Diagnosing Calcaneus Fracture in Children

Clinical Signs to Assess

The American College of Radiology recommends that 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 in children with suspected calcaneus fracture 1
Visible heel swelling, ecchymosis, or deformity should raise immediate concern, particularly for displaced fractures in pediatric patients 3
Skin compromise or impending skin breakdown over the heel requires urgent evaluation within 24 hours, especially with tongue-type or tuberosity avulsion fractures 3

Standard three-view foot radiographs (anteroposterior, lateral, oblique) should be obtained first, and an axial Harris-Beath view should be added specifically for calcaneal evaluation, as this increases diagnostic sensitivity and helps determine intra-articular involvement 2, 3
Initial radiographs have only 87% sensitivity for calcaneal fractures compared to CT, meaning fractures can be missed in children 4
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 3, 4

Failing to recognize urgent fracture patterns, such as tongue-type and tuberosity avulsion fractures, which require intervention within 24 hours to prevent skin necrosis 3
Relying solely on initial radiographs, as if clinical suspicion remains high despite negative radiographs, proceed to CT imaging 4
Inadequate immobilization, as even if radiographs are initially negative but clinical suspicion exists, immobilize and arrange follow-up imaging or orthopedic consultation 5

Any confirmed calcaneal fracture warrants orthopedic consultation, as complex fractures and dislocations in children should be managed by pediatric orthopedic specialists 6
Immediate referral (within 24 hours) is required for displaced fractures, tongue-type fractures, or any fracture with skin compromise 3