A 45-year-old male presents to the emergency department following a fall from a 15-foot scaffold onto his feet. Lateral foot X-ray is obtained. The angle marked **D** (Böhler angle) on the lateral calcaneus view measures 15°. Which of the following is the most appropriate next step in management of this patient's injury?

Explanation

## Why CT imaging of the foot and lumbar spine is correct A Böhler angle of 15° (normal 20–40°) indicates flattening of the calcaneal angle, which is pathognomonic for calcaneal fracture. The mechanism (fall from height with axial loading) and depressed angle confirm intra-articular fracture in this patient. According to Apley and Gray's Anatomy, calcaneal fractures are associated with lumbar spine fractures in ~10% of cases due to transmission of axial loading force up the spine. CT imaging is essential to: (1) classify the fracture using Sanders classification (which guides surgical vs non-operative decisions), (2) assess degree of articular comminution and displacement, and (3) screen for occult lumbar spine fracture. This imaging is mandatory before definitive management decisions. ## Why each distractor is wrong - **Immediate weight-bearing mobilization with ankle-foot orthosis**: Contraindicated in acute calcaneal fracture with depressed Böhler angle. Weight-bearing must be deferred until fracture healing is confirmed and management strategy (operative vs non-operative) is determined. Early weight-bearing risks displacement and poor functional outcome. - **Non-weight-bearing immobilization for 6–12 weeks followed by imaging of the lumbar spine**: While non-weight-bearing immobilization is appropriate for many calcaneal fractures, imaging of the lumbar spine must be done *before* or *concurrent with* initial management, not deferred to 6–12 weeks later. Occult lumbar fractures require early identification and appropriate stabilization. - **Percutaneous pinning of the calcaneus without further imaging**: Surgical intervention without CT classification is inappropriate. Sanders classification (based on CT) is the gold standard for determining whether operative or non-operative management is indicated. Proceeding to surgery without this imaging risks inappropriate surgical selection and complications (wound infection, sural nerve injury). **High-Yield:** Böhler angle <20° = calcaneal fracture until proven otherwise; always image the lumbar spine in calcaneal fracture due to 10% association with LSPINE fracture from axial loading. [cite: Apley 10e; Gray's Anatomy 42e Ch 84]