What are the signs of a calcaneus fracture in a 9-year-old patient?

Diagnosing Calcaneus Fracture in a 9-Year-Old

In a 9-year-old with suspected calcaneus fracture, obtain standard three-view foot radiographs (anteroposterior, lateral, and oblique) plus an axial Harris-Beath view, and examine for point tenderness over the calcaneus, inability to bear weight, and visible heel swelling or deformity. 1, 2, 3

Clinical Signs to Assess

Key Physical Examination Findings

• Point tenderness directly over the calcaneus is a critical finding that indicates the need for radiographic evaluation per the Ottawa Ankle Rules, which apply to children 5 years and older 1
• Inability to bear weight immediately after injury or inability to take 4 steps in the examination room strongly suggests fracture 1
• Visible heel swelling, ecchymosis, or deformity should raise immediate concern, particularly for displaced fractures 3, 4
• Skin compromise or impending skin breakdown over the heel requires urgent evaluation within 24 hours, especially with tongue-type or tuberosity avulsion fractures 3, 5, 4

Mechanism of Injury

• Fall from height is the typical mechanism causing axial loading through the heel 3
• Even seemingly minor trauma can cause fractures in children, as pediatric calcaneal fractures can occur with lower-energy mechanisms than in adults 6

Imaging Approach

Initial Radiographs (First-Line Study)

• Standard three-view foot radiographs (anteroposterior, lateral, oblique) should be obtained first 3
• Add an axial Harris-Beath view specifically for calcaneal evaluation, as this increases diagnostic sensitivity and helps determine intra-articular involvement 2, 3
• Do not manipulate the ankle before obtaining radiographs unless neurovascular compromise or critical skin injury is present 3

Important Diagnostic Considerations

• Initial radiographs have only 87% sensitivity for calcaneal fractures compared to CT, meaning fractures can be missed 7
• Calcaneal fractures are frequently overlooked in children and require careful attention to avoid missed diagnosis 6, 8
• 60% of pediatric calcaneal fractures are extra-articular, which differs from the adult pattern and may appear more subtle on radiographs 6

Advanced Imaging When Needed

• CT without IV contrast is essential if radiographs are equivocal, if there is high clinical suspicion despite negative radiographs, or if comminution or intra-articular involvement needs better characterization 7, 3
• CT can identify occult fractures involving the posterior facet that are not visible on plain films 7

Common Pitfalls to Avoid

• Missing the diagnosis entirely: Calcaneal fractures in children are rare and easily overlooked, requiring a high index of suspicion with appropriate mechanism and clinical findings 6, 8
• Failing to recognize urgent fracture patterns: Tongue-type and tuberosity avulsion fractures require intervention within 24 hours to prevent skin necrosis 3, 5, 4
• Relying solely on initial radiographs: If clinical suspicion remains high despite negative radiographs, proceed to CT imaging 7
• Inadequate immobilization: Even if radiographs are initially negative but clinical suspicion exists, immobilize and arrange follow-up imaging or orthopedic consultation 1

When to Refer to Pediatric Orthopedics

• Any confirmed calcaneal fracture warrants orthopedic consultation, as complex fractures and dislocations in children should be managed by pediatric orthopedic specialists 1
• Immediate referral (within 24 hours) is required for displaced fractures, tongue-type fractures, or any fracture with skin compromise 3, 5, 4
• Avulsion fractures of the calcaneal tuberosity are particularly rare in children and require urgent orthopedic management 5