## Why Lumbar spine X-ray is correct A Böhler angle of 15° (normal 20–40°) indicates a calcaneal fracture from axial loading (fall from height). The SME anchor emphasizes that axial loading forces transmitted through the calcaneus are classically transmitted up the spine, resulting in lumbar spine fractures in approximately 10% of calcaneal fracture cases—the "Don Juan" or "Lover's fracture" association. This is a critical associated injury that must be actively screened for with imaging, as it can be life-threatening if missed. Apley's Orthopaedics mandates imaging of the lumbar spine in all calcaneal fractures from axial loading mechanisms. ## Why each distractor is wrong - **Pelvis X-ray and bilateral lower limb radiographs**: While associated lower limb and pelvic fractures do occur (and bilateral calcaneal fractures in ~10%), these are secondary screening priorities. The axial loading mechanism creates a specific, high-yield association with lumbar spine injury that takes precedence in the acute setting. - **CT scan of the foot with 3D reconstruction**: CT is essential for surgical planning (Sanders classification) but is not the *most important* additional imaging in the acute phase. Lumbar spine imaging must be obtained first to rule out life-threatening spinal injury. - **MRI of the ankle and subtalar joint**: MRI is not indicated in acute fracture management and does not address the critical associated injury (lumbar spine fracture) that the mechanism of injury demands. **High-Yield:** Calcaneal fracture from axial loading (fall from height) → always image lumbar spine; ~10% have concurrent lumbar fracture (Don Juan fracture). [cite: Apley 10e, Calcaneal Fractures section]
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