that the angle is less than 20 degrees.

Interesting Fact:  A calcaneal fracture is also known as Lover’s fracture or Don Juan fracture because a lover may jump from great heights to escape the lover’s spouse.

For those of you wanting to read more about the management of calcaneal fractures, check out the following link:  calcaneous fracture management 


7 thoughts on “X-ray Quiz: Foot pain

  1. Tough xray to see the fracture because in this case Bohler’s angle is normal. Measuring Bohler’s angle helps us in the orthopaedic work make surgical decisions because a flat Bohler’s angle means that the posterior facet of the calcaneus is depressed, which also means that the calcaneus is also wider and has fallen into a varus anglulation. (Think about a jelly donut. If you press down on top of the jelly donut it gets flatter and wider.) Wider calcaneus means more difficulty with shoe wear.
    This fracture is a small piece off the posterior tuberosity below the level of the Achilles tendon insertion, I would probably treat this nonoperatively with protected weightbearing. If surgical intervention was needed, I would consider excision of the fragment although ORIF is possible.
    One thing to remember from an Emergency Medicine standpoint is that a calcaneus fracture is an axial load injury. All joints above the calcaneus need to be examined to insure there are no other joint level injuries. Also, there is a strong correlation between calcaneus fractures and spinal compression fractures. Be sure to palpate and examine the cervical, thoracic, and lumbar spine.

  2. Great points by Dr. VanHoff!! What angle are others getting when they measure on the above lateral? This series came from an online teaching site (www.mypacs.net) The radiologist there commented that the angle was flattened. I measured right at 20 degrees. Get out your protractors people!

  3. I get about 20 degrees. I bet this is his normal. Would have to check the other side to confirm. If you look at the trabecular lines on both the lateral and Harris axial views you will see that they are unbroken except for the small posterior tuberosity piece.

    1. Should we always order a CT scan on calcaneous fractures while awaiting orthopaedic consults?

      1. I talked with Corey about CT and he felt that CT is indicated if there will be operative repair. I think talking with ortho prior to ordering CT is best. I’ll ask Corey that ASAP.

  4. I agree that Bohler’s angle here is about 20 degrees. What the case does illustrate is that the maxim of assessing two views is often true!

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