The Journal of Foot & Ankle Surgery 53 (2014) 279–281
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Association of Calcaneal and Spinal Fractures Jeremy L. Walters, DPM 1, Paula Gangopadhyay, DPM 2, D. Scot Malay, DPM, MSCE, FACFAS 3 1
Resident, West Houston Medical Center, Houston, TX Resident, Penn Presbyterian Medical Center, Philadelphia, PA 3 Director of Podiatric Research and Staff Surgeon, Penn Presbyterian Medical Center, Philadelphia, PA 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 2
Calcaneus fractures are common injuries that often lead to chronic pain and long-term disability. Appropriate initial management of calcaneal fractures involves assessment for concomitant trauma (polytrauma), and the vertebral column, in particular, the lumbar spine, is known to be especially vulnerable to simultaneous injury when the os calcis has been fractured. We undertook a retrospective cohort study that included 208 consecutive patients with data recorded in a radiographic database to determine the incidence of concomitant vertebral fracture in association with fracture of the calcaneus. A total of 15 calcaneal fractures (7.21%) were associated with concomitant vertebral fracture, and the lumbar spine was involved in 12 (80%) of these cases. The only clinical variable that was statistically significantly associated with the presence of concomitant calcaneal and vertebral fracture was localization of the vertebral fracture to the lumbar spine (p ¼ .0001). The results of our investigation have indicated that the incidence of concomitant calcaneal and vertebral fractures was significantly lower clinically than the traditional 10% association described in previous studies. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: calcaneus injury lumbar spine os calcis polytrauma vertebral fracture
In 1856, Malgaigne (1) described intra-articular fractures of the calcaneus, although a full appreciation of this injury was not available until the early 20th century with the advent of radiography. One of the most frequently cited statistics associated with calcaneal fractures has been that a lumbar fracture will coexist in approximately 10% of the cases (2–10). In 1962, Lance et al (2) described 205 fractures of the os calcis in which they observed 21 concomitant spinal fractures (10.24%), all but 3 of which were localized to the lumbar spine. Rowe et al (3) followed with a review of 146 fractures of the os calcis and noted the occurrence of an associated spinal fracture in 15 of the cases (10.27%). In 1966, Wilson (4) reported 10 concomitant spinal fractures (22.22%) in a cohort of 45 calcaneal fractures. Since those reports were published, a paucity of published research results have described the incidence of spinal fracture associated with calcaneal fracture. The annual prevalence of calcaneal fracture has been reported to be 11.5 per 100,000 persons, and the most common (71.5%) etiology for fracture of the os calcis has been a fall from a height (10). The aim of the present retrospective cohort study was to determine the incidence of vertebral fracture with a concomitant calcaneus fracture. Our secondary aim was to explain the association of these conditions.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jeremy L. Walters, DPM, West Houston Medical Center, 12121 Richmond Avenue, Suite 417, Houston, TX 77082. E-mail address: [email protected] (J.L. Walters).
Patients and Methods We hypothesized that the incidence of concomitant vertebral fracture occurring in association with fracture of the calcaneus would actually be lower than what has traditionally been reported in published studies, which has been reported to range from approximately 10% (2,3) to approximately 22% (4). To investigate this, we undertook a retrospective cohort study using an online radiology database at a level 1 trauma center and an urban community hospital. We used the Pathology-Radiology Enterprise Search Tool, a database containing greater than 14 million radiology reports from the University Pennsylvania Health System. The Pathology-Radiology Enterprise Search Tool can be used to search radiology reports for keywords and will chronologically display the full report with an accession number, and all vulnerable health information is protected. The inclusion criteria for our cohort consisted of consecutive calcaneal fractures identified by standard radiographic examination, computed tomography, or magnetic resonance imaging and confirmed by a board-certified musculoskeletal (MSK) radiologist from August 2008 to September 2012. The only exclusion criterion was a pre-existing spinal and/or calcaneal fracture. Using the search terms “calcaneal fracture” and “calcaneus fracture,” 220 consecutive potentially eligible patients were identified (Fig. 1), of whom 12 were excluded. These 12 patients were excluded from our investigation because their injury had been falsely identified as a calcaneal fracture in the initial radiology resident’s report and, subsequently, in the attending radiologist’s report addendum, determined not to represent a fracture of the calcaneus. For each of the 208 patients included in the analyses, we reviewed all the associated records in an effort to identify the presence of a concomitant acute vertebral fracture (Fig. 2), the level of vertebral fracture, and any other acute fracture (axial or appendicular), or infragenicular soft tissue trauma, regardless of whether additional spinal imaging had been obtained. If spinal imaging was not procured at any point for a patient, the case was considered negative for a spinal fracture. The following independent variables (e.g., exposures, risk factors) were considered in regard to their association with concomitant calcaneal and vertebral fractures (the outcome): patient gender, etiology of the fractures (i.e., fall from a height, motor vehicle accident, other known trauma, unknown), calcaneal fracture characteristics (intra- or extra-articular, unilateral or bilateral, open
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.01.012
280
J.L. Walters et al. / The Journal of Foot & Ankle Surgery 53 (2014) 279–281
Fig. 1. Coronal computed tomography scan of joint depression fracture of calcaneus in a patient with a concomitant lumbar spine fracture.
Fig. 2. Concomitant lumbar (L3) spinal fracture in a patient with a concomitant joint depression calcaneal fracture (Greenfield caval filter also noted).
or closed), the presence of other nonvertebral fracture (of the upper or lower extremity or the axial or appendicular skeleton), and the spinal level of the vertebral fracture (e.g., cervical, thoracic, lumbar, or sacral). The data were transferred to a microcomputer and analyzed by one of us (D.S.M.) using StataÒ, version 9.2 (StataCorp, College Station, TX). The incidence of concomitant calcaneus and vertebral fractures was calculated, and the Kruskal-Wallis equality-of-populations rank test and Spearman’s rank correlation and logistic regression analysis were used to test the association between independent variables, alone and combined, and concomitant calcaneal and vertebral fractures. Statistical significance was defined at the 5% (p .05) level.
conditions was low, and in no case was a soft tissue injury reported in conjunction with a vertebral fracture. Use of the Kruskal-Wallis equality-of-populations rank test and Spearman’s rank correlation and logistic regression analysis revealed the only statistically significant association between an independent variable (exposure) and concomitant vertebral and calcaneal fractures to be localization of the vertebral fracture in the lumbar spine (Kruskal-Wallis c2, p ¼ .0001).
Results Discussion Using our inclusion criteria, 208 consecutive calcaneal fractures were available for the analyses used in the present retrospective cohort study, and 15 (7.21%) of the 208 calcaneal fractures were associated with a concomitant spinal fracture, 12 (5.77%) of which were localized to the lumbar spine and 3 (1.44%) to the thoracic spine. All the calcaneal fractures associated with a concomitant vertebral fracture were unilateral and closed, with intra-articular (86.67%), male gender (80%), lumbar spine (80%), isolated calcaneal fracture (66.67%), and a fall from a height (46.67%) the most prevalent associations. Only the association with a lumbar fracture was clinically (80%) and statistically (p .05) significant. Table lists the prevalence of the various exposures with the outcome, namely concomitant calcaneal and vertebral fractures. Of the 15 cases with the outcome, 12 (80%) involved males, and the most common (46.67%) etiology was a fall from a height, followed by a motor vehicle accident (26.67%). A total of 14 of the calcaneal fractures (86.67%) were intra-articular; all were unilateral, and no open fractures were present. Of the vertebral fractures were localized to the lumbar spine, and 3 fractures (20%) were localized to the thoracic spine, and 1 (6.67%) involved the thoracic and lumbar segments. When we considered adjunct ankle ligament (n ¼ 1), peroneal tendon (n ¼ 2), and other (n ¼ 1) infragenicular soft tissue injuries occurring concomitantly with the calcaneal fracture, the prevalence of these
The present investigation into concomitant calcaneal and vertebral fractures involved one of the largest calcaneal fracture data sets to date and focused on information not recently explored. From a limited number of studies and what has become a generally accepted surgical understanding, calcaneal fractures are known to coexist with spinal fractures; however, the results of our investigation have suggested that the incidence of this association could be significantly less clinically than what has traditionally been reported (7.21% compared with approximately 10% to 22%). Moreover, our findings have shown that when concomitant calcaneal and vertebral fractures occurred, the lumbar spine was the most prevalent level of spinal involvement (80% of cases, p ¼ .0001), and this finding reinforced the generally known association between calcaneal and spinal fractures. As with most retrospective cohort studies, a number of shortcomings were present that could be considered threats to the validity of our conclusions. First, potential biases were present related to the entry of data into the Pathology-Radiology Enterprise Search Tool database, a lack of information (spinal radiographs), and other ascertainment biases. For instance, the protocol for evaluation of bone and joint imaging at our institution has been that all films should be evaluated by an MSK fellow or resident and then by the attending MSK radiologist, who dictates the final report. Thus, the diagnosis of
J.L. Walters et al. / The Journal of Foot & Ankle Surgery 53 (2014) 279–281
Table Prevalence of exposures with concomitant calcaneal and vertebral fractures (n ¼ 15 of 280 calcaneal fractures) Risk Factor (exposure) Gender Male Female Etiology Fall from a height Motor vehicle accident Other known trauma Unknown Subtalar joint involvement Intra-articular Extra-articular Other calcaneal fracture feature Unilateral fracture Open fracture Other fracture present None Lower extremity Upper extremity Axial skeleton Location of vertebral fracture Cervical Thoracic Lumbar Sacral Lumbar þ thoracic
n (%) 12 (80) 3 (20) 7 4 3 1
(46.67) (26.67) (20) (6.67)
13 (86.67) 2 (13.33) 15 (100) 0 10 3 1 1
(66.67) (20) (6.67) (6.67)
0 3 (20) 12 (80) 0 1 (6.67)
all fracture pathology used in our investigation, whether osseous or soft tissue, was determined solely from the board-certified MSK radiologist’s final report. In addition, it is conceivable that some calcaneal fractures went undiagnosed, because of the patient’s initial presentation and the problem-focused examination performed by the emergency department physician on a patient without polytrauma. Also, it was unlikely that a vertebral fracture went undiagnosed, because most emergency department physicians will obtain lumbar films when managing calcaneal fractures caused by high-energy trauma. Therefore, we considered the absence of spinal imaging as negative for vertebral fracture, which imparted a bias to our investigational method that could have prejudiced our findings toward a lower incidence of concomitant calcaneal and spinal fractures. Still further, another potential bias to consider was that numerous diagnoses of infragenicular soft tissue pathologic features were
281
analyzed using standard radiographs, instead of magnetic resonance imaging or computed tomography scanning, and this could have led to an underestimation of the overall incidence of soft tissue injury in our sample population. Thus, our analyses could have skewed the results toward a lower incidence of concomitant calcaneal and vertebral fractures with lower extremity soft tissue pathologic features. A strength of our study was the use of data from both a level 1 trauma center and an urban community hospital, which we believe contributed to the generalizability. In conclusion, the incidence of concomitant calcaneal and vertebral fractures was 7.21% in our study, and the lumbar spine was involved in 80% of these cases. Our research has indicated that previous studies reported a greater incidence of the coexistence between calcaneal and spinal fractures, which could possibly have resulted from a greater portion of polytrauma patients in previous studies. The present investigation, one of the largest to date, offers an update on a topic that, to our knowledge, has not been quantitatively studied for nearly 50 years. It is clear from our data that a well-designed prospective study could help further refine emergency department evaluations of patients with and without polytrauma who present with suspected calcaneal and/or lumbar spine injuries. References 1. Malgaigne JF. Die Knochenbr uche und Verrenkungen, Rieger, Stuttgart, 1856, pp. 810–816. 2. Lance E, Wade EC. Factures of the os calcis: a follow-up study. Proceedings of the 22nd Annual Session of the American Association for the Surgery of Trauma, Hot Springs, VA, October 29–31, 1962. 3. Rowe CR, Sakellarides H, Freeman P. Fractures of os calcis: a long-term follow-up study of one hundred forty-six patients. JAMA 184:920–923, 1963. 4. Wilson DW. Functional capacity following fractures of the os calcis. J Can Med Assoc 95:908–911, 1966. 5. Cohen M. Calcaneal fractures. In: McGlamry’s Comprehensive Textbook of Foot Surgery, ed 3, p. 1821, edited by AS Banks, MS Downey, DE Martin, SJ Miller, JB Lippincott, Philadelphia, 2001. 6. Sanders R, Clare M. Fractures of the calcaneus. Surgery of the Foot and Ankle, ed 6, vol 1, p. 3846, edited by RA Mann, MJ Coughlin, Mosby-Year Book, St. Louis, 1993. 7. Marti R. Fractures of the calcaneus. In: Fractures in Children, pp. 256–257, edited by BG Weber, C Brunner, Thieme, Stuttgart, 1979. 8. Schmidt TL, Weiner DS. Calcaneal fracture in children. Clin Orthop 171:150–155, 1982. 9. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures. J Bone Joint Surg Am 84-A:1733–1744, 2002. 10. Mitchel MJ, McKinely JC, Robinson CM. The epidemiology of calcaneal fractures. Foot 19:197–200, 1994.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Association of Calcaneal and Spinal Fractures Jeremy L. Walters, DPM 1, Paula Gangopadhyay, DPM 2, D. Scot Malay, DPM, MSCE, FACFAS 3 1
Resident, West Houston Medical Center, Houston, TX Resident, Penn Presbyterian Medical Center, Philadelphia, PA 3 Director of Podiatric Research and Staff Surgeon, Penn Presbyterian Medical Center, Philadelphia, PA 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 2
Calcaneus fractures are common injuries that often lead to chronic pain and long-term disability. Appropriate initial management of calcaneal fractures involves assessment for concomitant trauma (polytrauma), and the vertebral column, in particular, the lumbar spine, is known to be especially vulnerable to simultaneous injury when the os calcis has been fractured. We undertook a retrospective cohort study that included 208 consecutive patients with data recorded in a radiographic database to determine the incidence of concomitant vertebral fracture in association with fracture of the calcaneus. A total of 15 calcaneal fractures (7.21%) were associated with concomitant vertebral fracture, and the lumbar spine was involved in 12 (80%) of these cases. The only clinical variable that was statistically significantly associated with the presence of concomitant calcaneal and vertebral fracture was localization of the vertebral fracture to the lumbar spine (p ¼ .0001). The results of our investigation have indicated that the incidence of concomitant calcaneal and vertebral fractures was significantly lower clinically than the traditional 10% association described in previous studies. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: calcaneus injury lumbar spine os calcis polytrauma vertebral fracture
In 1856, Malgaigne (1) described intra-articular fractures of the calcaneus, although a full appreciation of this injury was not available until the early 20th century with the advent of radiography. One of the most frequently cited statistics associated with calcaneal fractures has been that a lumbar fracture will coexist in approximately 10% of the cases (2–10). In 1962, Lance et al (2) described 205 fractures of the os calcis in which they observed 21 concomitant spinal fractures (10.24%), all but 3 of which were localized to the lumbar spine. Rowe et al (3) followed with a review of 146 fractures of the os calcis and noted the occurrence of an associated spinal fracture in 15 of the cases (10.27%). In 1966, Wilson (4) reported 10 concomitant spinal fractures (22.22%) in a cohort of 45 calcaneal fractures. Since those reports were published, a paucity of published research results have described the incidence of spinal fracture associated with calcaneal fracture. The annual prevalence of calcaneal fracture has been reported to be 11.5 per 100,000 persons, and the most common (71.5%) etiology for fracture of the os calcis has been a fall from a height (10). The aim of the present retrospective cohort study was to determine the incidence of vertebral fracture with a concomitant calcaneus fracture. Our secondary aim was to explain the association of these conditions.
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jeremy L. Walters, DPM, West Houston Medical Center, 12121 Richmond Avenue, Suite 417, Houston, TX 77082. E-mail address: [email protected] (J.L. Walters).
Patients and Methods We hypothesized that the incidence of concomitant vertebral fracture occurring in association with fracture of the calcaneus would actually be lower than what has traditionally been reported in published studies, which has been reported to range from approximately 10% (2,3) to approximately 22% (4). To investigate this, we undertook a retrospective cohort study using an online radiology database at a level 1 trauma center and an urban community hospital. We used the Pathology-Radiology Enterprise Search Tool, a database containing greater than 14 million radiology reports from the University Pennsylvania Health System. The Pathology-Radiology Enterprise Search Tool can be used to search radiology reports for keywords and will chronologically display the full report with an accession number, and all vulnerable health information is protected. The inclusion criteria for our cohort consisted of consecutive calcaneal fractures identified by standard radiographic examination, computed tomography, or magnetic resonance imaging and confirmed by a board-certified musculoskeletal (MSK) radiologist from August 2008 to September 2012. The only exclusion criterion was a pre-existing spinal and/or calcaneal fracture. Using the search terms “calcaneal fracture” and “calcaneus fracture,” 220 consecutive potentially eligible patients were identified (Fig. 1), of whom 12 were excluded. These 12 patients were excluded from our investigation because their injury had been falsely identified as a calcaneal fracture in the initial radiology resident’s report and, subsequently, in the attending radiologist’s report addendum, determined not to represent a fracture of the calcaneus. For each of the 208 patients included in the analyses, we reviewed all the associated records in an effort to identify the presence of a concomitant acute vertebral fracture (Fig. 2), the level of vertebral fracture, and any other acute fracture (axial or appendicular), or infragenicular soft tissue trauma, regardless of whether additional spinal imaging had been obtained. If spinal imaging was not procured at any point for a patient, the case was considered negative for a spinal fracture. The following independent variables (e.g., exposures, risk factors) were considered in regard to their association with concomitant calcaneal and vertebral fractures (the outcome): patient gender, etiology of the fractures (i.e., fall from a height, motor vehicle accident, other known trauma, unknown), calcaneal fracture characteristics (intra- or extra-articular, unilateral or bilateral, open
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.01.012
280
J.L. Walters et al. / The Journal of Foot & Ankle Surgery 53 (2014) 279–281
Fig. 1. Coronal computed tomography scan of joint depression fracture of calcaneus in a patient with a concomitant lumbar spine fracture.
Fig. 2. Concomitant lumbar (L3) spinal fracture in a patient with a concomitant joint depression calcaneal fracture (Greenfield caval filter also noted).
or closed), the presence of other nonvertebral fracture (of the upper or lower extremity or the axial or appendicular skeleton), and the spinal level of the vertebral fracture (e.g., cervical, thoracic, lumbar, or sacral). The data were transferred to a microcomputer and analyzed by one of us (D.S.M.) using StataÒ, version 9.2 (StataCorp, College Station, TX). The incidence of concomitant calcaneus and vertebral fractures was calculated, and the Kruskal-Wallis equality-of-populations rank test and Spearman’s rank correlation and logistic regression analysis were used to test the association between independent variables, alone and combined, and concomitant calcaneal and vertebral fractures. Statistical significance was defined at the 5% (p .05) level.
conditions was low, and in no case was a soft tissue injury reported in conjunction with a vertebral fracture. Use of the Kruskal-Wallis equality-of-populations rank test and Spearman’s rank correlation and logistic regression analysis revealed the only statistically significant association between an independent variable (exposure) and concomitant vertebral and calcaneal fractures to be localization of the vertebral fracture in the lumbar spine (Kruskal-Wallis c2, p ¼ .0001).
Results Discussion Using our inclusion criteria, 208 consecutive calcaneal fractures were available for the analyses used in the present retrospective cohort study, and 15 (7.21%) of the 208 calcaneal fractures were associated with a concomitant spinal fracture, 12 (5.77%) of which were localized to the lumbar spine and 3 (1.44%) to the thoracic spine. All the calcaneal fractures associated with a concomitant vertebral fracture were unilateral and closed, with intra-articular (86.67%), male gender (80%), lumbar spine (80%), isolated calcaneal fracture (66.67%), and a fall from a height (46.67%) the most prevalent associations. Only the association with a lumbar fracture was clinically (80%) and statistically (p .05) significant. Table lists the prevalence of the various exposures with the outcome, namely concomitant calcaneal and vertebral fractures. Of the 15 cases with the outcome, 12 (80%) involved males, and the most common (46.67%) etiology was a fall from a height, followed by a motor vehicle accident (26.67%). A total of 14 of the calcaneal fractures (86.67%) were intra-articular; all were unilateral, and no open fractures were present. Of the vertebral fractures were localized to the lumbar spine, and 3 fractures (20%) were localized to the thoracic spine, and 1 (6.67%) involved the thoracic and lumbar segments. When we considered adjunct ankle ligament (n ¼ 1), peroneal tendon (n ¼ 2), and other (n ¼ 1) infragenicular soft tissue injuries occurring concomitantly with the calcaneal fracture, the prevalence of these
The present investigation into concomitant calcaneal and vertebral fractures involved one of the largest calcaneal fracture data sets to date and focused on information not recently explored. From a limited number of studies and what has become a generally accepted surgical understanding, calcaneal fractures are known to coexist with spinal fractures; however, the results of our investigation have suggested that the incidence of this association could be significantly less clinically than what has traditionally been reported (7.21% compared with approximately 10% to 22%). Moreover, our findings have shown that when concomitant calcaneal and vertebral fractures occurred, the lumbar spine was the most prevalent level of spinal involvement (80% of cases, p ¼ .0001), and this finding reinforced the generally known association between calcaneal and spinal fractures. As with most retrospective cohort studies, a number of shortcomings were present that could be considered threats to the validity of our conclusions. First, potential biases were present related to the entry of data into the Pathology-Radiology Enterprise Search Tool database, a lack of information (spinal radiographs), and other ascertainment biases. For instance, the protocol for evaluation of bone and joint imaging at our institution has been that all films should be evaluated by an MSK fellow or resident and then by the attending MSK radiologist, who dictates the final report. Thus, the diagnosis of
J.L. Walters et al. / The Journal of Foot & Ankle Surgery 53 (2014) 279–281
Table Prevalence of exposures with concomitant calcaneal and vertebral fractures (n ¼ 15 of 280 calcaneal fractures) Risk Factor (exposure) Gender Male Female Etiology Fall from a height Motor vehicle accident Other known trauma Unknown Subtalar joint involvement Intra-articular Extra-articular Other calcaneal fracture feature Unilateral fracture Open fracture Other fracture present None Lower extremity Upper extremity Axial skeleton Location of vertebral fracture Cervical Thoracic Lumbar Sacral Lumbar þ thoracic
n (%) 12 (80) 3 (20) 7 4 3 1
(46.67) (26.67) (20) (6.67)
13 (86.67) 2 (13.33) 15 (100) 0 10 3 1 1
(66.67) (20) (6.67) (6.67)
0 3 (20) 12 (80) 0 1 (6.67)
all fracture pathology used in our investigation, whether osseous or soft tissue, was determined solely from the board-certified MSK radiologist’s final report. In addition, it is conceivable that some calcaneal fractures went undiagnosed, because of the patient’s initial presentation and the problem-focused examination performed by the emergency department physician on a patient without polytrauma. Also, it was unlikely that a vertebral fracture went undiagnosed, because most emergency department physicians will obtain lumbar films when managing calcaneal fractures caused by high-energy trauma. Therefore, we considered the absence of spinal imaging as negative for vertebral fracture, which imparted a bias to our investigational method that could have prejudiced our findings toward a lower incidence of concomitant calcaneal and spinal fractures. Still further, another potential bias to consider was that numerous diagnoses of infragenicular soft tissue pathologic features were
281
analyzed using standard radiographs, instead of magnetic resonance imaging or computed tomography scanning, and this could have led to an underestimation of the overall incidence of soft tissue injury in our sample population. Thus, our analyses could have skewed the results toward a lower incidence of concomitant calcaneal and vertebral fractures with lower extremity soft tissue pathologic features. A strength of our study was the use of data from both a level 1 trauma center and an urban community hospital, which we believe contributed to the generalizability. In conclusion, the incidence of concomitant calcaneal and vertebral fractures was 7.21% in our study, and the lumbar spine was involved in 80% of these cases. Our research has indicated that previous studies reported a greater incidence of the coexistence between calcaneal and spinal fractures, which could possibly have resulted from a greater portion of polytrauma patients in previous studies. The present investigation, one of the largest to date, offers an update on a topic that, to our knowledge, has not been quantitatively studied for nearly 50 years. It is clear from our data that a well-designed prospective study could help further refine emergency department evaluations of patients with and without polytrauma who present with suspected calcaneal and/or lumbar spine injuries. References 1. Malgaigne JF. Die Knochenbr uche und Verrenkungen, Rieger, Stuttgart, 1856, pp. 810–816. 2. Lance E, Wade EC. Factures of the os calcis: a follow-up study. Proceedings of the 22nd Annual Session of the American Association for the Surgery of Trauma, Hot Springs, VA, October 29–31, 1962. 3. Rowe CR, Sakellarides H, Freeman P. Fractures of os calcis: a long-term follow-up study of one hundred forty-six patients. JAMA 184:920–923, 1963. 4. Wilson DW. Functional capacity following fractures of the os calcis. J Can Med Assoc 95:908–911, 1966. 5. Cohen M. Calcaneal fractures. In: McGlamry’s Comprehensive Textbook of Foot Surgery, ed 3, p. 1821, edited by AS Banks, MS Downey, DE Martin, SJ Miller, JB Lippincott, Philadelphia, 2001. 6. Sanders R, Clare M. Fractures of the calcaneus. Surgery of the Foot and Ankle, ed 6, vol 1, p. 3846, edited by RA Mann, MJ Coughlin, Mosby-Year Book, St. Louis, 1993. 7. Marti R. Fractures of the calcaneus. In: Fractures in Children, pp. 256–257, edited by BG Weber, C Brunner, Thieme, Stuttgart, 1979. 8. Schmidt TL, Weiner DS. Calcaneal fracture in children. Clin Orthop 171:150–155, 1982. 9. Buckley R, Tough S, McCormack R, Pate G, Leighton R, Petrie D, Galpin R. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures. J Bone Joint Surg Am 84-A:1733–1744, 2002. 10. Mitchel MJ, McKinely JC, Robinson CM. The epidemiology of calcaneal fractures. Foot 19:197–200, 1994.
