The patient was a 49-year-old male visiting Catalina Island when he suffered a fall from the back row of a concrete amphitheater. He described a fall of approximately ten feet, where he landed on the lateral aspect of his right heel on concrete ground. He then fell sideways and rolled through the rest of the fall. The patient described constant, severe, sharp pain in the right heel after the fall, which made him unable to ambulate at the scene without assistance. He could not put weight on the affected foot due to pain. He did not strike his head, nor did not lose consciousness, and he had no back pain. His review of systems was grossly unremarkable, except for pain in the posterior ankle and nausea when the pain was worst. His vital signs were unremarkable throughout his presentation. His medical, family, and social history were noncontributory.
Examination of the right ankle demonstrated a large deformity of the superior talus with bruising and blanching of the overlying skin in the area of the Achilles tendon (see images 2,3). The remaining bones of the foot were not tender to palpation and the foot was neurovascularly intact throughout with only mild numbness in the area of the tented skin. Completing the trauma exam, the patient had no signs of head injury and no midline spinal tenderness to palpation. Inspection of the remaining long bones and joints showed no other injuries. There were mild skin scrapes on the right flank from the fall. X-rays of the right foot and ankle showed a longitudinal fracture of the calcaneal tuberosity from the articular surface to the posterior surface (see red outline) with extension into the subtalar joint (blue lines) and roughly 1.8 cm displacement between the fracture segments (yellow double arrow). These findings represented a tongue-type calcaneal bone fracture.
Based on history, physical exam, and imaging, the diagnosis of tongue-type calcaneus fracture was made. A tongue-type calcaneal fracture is a longitudinal fracture that involves a portion of the articular surface and exits the calcaneal tuberosity posteriorly. The skin tenting, blanching, decreased sensation, and bruising suggested pressure from the fracture fragment on the skin was limiting perfusion and putting the tissue at risk of necrosis. This constellation of findings indicated a need for emergency surgery to preserve the tissue and limit complications. Since the patient was on an island at a critical-access emergency department (ED), resources were limited, with no orthopedic surgeons available to perform the surgery. To reduce pressure on the skin, the patient's lower leg was wrapped in bulky padding with anterior and posterior splints placed to hold the foot in plantarflexion. The patient was then endorsed to an orthopedic surgeon and airlifted by helicopter to a mainland hospital where he could be taken to the operating room immediately. On arrival, he was taken for emergent open reduction internal fixation (ORIF) of the right calcaneus to relieve the stress on the skin and align the tongue fragments using three orthopedic screws. The patient tolerated the procedure well with no complications. He was discharged one day after surgery, non-weightbearing on the right lower extremity. Unfortunately, the patient's post operative course was complicated by a fall in the shower which broke his original hardware, requiring two additional surgeries to repair. Fortunately, the patient recovered well after the third surgery, approximately 3 months after his original injury.