The calcaneus is the bone that makes up the heel of the foot. It is uncommonly fractured, accounting for about 2 percent of all fractures. Of the tarsal bones, it is the most commonly fractured one. About 60-75 percent of calcaneus fractures involve a joint surface. Most calcaneus fractures occur in men between the ages of 21 and 45 and are due to industrial accidents. Only about ten percent of these fractures are open.
The major mechanism of injury is an axial load onto the bottom of the foot such as falling from a height onto the heels. It can also occur in a motor vehicle accident when the foot impacts the accelerator or the brake pedal. Twisting forces can cause a fractured calcaneus as well.Evaluation of Calcaneus Fractures
Many patients with a calcaneus fracture have moderate or severe pain in the affected heel along with widening of the heel, tenderness and swelling in the affected area. There can be blistering and massive amounts of swelling, especially within the first day and a half. If the fracture is open it is usually on the medial aspect of the calcaneus. The neurovascular status of the fracture should be evaluated and compartment syndrome must be looked for as this occurs in ten percent of cases. If left untreated, it can result in clawing of the small toes.
Half of all calcaneus fractures involve other injuries as well. These can include injuries to the lumbar spine, other fractures of the lower extremities and soft tissue injuries. Bilateral calcaneus fractures are present 5-10 percent of the time.
X-ray of the calcaneus involves a font and lateral view of the foot along with an axial view, called the Harris axial view. The rest of the ankle should be included in the films. There are several angles that must be measured which will show displacement of the fracture. CT scanning can also be helpful in delineating the fracture displacement.Classification of the Calcaneus Fracture
Extra-articular fractures do not involve the posterior facet and make up about 25-30 percent of all calcaneus fractures. There are multiple ways that the calcaneus can be fractured that depend on the angulation of the calcaneus at the time of the fracture.
Intra-articular fractures involve several named classification systems, such as the Essex-Lopresti Classification. In this system, there is a primary and a secondary fracture line. Om the Sanders classification system, a CT scan is done of the calcaneus with four types of fractures involving four different potential pieces of the bone.Treatment of Calcaneus Fractures
These can be severely disabling injuries associated with chronic pain. Treatment is controversial and include operative and non-operative measures. Non-operative fracture repair involves treating a fracture that is non-displaced or minimally displaced intra-articular or extra-articular fractures. If the patient already has peripheral vascular disease, surgery might be risky. If the patient has other, more severe injuries, a non-surgical treatment is recommended. A bulky Jones dressing is recommended with a supportive splint to allow for swelling to dissipate. After the swelling goes down, a boot can be applied that prevents deformity of the heel during the heeling process. Range of motion exercises are started early with non-weight bearing for 10-12 weeks until the bone unifies.
Surgery is used if the fracture is displaced and intra-articular. Open fractures are usually treated in the operating room and fracture/dislocations of the calcaneus are treated with surgery. Surgery needs to take place within 3 weeks of injury but should wait until swelling is down and wrinkles begin to appear on the skin again.
Operative ideals include the following:
- Restoration of the articulation between the calcaneus and the talus
- Restoration of the Bohler angle.
- Maintenance of the calcaneus and cuboid articulation
- Neutralization of the varus deformity of the calcaneus
- Restoration of the height and width of the calcaneus
A lateral L-shaped incision should be made so as to spare vessels and nerves in the other areas of the calcaneus. Screws and plates are used to hold the fracture segments together.Complications of Calcaneus Fractures
The most common complication is wound dehiscence and the angle of the incision. Skin grafting or muscle flap closure may need to be necessary to fix the dehiscence. There can be infection in the form of calcaneal osteomyelitis. This can be lessened by allowing the swelling to go down before doing surgery. Posttraumatic arthritis is possible which can be treated surgically or through the use of injections into the joint. Increased heel width is a common complication. There can be a loss of subtalar motion with operative and non-operative cases of calcaneus fracture.
Peroneal tendonitis is seen if there is lateral impingement of the tendon. Sural nerve injury can happen whenever surgery is done using a lateral approach. Chronic heel pain is such that many people cannot return to gainful employment. Complex regional pain syndrome is possible after even the most minor calcaneus fractures.
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