Demographics, Mechanisms of Injury, and Concurrent Injuries Associated With Calcaneus Fractures: A Study of 14 516 Patients in the American College of Surgeons National Trauma Data Bank. Share cases and questions with Physicians on Medscape consult. This website also contains material copyrighted by 3rd parties. (See also the previous image.). The presence of fluid in these locations, even when unilateral or asymmetric, does not necessarily imply underlying abnormality. [QxMD MEDLINE Link]. Calcaneus, fractures. Michael A Bruno, MD, MS, FACR is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging, Society of Skeletal RadiologyDisclosure: Received royalty from Oxford Press for book author/editor & reviewer; Received royalty from Elsevier Press for book author / editor. ), (For Essex-Lopresti fractures, see the images below. The goal of heel fracture surgery is to restore the shape of the heel bone as close to normal as possible. Calcaneal cysts are normal variants and should not be confused with pathology. Gltekin A, Acar E, Uur L, Yldz A, Serarslan U. Conventional radiography is the primary imaging modality in cases of suspected ankle fractures. The calcaneus is the heel bone. 2019 Nov 12. 2016 Nov 28. Is Bone Mineral Density Testing Underused in Prostate Cancer Care? Orthop Clin North Am. Study results are reproducible, and the images are easy to interpret. Bohler's angle is normally between 28-40 degrees. 2015. Lower tangential view also shows dense band of sclerosis (white arrow) Radiology of the foot and ankle, 2nd edition. ), (For Rowe type fractures, see the images below. There were spinal fractures (lumbar spine being the most common) in 23%. Calcaneus fractures may occur as a result of falls from heights or from twisting injuries or through a pathologic process such as osteoporosis, cysts, and tumors. Open reduction and internal fixation of associated fractures of the talus, navicular, calcaneus and cuboid was performed. Calcaneus fractures sanders type 3/4 were 9 times more prone to tendon injury ( <p 0.001; OR 8.67; . The extent of injury is easily underestimated by X-ray appearances. MRI is increasingly being used to characterize ankle sprains, occult fractures, bone bruises, growth-plate injuries, and ligamentous/tendon injuries. (For the axial [Harris]view, see the images below. [40] The injury is manifested by increased radionuclide uptake at the fracture site. This classification is based on the number of intraarticular fracture lines and their location on semicoronal CT images. From My Column on The Medical Blog Network-Patient Good Link for Lung radiology teaching files. [QxMD MEDLINE Link]. According to Lauge-Hansen, it is the result of an exorotation force on the pronated foot. J Orthop Surg Res. 2019 Feb. 477 (2):467-471. The first line is drawn from (1) - the upper edge of the calcaneal body posteriorly to (2) - the upper edge of the posterior articular facet of the calcaneus at the subtalar joint. For these same photos without the arrows, click here and here Anatomic resolution is better with MRI than with radionuclide imaging. 2022 Jul;304(1):50-62. They often appear as a band of low signal intensity that arises from the cortex of the bone and extends perpendicular to the surface of the bone. The main function of the calcaneus is to transfer the weight of the body to the ground, as well as to serve as a lever for the muscles of the calf. Chemic Young adult presented with lateral force injury and right nasal bone tenderness pictures show possible high fracture of right side better We live in an era where a scientist has to think about being politically correct. The main predisposing factors, clinical features, therapy, and outcome were recorded. Line 1 is made by connecting point 1 on the radiograph (the most cephalic part of the posterior process of the calcaneus bone) to point 2 (the most cephalic or highest point of the posterior facet). The articular involvement has been associated with a poor functional outcome. Powered by, Pediatric imaging and Sedation (Pedicloryl). RADIOGRAPHIC POSITIONING: Post-Test Examination Signs of pathology that are apparent on sonograms of soft tissue include articular effusion, fluid conglomeration, ossification, and the development of vascular lesions. Indian Medical Informatics News-Telemedicine link How Relevant are Peer Review Journals Nowadays? Technetium-99m diphosphonate bone scan depicts a stress fracture of the calcaneus, which was not apparent on plain radiographs. [QxMD MEDLINE Link]. Philadelphia, Pa: JB Lippincott;. cuboid by an interosseous ligament. 34(6):454-9. 2017 Jan. 48 (1):91-103. J Ultrasound Med. [9]. MRI also has a place in the investigation of ligamentous and tendon injury in association with calcaneus fractures. In the absence of a linear component, it may be difficult to distinguish an underlying severe stress reaction associated with a bone contusion from a stress fracture on MRI. In adults, detection of hyperemia is straightforward, but problems may arise in children, because in children, the uptake of radionuclide is often increased around the epiphyses; contralateral images are often needed for comparison. Clement H, Grechenig W, Peicha G, Grechenig S. [Ultrasound diagnosis in knee and foot trauma]. Dapagliflozin Reduces Hospitalizations in Patients With CKD, A Beach Drowning and Car Crash Rescue Back to Back, Falls in the Elderly: Causes, Injuries, and Prevention, Older Cancer Survivors Face Increased Risk for Bone Fracture, How to Prevent a Feared Complication After Joint Replacement. Calcaneus fracture - Axial (Same patient as image above) On the axial view look for fracture lines and breaks in the cortex Calcaneus fracture - Normal Bohler's angle - Lateral Hover on/off image to show/hide findings Calcaneus fracture - Normal Bohler's angle - Lateral Not all fractures of the calcaneus result in reduction of Bohler's angle This normal variantan unfused secondary ossification centermust not be mistaken for a calcaneal fracture. theYear=now.getFullYear() Color Doppler imaging showed local hypervascular changes of the periosteum in all patients. Various anatomic variants in the calcaneus may mimic fractures. [1] They account for 1-2% of all fractures of the body, with the majority involving the subtalar joint (about 75%) and the calcaneocuboid joint (about 68%). In particular, real-time ultrasonography may be performed to assess dynamic stability. In: Rockwood CA Jr, Green DP, eds. Axial radiograph shows soft tissue swelling with amorphous calcification. Most calcaneal fractures (70%-75%) are intraarticular and result from axial loading that produces shear and compression fracture lines. [QxMD MEDLINE Link]. 14 (1):359. [20, 21, 14, 22, 23], Zelle et al identified several sociodemographic factors influencing the utilization of surgical treatment of calcaneus fractures in the US patient population. [15]. [31] Radiographs of the dorsal and lumbar spine are also often indicated, because an associated fracture is seen in a vertebral body in 10% of all patients. This is a chest CT image of a young male with fever, recurrent cough. It exposes the patient to a modest radiation dose. J Orthop Trauma. J Foot Ankle Surg. It usually occurs when a person lands on their feet following a fall from a height or during a motor vehicle collision. Heel bones are often injured in a collision where other skeletal parts sustain injury as well. The Bohler angle may also be decreased in some calcaneus fractures that do not involve the subtalar joint. The degree of confidence is high, because the diagnosis of stress fracture may be reliably excluded when bone scans are normal. Calcaneus, fractures. Isolated anterior process fractures account for approximately 15% of all cal-caneal fractures and are often overlooked and misdiagnosed as ankle sprains [1, 2]. This view also demonstrates avulsion fractures of the anterior lateral aspect of the calcaneus. 2003 Jun. J Emerg Med. Note loss of the crucial angle of Gissane. Your physician will discuss your treatment options and create a treatment plan that is best for you. [QxMD MEDLINE Link]. Normal variants, complications, and differential diagnosis. J Foot Ankle Surg. Scintigraphy may be useful in occult fractures and in the differential diagnosis of pathologic fractures. Privacy Policy, Dr Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist -. The contrast material then descends behind the lateral malleolus. Older children are more likely to have intra-articular . Overuse injury seen in athletes, especially with running and aerobics, and military recruits. - AP Oblique projection (lateral rotation) What procedural compensation is required for the plantodorsal axial projection of the calcaneus when the patient cannot dorsiflex the foot sufficiently to place the plantar surface vertical? Fractures to the anterior process of the calcaneus : Clinical results following functional . J Nucl Med. Calcaneal fracture When a calcaneal fracture is suspected, both an axial and lateral image should be made. New Hall Hospital, Salisbury, Wiltshire, UK, SP5 4EY. Orthop Clin North Am. The calcaneus functions as a lever arm for the gastrocsoleus complex, providing a foundation or vertical support for one's body weight and providing support for and maintaining the lateral column of the foot. MRI is the criterion standard for identifying peroneal tendon injury. Sanders Classification of Calcaneal Fractures Use coronal image with the widest undersurface of the posterior facet of the talus. Calcaneal fracture rep-resents 60% offractures of the tarsal bones. A flat Bohler angle is associated with intra-articular fractures; in such cases, the prognosis is poorer than it is in cases in which the angle is maintained. Osteomyelitis, calcaneonavicular bars, osteoarthritis, erosive arthritis, tumors, and pathologic fractures may have an appearance similar to that of fractures on scintigraphy. Injury. ILD is one of the most difficult topics for the residents to understand. Conventional radiography is inexpensive and is universally available. The Sanders classfiication system is the one most widely used. This patient presented following trauma to the calcaneus. Because these injuries are associated with a poor prognosis, it is important to identify patients with these fractures. Old calcaneal fracture. Therefore, in the appropriate clinical setting, CT may be skipped, and either MRI or bone scanning may be performed. A calcaneal stress fracture is one or more tiny breaks in your heel bone (calcaneus). Rowe type V, intra-articular calcaneal fracture. 2011 Jan-Feb. 31(1):81-92. This patient presented following trauma to the calcaneus. 2015 Feb. 56 (2):190-5. Falling from height can lead to severe calcaneal fractures, which may be accompanied by axial loading fractures of the spine. From a radiographic perspective, the calcaneus is a relatively difficult bone to visualize in its entirety. Buckingham R, Jackson M, Atkins R. Calcaneal fractures in adolescents. Approximately 75% of calcaneus fractures are intra-articular and involve the subtalar articular surface. Study the course material in the free to access tutorials and galleries sections - then sign up to take your course completion assessment. Pathologies associated with edema include osteomyelitis and neoplasm. The presence of a lateral malleolarfleck sign suggestsperoneal tendon instability. Epidemiology. [11, 12] This classification is the one used most frequently today in treatment decision making and reporting of results. (Read bio). Zelle BA, Morton-Gonzaba NA, Adcock CF, Lacci JV, Dang KH, Seifi A. Healthcare disparities among orthopedic trauma patients in the USA: socio-demographic factors influence the management of calcaneus fractures. Line 2 is created by connecting point 2 on the radiograph (the most cephalic or highest point of the posterior facet of the calcaneus bone) to point 3 (the highest point of the calcaneus bone that forms the articular surface for the cuboid bone). Essex-Lopresti depression-type calcaneal fracture. PubMed. These images are obtained by internally rotating the foot 45, with the heel resting on the radiographic plate; the beam is directed cephalad in angles varying from 10 to 40. Calcaneus, fractures. Comminuted fractures with fragment displacement of the calcaneus are common, and the relationship of the multiple fragments is difficult to appreciate on conventional radiographs. The fourth articular facet articulates with the cuboid of the midfoot. Modified Essex-Lopresti procedure with percutaneous calcaneoplasty for comminuted intra-articular calcaneal fractures: a retrospective case analysis. Calcaneus, fractures. Coronal and axial views are generally obtained. 24 (10), 2003, 744-53. . [QxMD MEDLINE Link]. [Full Text]. Its sensitivity is higher than that of plain radiography. J Bone Joint Surg Am. MRI is highly sensitive for the detection of bone marrow changes. 2009 Mar-Apr. Nazarian LN, Rawool NM, Martin CE, Schweitzer ME. 2004 May. [39]. [QxMD MEDLINE Link]. [35]. MRI findings may be positive within 24 hours of the onset of symptoms. It is noteworthy that CT tends to be somewhat overutilized in the United States. CT is the modality of choice for calcaneus fractures. [6, 7, 8, 9, 10], The Essex-Lopresti classification system consists of 2 types of fractures: (1) joint-depression type with a single vertical fracture line through the angle of Gissane separating the anterior and posterior portions of the calcaneus; and (2) tongue type, which has the same vertical fracture line as a depression type but with another horizontal fracture line running posteriorly, creating a superior posterior fragment. Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Association for the Advancement of Science, American Institute of Ultrasound in Medicine, British Medical Association, Royal College of Physicians and Surgeons of the United States, British Society of Interventional Radiology, Royal College of Physicians, Royal College of Radiologists, Royal College of Surgeons of EnglandDisclosure: Nothing to disclose. [30] ; however, in most cases, supplemental imaging is needed to define characteristics fully, because of the complex anatomy of this region. Knight JR et al. The incidence of partial rupture of the peroneal tendons in the chronic group was approximately one third that in the acute group, but the low incidence of complete tendon rupture remained unchanged. The unfused secondary ossification center for calcaneal tuberosity may produce a simulated fracture. Methods: We retrospectively reviewed clinical charts and imaging findings for 6 patients with 7 IF of the calcaneus who were referred with the diagnosis of ankle arthritis. [1], According to a study based on data from the American College of Surgeons National Trauma Data Bank (NTDB), of 14,516 patients with calcaneous fractures, concurrent injuries were present in 11,137, with associated lower extremity fractures being present in 61% (the most common of which were other foot and ankle fractures). Soft tissue injuries include subluxation or dislocation of the peroneal tendons from the fibular sulcus, entrapment of neurovascular bundle, and interposition of the flexure hallucis longus tendon between bone fragments from sustentaculum tali. [Full Text]. However, MRI is often useful in patients with suspected stress fractures, particularly those with severe osteoporosis in whom skeletal scintigraphy may produce false-negative findings as a result of generalized poor uptake of tracer (see the images below). Chen MY et al. Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, International Skeletal Society, Radiological Society of North AmericaDisclosure: Nothing to disclose. Calcaneal fractures have characteristic appearances based on the mechanism of injury . [QxMD MEDLINE Link]. These fractures may remain undiagnosed clinically, as there may be no obvious deformity. Are Children With Atopic Dermatitis More Likely to Fracture Bones? Stress fractures are associated with hyperemia in the first 2 phases of the 3-phase bone scan. [QxMD MEDLINE Link]. JW Leabhart. Confidence in the imaging findings is usually high in a patient who is believed on clinical grounds to have a stress fracture. Login or register to get started. Boehler's angle and the critical angle of Gissane are of limited use in diagnosing calcaneous fractures in the ED. From this point another line is drawn to (3) - the upper edge of the anterior process of the calcaneus. Radiography versus computed tomography for displacement assessment in calcaneal fractures. Lateral and axial radiographs demonstrate a Rowe type II calcaneal fracture. Calcaneus, fractures. 60 (6), 1953, 850-4. Gotha HE, Zide JR. Current Controversies in Management of Calcaneus Fractures. Keywords Calcaneal fractures Three orthopedic surgeons and 1 senior orthopedic resident reviewed the scans and classified the fractures. On a lateral view this angle is formed by the intersection of two lines. Davis D, Seaman TJ, Newton EJ. Lorenz Bohler described the tuber-joint angle (the so-called Bohler angle). CT scans of 50 acute calcaneus fractures were compared with scans of 77 fractures in which the date of injury preceded the CT study by 6 months or more. Normal variants, complications, and differential diagnosis. Calcaneus, fractures. Radiology. Radiographic and CT Assessment of Reduction of Calcaneus Fractures Using a Limited Sinus Tarsi Incision. The Journal of Bone and Joint Surgery; Vol L. 41-A, NO. Key Points: Fractures of the pediatric calcaneus are rare injuries and are frequently missed. Conventional radiographs provide a benchmark for the diagnosis of fractures around the ankle in general, and they usually suffice for the diagnosis of the osseous component of the injury Foot Ankle Int. References: The investigators found that 42 of the fractures (84%) in the acute group and 55 in the chronic group (71%) were classified as intra-articular; these fractures formed the basis of the study. In cases of stress fractures, a well-defined cortical discontinuity is suggestive of a fracture. Traumatic bone marrow lesions (TBMLs) are considered to represent a range of concealed bone injuries, including haemorrhage, infarction, and localised oedema caused by trabecular microfracture occurring in the cancellous bone. Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies and recent developments. The most common etiology is a forceful axial load to the hindfoot, frequently occurring during a fall. [QxMD MEDLINE Link]. Calcaneus Fractures - Trauma - Orthobullets orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports If the angle is reduced, a calcaneal fracture is present; however, a normal angle does not exclude a calcaneal fracture. Brunner et al conducted a study to evaluate the impact of 3-dimensional (3D) CT volume rendering on the interobserver and intraobserver reliability of 6 commonly used classification systems in the assessment of calcaneal fractures. On MRI, stress fractures typically appear as areas of low signal intensity on T1- and T2-weighted images. The most common mechanism asso-ciated with this type of injury is inversion of . Calcaneus, fractures. 2008 Apr. Snoap T, Jaykel M, Williams C, Roberts J. Calcaneus Fractures: A Possible Musculoskeletal Emergency. (See the images of calcaneus fractures below.). . Fracture characterization is essential to guide the management of these injuries. et al. CT is the modality of choice, especially in complex fracture patterns, although it is expensive and it imparts a relatively high dose of radiation; it should be used sparingly in young patients or in pregnant patients. In addition, 18% had concurrent head injuries and 15% concurrent thoracic organ injuries. Fibulasmaller bone in the lower leg. Radiography may be the only modality required, though it is not always capable of depicting the relationship of bone fragments to the joint and to each other. 48 (2):156-62. Calcaneus fractures are divided into intra-articular and extra-articular fractures based on involvement of the subtalar joint. The weighted kappa value was 0.48, with a 95% CI of 0.37-0.59. Rowe type V calcaneal fracture. 2014 Sep. 97 Suppl 9:S1-9. Calcaneus, fractures. 2018 Feb. 37 (2):521-529. Angthong C, Atikomchaiwong A, Yoshimura I, Kanazawa K, Hamrnroongroj T, Angthong W, et al. J Am Acad Orthop Surg. 25(2):183-201, vi. Michael A Bruno, MD, MS, FACR Professor of Radiology and Medicine, Pennsylvania State University College of Medicine; Director, Radiology Quality Management Services, The Penn State Milton S Hershey Medical Center 1991. [24], CT imaging is the investigation of choice in calcaneus fractures. Trauma to the calcaneus and its tendon. CT best defines the relationship of bone fragments. Axial (Harris) view. A thorough understanding of the pathoanatomy and potential complications of calcaneal fractures also helps radiologists in tailoring the radiology report in contribution to overall patient's management and prognostication. In a retrospective study at a single level 1 trauma center of 120 consecutive ankle radiographs for ankle injuries but normal bone anatomy the mean +/- SD of Bohler's angle was 30 +/- 6 degrees (range, 14 to 50 degrees), no differences between gender, no differences between right or left ankles and found that if 28 degrees was taken as cut off there would be a 31% false positive rate, 20 degrees would create a 2.5% false positive rate, and if 18 degrees was the cut off would give < 1% false positives. and the surrounding edema (white arrows)in another patient. Linsenmaier U, Brunner U, Schning A, et al. Attend the weekly diabetic MDT meeting to discuss management of diabetic feet infections with Microbiology & Radiology consultants as well as lead Pharmacist. Bone scintigraphy is typically utilized in cases in which radiographic and CT findings are negative for suspected fractures (see the image below). However, compared with MRI or bone scanning, CT has low sensitivity for stress reactions and fractures; this leads to a high rate of false-negative results. Dr Graham Lloyd-Jones BA MBBS MRCP FRCR - Consultant Radiologist - Stress fractures may take up to 7-14 days to appear on conventional radiographs. You're also more likely to get a stress fracture if you suddenly and significantly increase your activity levels. J Emerg Med. Fat-suppressed sequences are sensitive to bone marrow edema, which accompanies bone bruises and stress fractures. Calcaneal Stress Fractures. encoded search term (Calcaneus Fracture Imaging) and Calcaneus Fracture Imaging. Page author: Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, University of Washington School of Medicine Axial (Harris) view demonstrates a calcaneal fracture. ), (Normal variants of calcaneus fractures are shown in the images below. [3] In adults, about 75% of calcaneal fractures are intra-articular. [QxMD MEDLINE Link]. Oblique views (ie, the Broden view) can define incongruity of the subtalar joint. Calcaneus, fractures. All courses are CME/CPD accredited in accordance with the CPD scheme of the Royal College of Radiologists - London - UK. Swords MP, Alton TB, Holt S, Sangeorzan BJ, Shank JR, Benirschke SK. Further fractures of the tibia and fibula are seen in 9% of patients. The sustentaculum tali can produce a simulated fracture on the superior margin on lateral views. [QxMD MEDLINE Link]. An increasing number of studies are using artificial intelligence (AI) techniques to . Bohl DD, Ondeck NT, Samuel AM, Diaz-Collado PJ, Nelson SJ, Basques BA, et al. 7, Oct 1959, Overuse injury seen in athletes, especially with running and aerobics, and military recruits, Most stress fractures are in lower extremities, Increasing pain in the heel with exercise or activity, Tenderness to palpation over outer aspects of the heel, Stress fractures may take up to 7-14 days to appear on conventional radiographs, Most occur in posterior half of calcaneus, Vertically oriented zone of increased density on lateral radiograph, Usually oriented parallel to the curve of the posterior calcaneus, Fracture line usually disappears by 6 weeks, Radionuclide bones cans may be positive (increased uptake) within 72 hours, Surrounding marrow edema will show high signal, May be particularly helpful in setting of marked osteoporosis, Heel pain may clinically be caused by plantar fasciitis, Avoiding aggravating activities like running for 4-8 weeks, For more information, click on the link if you see this icon. Unfair comments in the Press About Mammography int MRCP at 3.0 Tesla and 1.5 Tesla- A comparison, What is new in the Medical Imaging Research. Biopsy proved a malignant synovioma. About 60% of calcaneal. Klaus L Irion, MD, PhD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North AmericaDisclosure: Nothing to disclose. Many pathologies can cause bone marrow edema; in patients with a history of trauma, the presence of edema may lead to an incorrect diagnosis of fracture. This is a comminuted fracture involving the subtalar joint; it has a central depression. Conventional radiographs may be negative in cases involving subtle fractures, particularly in cases involving stress fractures. 2009 Oct. 30(10):1005-10. Think about it. Calcaneal fractures represent about 1-2% of all fractures and 60% of the tarsal bones fractures. Other classifications exist, such as Essex-Lopresti, AO-ICI, Zwipp, and Crosby. Scintigraphy is sensitive in imaging bone trauma but lacks the specificity and the spatial resolution that MRI provides. Talussmall foot bone that works as a hinge between the tibia and the fibula. Aspiration of the injected contrast material following use of a local anesthetic may relieve pain and help determine the source of the pain. But test results provide little insight into how he died King Tut wasn't murdered by a blow to the head, nor was his chest crushed i NBE has introduced FNB for Interventional Radiology, Breast imaging and Body Imaging. 2016 Sep. 37 (9):950-7. Essex-Lopresti depression-type calcaneal fracture. Prominent trabeculation can simulate a fracture on plain radiographs and CT scans. [QxMD MEDLINE Link]. These fractures are complicated by a compartment syndrome in 10% of cases, with half of these involving development of clawing of the lesser toes or other chronic problems, such as stiffness and neurovascular dysfunction. Bone contusions are also well depicted on MRI. [25, 1, 26] Coronal and axial views are generally taken. Essex-Lopresti describes 2 fracture types involving the subtalar joint. Sanders R, Hansen ST, McReynolds IS. Calcaneus, fractures. Note the fracture line divides the calcaneus into anteromedial and posterolateral fragments. Achilles tendonitis calcification is a differential diagnosis in cases of suspected calcaneal fracture. Orthop Clin North Am. 2013 Dec. 45 (6):879-84. Foot Ankle Int. Radiology Masterclass, Department of Radiology, Severe calcaneus fractures often result in loss of Bohler's angle, Calcaneus fracture often result from falling from height but may be due to more trivial injury, Bohler's angle is normal (39 in this case), Flattening of Bohler's angle (18 in this case), Depression of the articular surface of the posterior subtalar joint (, Fracture lines can be seen passing through the calcaneus. [QxMD MEDLINE Link]. This results in a reduction of 'Bohler's angle'. Calcaneus, fractures. Furey evaluated 30 calcaneus fractures to assess the degree of interobserver variability by using the Sanders classification system and found that the Sanders classification system achieved moderate agreement among users and was thus useful. Stress fractures may take longer to become evident on radionuclide bone scans, particularly in patients with osteoporosis. Repeat CT scanning is not an attractive alternative, though it may result in the correct diagnosis because of interval development of necrosis. Multidetector CT evaluation of calcaneal fractures. In patients with severe osteoporosis, the level of tracer uptake by the bone may be too low, and false-negative results may be produced. 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