What is Calcaneus Fractures?
Fractures of the calcaneus, or heel bone, are uncommon but can cause serious problems. The calcaneus is one of seven bones in the ankle and rear parts of the foot which is called the tarsus. It and the talus bone make up the back part of the foot, also known as the hindfoot. The hindfoot connects with the bones of the lower leg, the tibia and fibula, forming the ankle joint.
The joint between the calcaneus and talus, also known as the subtalar or calcaneotalar joint, allows some bending and stretching movements of the foot and ankle.
An interesting trivia is that a particular type of calcaneus fracture, which happens when the bone is crushed or “burst,” was traditionally named a “Lover’s Fracture”. This unique name came from common scenarios where someone, traditionally a suitor, would jump off from a lover’s balcony to escape being caught.
What Causes Calcaneus Fractures?
Calcaneal fractures, or breaks in the heel bone, usually happen during high-impact events that put a lot of pressure on the bone. They can also occur from any injury to the foot or ankle. The most common causes are falls from great heights and car accidents, but they can also result from jumping onto hard surfaces, blunt or penetrating injuries, and twisting or shearing events.
Most of these injuries cause the heel bone to become flat, wide, and shorter. Overuse or repetitive stress, like running, can also cause smaller fractures, known as stress fractures, to occur in the heel bone.
Risk Factors and Frequency for Calcaneus Fractures
Tarsal fractures, which are injuries to the bones in the foot, have some specific characteristics and trends:
- Tarsal fractures represent 2% of all fractures.
- Of all the tarsal fractures, 50-60% are fractures of the calcaneus, a specific bone in the foot.
- Less than 10% of tarsal fractures are open fractures, meaning the bone breaks the skin and is exposed.
- Traditionally, more males have these injuries due to work-related accidents. However, recent studies show this can vary depending on the region and types of accidents that happen there.
- Most people who fracture their calcaneus are young adults, specifically those aged 20-39.
- People with conditions like diabetes and osteoporosis are more likely to suffer from any type of fracture.
- Calcaneal fractures are uncommon in children.
Signs and Symptoms of Calcaneus Fractures
If you’ve had a traumatic event and you’re now experiencing certain symptoms in your foot, you might have injured your heel bone (calcaneus). Here’s what you might notice:
- Widespread pain, swelling, and bruising at the hurt area
- Difficulty putting weight on the foot
- Bruising extending through the arch of your foot
- Possible issues with your Achilles tendon, which can suggest a heel bone injury
- Changes in the skin around your heel, like pulling tight (tenting) or looking at risk of breaking down. This is particularly meaningful if you’ve had a specific type of heel bone fracture known as a Tongue-type calcaneus fracture.
Testing for Calcaneus Fractures
If you think you may have broken your heel bone (also known as the calcaneus), your doctor may need to do a few tests to confirm this. The first step will involve a complete examination of nerves, blood flow and tendon function in your lower leg. If the pulse in your foot (dorsalis pedis or posterior tibial pulse) is weaker than in your other foot, it could indicate arterial damage. Your doctor might order an angiography or Doppler scanning, which are special tests to check the blood flow in your arteries.
Next, your doctor will probably order a set of X-rays (also known as plain films) of your foot and ankle. They may also order a specific view called the Harris View, which provides a detailed image of the heel bone. Even if the X-ray does not show a clear fracture, your doctor might still suspect a broken heel bone based on other signs and symptoms.
Evaluation of a potential injury of heel bone can also include a test called a CT scan, which offers a more detailed view of your heel. A CT scan is especially helpful in planning for surgery (if needed), figuring out how serious the injury is, and spotting a suspected fracture even when the initial X-ray doesn’t provide clear results.
CT scans can also be used to identify a sign called Mondor’s Sign: this is a collection of blood found in the heel that is often associated with a fractured heel bone. Other types of damage to the heel (like stress fractures which are common in runners) can be evaluated with a bone scan or an MRI scan.
Your doctor will also look at certain angles on the X-rays to identify possible heel bone fractures. For example, Bohler’s Angle and the Critical Angle of Gissane. These specific angles are associated with certain points on your heel bone. In cases of fracture, these angles might be altered. If these angles are abnormal, your doctor will usually order a CT scan to further evaluate the injury.
Heel bone fractures are generally grouped into two categories. Extraarticular fractures, or fractures that occur outside of the joint, make up 25% of heel fractures. Intraarticular fractures, those that occur within the joint, account for the remaining 75% of heel fractures.
There are specific types of fractures that may occur, such as the Essex-Lopresti fractures and those classified by the Sanders system. The Essex-Lopresti fractures involve injury to specific locations in the heel bone, while the Sanders classification is based on the number and locations of fractured bone fragments seen on a reconstructed CT scan. The type of fracture you have will guide your treatment plan.
Treatment Options for Calcaneus Fractures
Treating a fractured heel (calcaneal fracture) starts with providing immediate care for the wound, which might involve cleaning the wound and antibiotics to reduce the chance of infection, as well as providing pain relief. The leg is also immobilized using a split, helping alleviate discomfort and prevent further injury. If the injury is not serious enough to warrant immediate hospitalization, the individual is advised not to put any weight on the injured foot when they leave the medical facility.
Non-surgical treatment for fractures typically involves the restoration of the original structure of the heel and alignment of the bone fragments. For fractures that have not displaced the bone fragments (Sanders type I), a non-surgical, or closed, treatment plan may be followed.
In some cases, fractures that involve displacement of the bone subsistence or a substantial fracture of the heel bone might need surgical intervention. Also, some joint injuries could be treated without surgery, depending on their severity, while others might require surgical realignment or fixation, or in some cases fusion of the bones.
Research shows varied outcomes for surgical versus non-surgical treatment for closed, displaced, intra-articular calcaneus fractures (where the bone is broken and pushes into the joint space). A study noted that while surgical treatment had a higher complication rate, including infection and hardware removal, both surgical and non-operative treatment patients experienced similar health outcomes in terms of range of motion, heel width, walking speed, and gait. It was also observed that recovery was quite slow for all study participants.
Other analyses indicate some benefits of surgical intervention, like improved restoration of the original bone structure and a higher chance of getting back to work, despite a higher complication rate.
If surgery is recommended, it aims to reconstruct the heel shape and correct alignment of the joint. It is important that the patient understands the associated risks and possible benefits before the surgery. A sign that it is safe to go ahead with surgery is when the swelling around the injury subsides and any blisters dry up, which usually takes about 21 days.
Open fractures, where a wound is directly linked to a broken bone, are typically more severe and require immediate cleaning. Healing outcomes from open calcaneal fractures are usually not as favourable as those from closed fractures.
How the surgery is performed will depend on the specifics of the injury- the surgery can happen through a large or small incision. Both procedures involve the use of a tourniquet. The traditional, extensile, lateral approach allows for better visualization and manipulation of the fracture during surgery to restore alignment and joint surfaces. Depending on the fracture, Kirschner wires can be temporarily placed to aid in repositioning the bones. Lastly, the bony fragments and joint surfaces are appropriately aligned and secured in place.
What to expect with Calcaneus Fractures
The Sanders classification is a key tool in predicting how well someone will recover from a fracture in their calcaneus, which is also known as the heel bone. In a study involving 108 patients with type II and III fractures who had surgery, their progress was tracked for an average of 15.22 years. After their surgery, a CT scan was done to check if the heel bone had returned to its original position. This happened in 95% of the cases, with the bones aligning properly with no significant missteps or irregularities.
Nevertheless, patients with more severe type III fractures were four times more likely to require additional procedures, like subtalar fusion, a surgery that helps reduce painful motion in the foot, compared to those with type II fractures.
In the long run, people in this study typically experienced mild pain and some changes in how they go about their daily activities.
The study also found that certain groups of people tend to recover better from such fractures. These groups include women, younger adults, and people with lighter workload such as office workers compared to those engaged in heavy physical labour. Patients who didn’t receive workers compensation and those who had a higher initial Bohler’s angle (a measure used by doctors to assess the severity of a calcaneus fracture) also fared better. If a patient’s Bohler’s angle was less than 0 degrees, the study found a correlation with lower functional outcomes, meaning they might face more challenges in their recovery. However, if their Bohler’s angle was more than fifteen degrees at the beginning, their recovery was generally better even if they had to have surgery or not.
Possible Complications When Diagnosed with Calcaneus Fractures
Calcaneal fractures, or heel bone breaks, are serious injuries. They require a lot of force to occur, so more than 70% of patients with these injuries also have other damages.
- A detailed examination of the entire spine is necessary every time a calcaneal fracture is detected. This is particularly important in cases of falls. The force from the impact can move from the lower body upward, potentially causing fractures in the spine.
- Compartment syndrome, a painful and dangerous condition of the foot, is a rare but serious complication that can occur in up to 10% of calcaneal injuries.
- Infections, improper healing of injuries, and arthritis in the subtalar (ankle joint) can also occur as complications from calcaneal fractures and their treatment.
- Infections and wound healing problems are common and damaging complications of the approach used to treat these fractures. They can occur in up to 37% and 20% of cases after a surgical intervention accordingly.
- Irrespective of whether the treatment was surgical or nonsurgical, subtalar arthritis, a type of degenerative joint disease, can result in the hindfoot. This has been observed to lead to a need for surgery later.
- It is possible that nearly 15% of cases may result in sural nerve injury (in the lower leg and foot) during surgical treatment. Lessening the risk of this damage involves a differently positioned incision.
- Chronic pain is a recurring concern mostly due to post-traumatic subtalar arthritis, or other effects of the injury like misalignment or stiffness.
- Displaced intra-articular calcaneus fractures can result in instability of the peroneal tendons. This can be due to the tendons being directly damaged by the injury or fracture fragments imposing on the tendons. Special techniques are available to try to lessen this occurrence.
Recovery from Calcaneus Fractures
Right after surgery, the patient’s foot and ankle should be put into a well-padded cast or support from the back. This is usually taken off within two to five days or up to two weeks, depending on the doctor’s advice. As soon as the cast is off, the patient should start moving the foot and ankle to help regain flexibility.
Drains, which are small tubes to remove excess fluid, are normally taken out two days after surgery or earlier, again based on the surgeon’s judgment.
Patients should be informed about the importance of raising the affected leg for the first few weeks post-surgery. This helps to reduce swelling and decreases the chance of any issues with wound healing.
For the first 8 to 12 weeks (or longer depending on the severity of the injury and healing progress seen in X-rays), the patient should avoid putting weight on the operated foot.
Regular X-rays should be taken to make sure that the foot and ankle are healing properly.