Calcaneal fractures most commonly occur during high energy events leading toaxial loading of the bone but can occur with anyinjury to the foot and ankle. Some have more simple patterns that do not involve the joint and usually heal without any long term issues while others are more complex with fragment displacement and extend into one of multiple joints and are very challenging to get to heal properly, often requiring surgical intervention to optimize healing. This study concluded with recommendations against operative intervention for closed, displaced, intra-articular fractures of the calcaneus. He offers Online Physiotherapy Appointments for 45. Heel Bone Fractures (Calcaneal Fractures) Rearfoot fractures of either the heel bone (calcaneus) typically occur after a high impact/velocity injury, such as a fall from height or motor vehicle accident. A traumatic event will almost invariably precede the presentation of calcaneal injury. CT scan was performed immediately postoperatively and 95% of the fractures have posterior facet reduction to the anatomic position (with no appreciable step-off of the articular surface) and with no reductions >5mm inaccurately reduced. Journal of orthopaedic surgery (Hong Kong). You should avoid bearing weight on the foot for 10-12 weeks until it is sufficiently healed. Urgent fracture reduction should proceed at the first sign of skin compromise. The patient should be counseled of the expected sequela of surgical treatment and that, despite an adequate reduction, in more severe injuries subtalar osteoarthritis is extremely common. Pathology Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8: extra-articular: 25-30% anterior calcaneal process fracture This activity reviews the causes, presentation, and diagnosis of calcaneus fractures and highlights the role of the interprofessional team in their management. jumping out of a window or off a balcony. Many times, surgery is necessary to restore normal anatomy and mobility. Calcaneus fractures are rare but potentially debilitating injuries. Describe the pathophysiology of calcaneus fractures. They found that despite a higher complication rate than closed calcaneal fractures treated operatively the complication rate in their paper was not as high as had been previously reported in the literature. Calcaneus fractures are the most common fractured tarsal bone and are associated with a high degree of morbidity and disability. Calcaneal anatomy is demonstrated in Figure 1. The hindfoot articulates with the tibia and fibula creating the ankle joint. Calcaneus Fracture. In a head-on collision, it is common for the driver or a passenger to suffer from a broken heel upon impact. Often because of the great force needed to break the heel bone, other injuries to the knees and spine are common. 2019 Oct [PubMed PMID: 31921576], Albin SR,Koppenhaver SL,Marcus R,Dibble L,Cornwall M,Fritz JM, Short-Term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial. A calcaneal fracture occurs when an excessive force crushes the heel bone against the talus (the lowest bone of the ankle). Falls. The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3. Calcaneus Fractures - Trauma - Orthobullets orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports Usually due to a fall from a height at work or a road traffic incident, calcaneal fractures are often intra-articular and displaced, affecting primarily the subtalar joint. -, Hordyk PJ, Fuerbringer BA, Roukis TS. Medicine. Up to a 40% displacement of the peroneal tendons has been appreciated on CT scans of calcaneus fractures. We do not capture any email address. Furthermore, with significant height loss, calcaneal widening and hindfoot varus subfibular impingement may result from soft tissue or osseous abnormalities. Overall the outlook for patients with calcaneus fractures is guarded. 2018 Nov 5; [PubMed PMID: 30467055], Zhang Z,Wang Z,Zhang Y,Qiu X,Chen Y, Risk factors for increased postoperative drainage of calcaneal fractures after open reduction and internal fixation: An observational study. [1][2][3]. After surgery complications are common and may include compartment syndrome, osteomyelitis, wound infection malunion and subtalar arthritis. In a linked paper (doi:10.1136/bmj.g4483), Griffin and colleagues report the results of a pragmatic, multicentre, randomised controlled trial comparing operative with non-operative care of closed, displaced intra-articular calcaneal fractures two years after injury.2 They excluded open injuries and grossly displaced fractures, where surgery is absolutely indicated. There are two main categories of Calcaneus Fracture. These injuries are also closely associated with the . Over penetration of the medial cortex of the constant fragment may lead to entrapment of the flexor hallucis longus tendon and fixed great toe flexion. MeSH Once the patient and the surgeon have determined to proceed with surgical treatment the goals must include adequate reduction of articular surfaces and restoration of calcaneal morphology. If a Calcaneus Fracture is demonstrated on the x-ray, you may be referred for a CT scan for further clarity on the size and location of the fracture. These injuries are also closely associated with the development of post-traumatic arthritis of the subtalar joint (rearfoot). Help others by leaving a review of your experience. Calcaneal fractures can also occur with other types of injuries, such as an ankle sprain. There are two main classification systems of extraarticular fractures. Treasure Island (FL): StatPearls Publishing; 2022 Jan. 2015 Jul [PubMed PMID: 26111874], Seat A,Seat C, Lateral Extensile Approach Versus Minimal Incision Approach for Open Reduction and Internal Fixation of Displaced Intra-articular Calcaneal Fractures: A Meta-analysis. The sinus tarsi approach is performed by creating a 2-4cm incision along a line from the tip of the fibula towards the base of the fourth metatarsal base. Restoration of normal alignment and contour is considered the . 2016 Sep [PubMed PMID: 27603354], Gardner MJ,Nork SE,Barei DP,Kramer PA,Sangeorzan BJ,Benirschke SK, Secondary soft tissue compromise in tongue-type calcaneus fractures. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. Calcaneus (Heel Bone) Fractures A fracture of the calcaneus, or heel bone, can be a painful and disabling injury. The type of surgery required should be discussed with an orthopaedic consultant. Abnormalities of either of these findings should prompt a CT scan for further classification and evaluation of the fracture. Nondisplaced Sanders type I fractures may be treated in a conservative, closed fashion. sharing sensitive information, make sure youre on a federal When this occurs, the heel can widen, shorten, and become deformed. Foot Ankle Int. Foot & ankle international. Injury. FOIA These high forces associated with landing from a height directly onto the Calcaneus are often sufficient to create an impact fracture. [14]. Some intraarticular injuries may be treated in a closed fashion depending upon severity. This is not medical advice. Acta radiologica (Stockholm, Sweden : 1987). [33]. Fracture to the calcaneus is rare, with tarsal bones accounting for approximately 2% of all fractures, while Calcaneus Fractures account for 50-60% of those tarsal fractures. Does internal fixation work? Emergent reduction to relieve this tented skin is often recommended. American volume. There was, however, a difference between wound complications, superficial infection, nerve injury, VAS pain scores, American Academy of Orthopedic Foot and Ankle Society (AOFAS) scores, calcaneal height and post-operative Bohler's angle in favor of minimally invasive techniques. -, Schepers T. Sinus Tarsi Approach with Screws-Only Fixation for Displaced Intra-Articular Calcaneal Fractures. You doctor will evaluate your foot for swelling and other signs of a fracture or joint damage. Test. An official website of the United States government. As severe as calcaneal fractures can be, studies have shown that non-surgical treatment can be very nearly as effective as surgical treatment in the right individuals. Care must be taken to ensure one does not over-penetrate the medial cortex. 2019 Jun;40(6):634-640. The goal of heel fracture surgery is to restore the shape of the heel bone as close to normal as possible. Diagnosis is made radiographically with foot radiographs with CT scan often being required for surgical planning. Discrepancy between the normal angles of . Archives of orthopaedic and trauma surgery. However, a recent meta-analysis was performing comparing minimally invasive techniques with the standard lateral extensile approach. 2004 May-Jun; [PubMed PMID: 15161170], Jimnez-Almonte JH,King JD,Luo TD,Aneja A,Moghadamian E, Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. The tuberosity fragment may then rotate superiorly. Kline et al concluded that the minimally invasive technique was valuable and could lead to a lower complication rate and comparable results. The three bones of the ankle include: The tibia, or shinbone The fibula, the smaller bone in the lower leg Auto Accident. The tibial artery and nerve run along the medial aspect of the calcaneal body and are thought to be shielded by the sustentaculum tali thus neurovascular injuries are uncommonwith calcaneal fractures. Percutaneous fixation with Kirshner wires (K-wires) or screws may be implemented when soft tissue injury precludes an open approach. 2010 Mar [PubMed PMID: 20194342], 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: a prospective, randomized, controlled multicenter trial. Mondor's sign or ecchymosis of the foot extending distally onto the heel is a hallmark of this injury. Subdivided into types AB, AC, and BC, depending on the position and location of the fracture lines. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. Treatment of these fractures may require surgery. The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3. 2005 Dec;13(8):492-502. doi: 10.5435/00124635-200512000-00002. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. When the calcaneus fractures, the hard outer layer can break into multiple irregular fragments and fold in on itself, just like an egg with a broken shell. The Journal of bone and joint surgery. [1] Clinically Relevant Anatomy Fractures: Non-displaced or minimally displaced fragment, 2 bony fragments which are subdivided into A, B or C depending on if they are medial process or lateral process fracture, 3 bony fragments, divided into AB, AC or BC relative to the position and location of fracture lines. Disclaimer, National Library of Medicine 2019 Feb; [PubMed PMID: 30448328], Buckley RE,Tough S, Displaced intra-articular calcaneal fractures. 2019 Apr; [PubMed PMID: 30784536], Hordyk PJ,Fuerbringer BA,Roukis TS, Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures. Immobilization with splinting, Bulky Jones type splints are commonly applied. This is especially important in the setting of Tongue-type calcaneus fractures. The amount of initial displacement based on Bohler's angle of <0 degrees is correlated with lower functional outcomes. [25] However, other studies have found that patients who develop post-traumatic arthritis who first undergo open reduction internal fixation of their fractures with the intraoperative restoration of calcaneal morphology do better than those who develop subtalar arthritis due to malunion following non-operative treatment. When conservative treatment is appropriate, a period of 4-6 weeks in a walker boot is recommended whereas walking short distances as pain allows is normally recommended. The closure is typically recommended with an interrupted Allgwer-Donati stitch to try to relieve tension on the incision itself. Kline et al retrospectively reviewed a cohort of 112 calcaneal fractures in which 79 underwent the traditional extensile lateral approach and 33 were treated using minimally invasive techniques. Alignment is still evaluated under fluoroscopy. However, because of the lack of elevation of the L-flap, there is a decreased risk of peroneal tendon irritation and sural nerve complications. 2014 Oct [PubMed PMID: 24983433], Radnay CS,Clare MP,Sanders RW, Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? Clinics in podiatric medicine and surgery. -, Bibbo C, Siddiqui N, Fink J, Powers J, Ehrlich DA, Kovach SJ. Open fractures will most likely present with a laceration or puncture wound on the medial aspect of the foot. This type of fracture commonly occurs during a high-energy eventsuch as a car crash or a fall from a ladderwhen the heel is crushed under the weight of the body. The hindfoot articulates with the tibia and fibula creating the ankle joint. Your foot and ankle specialist will assess your injury and determine whether to treat the fracture surgically or non-surgically. Copyright 2022, StatPearls Publishing LLC. About 10% of patients with calcaneal fractures also suffer a back injury called a Lumbar spinal burst fracture. Recent studies suggest regional variation in male/female predominance due to disparities in the types ofregional accident occurrence. If you have a subscription to The BMJ, log in: Subscribe and get access to all BMJ articles, and much more. The risk is reduced with a more inferiorly based L-incision. Immediately post-operatively the patient's foot and ankle should be placed into an extremely well-padded posterior splint. Scenario: A 43-year-old man fell off of a ladder from approximately 7 ft high and landed completely on one foot. Learn. American volume. A Shantz pin is still used through a percutaneous incision for manipulation of the calcaneal tuberosity. The provider must also keep in mind that certain fracture morphologies necessitate surgical care and that certain patient groups will do more poorly with surgery. Initial bony evaluation with AP, lateral, and oblique plain films of the foot and ankle is needed. J Am Acad Orthop Surg. Clinical orthopaedics and related research. One hundred and eight calcaneus fractures operatively treated (Type II and III) were evaluated at a minimum of 10 years with an average follow-up time of 15.22 years. The subtalar joint is formed by the calcaneus and the bone above it, which is called the talus. Tongue type which has the same verticle fracture line as a depression type with another horizontal fracture line running posteriorly, creating a superior posterior fragment. The extensile lateral approach has been the primary approach for many years for operatively treating calcaneal fractures. Acta ortopedica mexicana. 2004 Jan; [PubMed PMID: 14676550], Siebert CH,Hansen M,Wolter D, Follow-up evaluation of open intra-articular fractures of the calcaneus. Flashcards. Calcaneal fractures are rare in children. In: StatPearls [Internet]. Journal of orthopaedic trauma. that allows for direct visualization of the posterior facet and the anterolateral fragment of the lateral wall. Most patients with calcaneus fractures are young, with the 20-39 age group the most common. Fracture blisters may appear within 36 hours of injury. Your doctor will examine your heel and foot, and get an x-ray to see if it is broken or not. technical support for your product directly (links go to external sites): Thank you for your interest in spreading the word about The BMJ. Gravity. The Journal of bone and joint surgery. When the initial Bohler's angle is greater than fifteen degrees upon presentation their functional results will be better regardless of operative versus non-operative treatment. After 2 weeks, practice drawing a figure-8 with the toes to increase your range of motion in the ankle. Feel free to get in touch with us and send a message. What do they look like - clinically? Historically a burst fracture of the calcaneus was coined a "Lovers Fracture" as the injury would occur as a suitor would jump off a lover's balcony to avoid detection. Pain medication. This occurs from a sudden movement and typically involves the Achilles Tendon or the Bifurcate Ligament. The indication for this approach includes Sanders type II and III, patients with comorbidities that make soft tissue more vulnerable to complications include diabetes mellitus, smoking and/or obesity, peripheral vascular disease, and minimal posterior facet fragment comminution. Fracture to the calcaneus is also known as a Lovers Fracture as historically it occurs when landing from a fall, i.e. Avulsion fractures are when a tendon or a ligament pulls off a fragment of bone from the Calcaneus. Your doctor may prescribe you pain medication or you can take over-the-counter NSAIDs, such as Ibuprofen and Naproxen. A patient may notice swelling and heat around their heel bone, and there may be subtle bruising on the heel bone. 2003 Feb [PubMed PMID: 12571499], Eastwood DM,Langkamer VG,Atkins RM, Intra-articular fractures of the calcaneum. Avulsion fractures require a large amount of twisting or shearing force due to the strength of the ligamentous and tendinous attachments to the calcaneus. Wrap your heel in a compression sock or ace bandage. Heel bone fractures are notoriously difficult to treat, and usually require prolonged healing times. Overall the outlook for patients with calcaneus fractures is guarded. Since the calcaneus plays . The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. 2019 Apr; [PubMed PMID: 30784528], Schepers T, Sinus Tarsi Approach with Screws-Only Fixation for Displaced Intra-Articular Calcaneal Fractures. The hindfoot articulates with the tibia and fibula creating the ankle joint. Although screws are thought to provide greater stability . Drains are typically removed on postoperative day 2 or even earlier based on surgeon preference. The meta-analysis did confirm the higher complication rate of operative intervention but concluded that operative treatment of displaced, intra-articular calcaneal fractures has better anatomic recovery, functional outcomes and return to work. Stress fractures may occur with overuse or repetitive use, such as running. Intraoperative Reduction Techniques for Surgical Management of Displaced Intra-Articular Calcaneal Fractures. Low Vitamin-D levels, Osteopenia or Osteoporosis, can increase your risk of developing a Calcaneus Stress Fracture. Repetitive stress on the Calcaneus bone from activities such as running can cause a Calcaneus Stress Fracture. The broken bone and swelling may cause you to feel throbbing where the bone is broken. 2019 Apr;36(2):269-277. Normal = 25 -40 degrees; posterior facet/calcaneal tuberosity fx decreases this angle If remains above 15 degrees nonoperative treatment is an option. This part of the growing body of evidence that the smaller incision techniques may be useful in certain groups. The authors had no deep or superficial wound infections requiring surgical intervention, which is promising but the authors simultaneously cautioned against drawing conclusions from such a small and limited series without statistical power or a control group. Common complications may include: Following surgery, your foot and ankle specialist will likely immobilize your foot in a splint to allow the bone and joints time to heal. It is a rare type of fracture but has potentially debilitating results. 1993 Mar; [PubMed PMID: 8444935], Toussaint RJ,Lin D,Ehrlichman LK,Ellington JK,Strasser N,Kwon JY, Peroneal tendon displacement accompanying intra-articular calcaneal fractures. A clinical assessment by a Physical Therapist can identify the likelihood of a Calcaneus Fracture through clinical tests such as the Calcaneal Squeeze test. The most common cause of a Calcaneus Fracture is a fall from a balcony, ladder, table or window. Tarsal fractures account for 2% of all fractures. 2018 Aug; [PubMed PMID: 30095652], Csizy M,Buckley R,Tough S,Leighton R,Smith J,McCormack R,Pate G,Petrie D,Galpin R, Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. [17]. 2019 Apr;36(2):323-337. [19], The goals of the minimally invasive technique (or sinus tarsi approach) are to minimize soft tissue injury while simultaneously allowing for fracture reduction and stabilization. There may be associated disability of the Achilles tendon, also raising the suspicion of a calcaneus injury. Fractures involving the joints (intra-articular fractures) are the most severe calcaneal fractures, and include damage to the cartilage (the connective tissue between two bones). Calcaneus fracture fixation is associated with high rates of morbidity and disability from wound complications, infection, subtalar arthritis, and malunion. Copyright 2022 BMJ Publishing Group Ltd, North Petherton Surgery: GP Opportunity (up to 8 sessions) - North Petherton Surgery, Meadows Surgery: GP Opportunity (up to 8 sessions) - The Meadows Surgery, Ilminster, Bruton Surgery: GP Opportunity (8 sessions) - Bruton Surgery, Government of Jersey: Staff Grade in Trauma & Orthopaedics, Womens, childrens & adolescents health. He presented with constant pain, swelling of the foot and ankle and worsening pain with all ankle/foot movements. 2022 Aug 8. Consideration must also be given to imaging of other parts of the patient's body based on history given the high energy nature of the injuries that tend to cause calcaneal fractures. Journal of orthopaedic trauma. Pathology Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8: extra-articular: 25-30% anterior calcaneal process fracture A temporary reduction may be maintained by the placement of Kirschner wires through this tuberosity fragment into the "constant" fragment of the medial sustentaculum. [32] This may result from direct damage to the tendons themselves as a result of the injury or fracture fragments that may impinge on the tendons. A bstrAct. Correct diagnosis and workup must include orthogonal X-Rays, specialized views, and a CT scan is considered the gold standard for a complete diagnosis. The calcaneus is the most fractured of all tarsal bones. Traditionally, a burst fracture of the calcaneus was known as "Lovers Fracture" as the injury would occur as a suitor would jump off a lover's balcony (axial loading) to avoid detection. He offers. Out of those fractures, 60 percent are classified as a calcaneus fracture. Calcaneal tuberosity avulsion displaced sustentaculum tali, and large substantial calcaneal body fractures may require operative management. Calcaneal fractures account for 50-60% of allfractured tarsal bones. Because of this calcaneal fractures tend to come with other problems that vary with the extent of the injury. A calcaneal stress fracture is one or more small breaks in your heel bone (calcaneus). The calcaneus assumes a shortened and widened position with heel varus as a result of the fracture displacement and loss of Bohler's angle. You can download a PDF version for your personal record. Journal of orthopaedic trauma. Loss of ipsilateral dorsalis pedis or posterior tibial pulse compared to contralateral limb should raise suspicion of arterial injury and prompt further investigation with angiography or Doppler scanning. 2019 Feb 13; [PubMed PMID: 30759357], Toro G,Langella F,Gison M,Toro G,Moretti A,Toro A,Iolascon G, Stentoplasty of calcaneal fractures: Surgical technique and early outcomes. The splint may be removed as early as 2-5 days based on some recommendations or left in place for 2 weeks in some cases, but after removing the splint the patient should begin his or her range of motion exercises for the subtalar joint and ankle joint as soon as possible. Typically, non-surgical treatment involves: Surgical correction of a fractured heel bone is a risky procedure. Calcaneus fractures have enormous morbidity and are often associated with many other injuries. Initial care includes full neurovascular and musculoskeletal examination and patient history. Radiographics. The hindfoot articulates with the tibia and fibula creating the ankle joint. [28][29] Studies have shown greater than 70% of patients with calcaneus fractures have additional injuries. Match. Alexander Orthopaedic AssociatesAdam D. Perler, DPM, FACFAS2438 Dr. ML King Jr. St. N. | Suite ASt. Anterior calcaneal process fractures are often missed fractures of the calcaneus (up to 88% are not reported on radiographic examination of the ankle) 1 leading to non-union of bone fragments, unrecognised associated ligamentous injuries, and persistent ankle or foot pain. In: StatPearls [Internet]. Unable to load your collection due to an error, Unable to load your delegates due to an error. Once the surgeon has committed to the minimal approach conversion to the extensile lateral approach is not recommended and thus great care must be taken in determining the correct approach for the correct patient. The extensile group's fracture composition was 53% Sanders II and 47% Sanders III. Comorbidities such as diabetes and osteoporosis may increase the risk of all types of fractures. In: StatPearls [Internet]. Infections and wound breakdown are the most common and devastating complications of the extensile lateral approach. In this analysis, there were 2179 participants followed for an average of 22.41 months. The calcaneus connects with the talus and cuboid bones. It is an overuse injury which was seen mostly in soldiers marching long distances carrying heavyweights. See what our patients have to say. Level 1 evidence supports theAllgwer-Donati stitch's use over the vertical mattress suture in lower extremity trauma as theAllgwer-Donati yields improved tissue perfusion at the incision site. The Journal of bone and joint surgery. A recent randomized controlled trial reviewed operative versus non-operative treatment for closed, displaced, intra-articular calcaneus fractures. [22]. Overall, they screened 2006 patients with calcaneal fractures, of whom a quarter (n=502) were eligible . Journal of orthopaedic trauma. [8]Sanders et all describe that the soft tissue swelling may take up to 21 days to resolve and that surgery should not proceed until this has occurred. Sanders Classification: Based on reconstituted CT findings. Treatment for Calcaneus Fracture is decided based on the type and location of the fracture. Evaluation of a potential calcaneus fracture should include the following: Calcaneal fractures can be classified into two general categories.[9][10]. When this occurs, the heel can widen, shorten, and become deformed. Gunshot wounds and other ballistic injuries cause a more diffuse nonpredictable fracture pattern but remain uncommon. HHS Vulnerability Disclosure, Help Treating a calcaneal fracture can be extremely tricky, because the fracture is rarely a clean break like you might see in a broken shin or arm. The results of the trial included a higher complication rate including infection and a requirement to remove hardware in 11% of the operative group, but there were no differences between the group with regards to health outcomes, range of motion, heel width, walking speed, and gait. 2017 Dec [PubMed PMID: 29245290], Sanders R,Vaupel ZM,Erdogan M,Downes K, Operative treatment of displaced intraarticular calcaneal fractures: long-term (10-20 Years) results in 108 fractures using a prognostic CT classification. [8] Another study found that non-operative measures were up to 6 times more likely to lead to a late subtalar fusion due to symptomatic subtalar arthritis. The peak incidence occurs in younger males [ 2 ]. BMJ (Clinical research ed.). PLAY. [14](Level III), Complete recovery from a calcaneus fracture may take months or even years. Calcaneal stress fractures can cause intense pain and make walking more difficult. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal/plantar flexion. STUDY. The operative group was treated as described below with the extensile lateral approach and the non-operative group was treated with initial immobilization followed by gentle mobilization as allowed by pain. Bookshelf Outcomes with open calcaneal fractures are generally poorer than closed fractures. A fracture from a fall may require simple strengthening and rehabilitation while a Calcaneus Stress Fracture from running can require a thorough gait analysis and running re-training alongside insoles and changes in footwear. The wound complication rate was 29% in the extensile lateral group with 9% of the total treated cases requiring repeat surgery for those complications. 2019 Feb; [PubMed PMID: 30664605], Shih JT,Kuo CL,Yeh TT,Shen HC,Pan RY,Wu CC, Modified Essex-Lopresti procedure with percutaneous calcaneoplasty for comminuted intra-articular calcaneal fractures: a retrospective case analysis. This will usually occur five to ten days following the injury. Fractures that don't involve the . The varus deformity must also be corrected at this time. Clipboard, Search History, and several other advanced features are temporarily unavailable. We recommend a consultation with a medical professional such as James McCormack. Previous literature by Siebert et al included 36 open calcaneal fractures in which there were 23 cases with complications including need for soft tissue coverage, nine cases of osteomyelitis, five amputations and one arthrodesis. PMC The calcaneus is the heel bone. These fractures will heal if treated non-operatively, but patients can be left with persistent deformity, incongruent joint surfaces, and loss of alignment of the leg to the heel. Furthermore, all serous and hemorrhagic blisters must be epithelialized. [4][5]Falls from height and automobile accidents are the predominant mechanisms of injury, although jumping onto hard surfaces, blunt or penetrating trauma and twisting/shearing events may also cause injury. Also, many patients will benefit from either custom or over the counter arch supports. There are several types of fracture patterns that can occur with trauma to the heel bone. However, they are also seen in long-distance runners, ballet dancers and sports involving jumping. The calcaneus is the most commonly fractured tarsal bone, representing 60 percent of all tarsal fractures in adults [ 1 ]. When this occurs, the heel can widen, shorten, and become deformed. Patients must be counseled that there are advantages and disadvantages to surgical treatment. Many are treated with either open surgical reduction and internal fixation, percutaneous pinning, or sometimes arthrodesis. . Type IV fractures: 4 comminuted bony fragments. A fracture of the calcaneus, or heel bone, can be a painful and disabling injury. This joint is important for normal foot function. The surgeon must then determine the appropriate approach and implants required to obtain that goal. [24]One hundred and thirty-nine tongue type fractures were reviewed at a single institution over a 5 year period and found an overall rate of 21% soft tissue compromise, further finding that fractures with greater initial displacement were at a greater risk of skin compromise. Calcaneus Fractures: FAQsCauses and Treatment for a Bruised HeelConditions that cause Heel Pain in the Morning, This is not medical advice. [31]. This joint is often involved in these types of facture which can lead to long term problems with the joint such as chronic pain, stiffness and the development of arthritis. [15]. 2022 May-Jun;42(3):661-682. doi: 10.1148/rg.210167. Explain the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by calcaneus fracture. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal/plantar flexion. A thorough evaluation of the entire spine should be performed anytime a calcaneal fracture is identified especially when a fall is a mechanism. [20]. Write. This type of fracture commonly occurs during a high-energy event such as a car crash or a fall from a ladder when the heel is crushed under the weight of the body. [12], A more recent meta-analysis from 2017composed of 18 trials including 1467 patients found significantly improved anatomical improvements with operative intervention with regards to the restoration of Bohler's angle, calcaneal heights and widths as well as the likelihood of resuming former work. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal . Due to the force of the injury, the damage is often extensive and often requires surgery. Medicine. The group demographics were comparable. Calcaneus Fracture Diagnosis. Their cohort of patients additionally had poor quality of life metrics post-operatively. Non-weight bearing status for up to 10-12 weeks, Immobilization in a cast, fracture boot or splint for 8-10 weeks. Arthroscopy techniques. Please note: your email address is provided to the journal, which may use this information for marketing purposes. The epidemiology of tarsal fractures is as follows: Falls from a height directly translate energy into the calcaneus on impact as the heel strikes a surface crushing the calcaneus against the talus. Your doctor may also order a CT scan to get a better idea of the pattern of the fracture, to determine whether surgery is needed. The results of this cohort ofverifiably well-reduced fractures demonstrated that the type III fractures were 4 times more likely to require eventual subtalar fusion compared to type II fractures. Clin Podiatr Med Surg. Think of the calcaneus as an egg with in intact shell it is hard to break when you squeeze it in the palm of your hand, however, if there is any defect or crack in the surface, any abnormal pressure to the shell cause it to crumble as the center is soft and sponge-like. Many other groups have similar findings in that the sinus tarsi approach seems to lead to similar radiographic and functional outcomes with fewer wound complications overall. 2019 Apr; [PubMed PMID: 30784540], Cottom JM,Douthett SM,McConnell KK, Intraoperative Reduction Techniques for Surgical Management of Displaced Intra-Articular Calcaneal Fractures. Calcaneus Fracture. Displaced Type III fractures have a higher likelihood of resulting in subtalar fusion than lower classification injuries and patients should be counseled that further procedures may be required, including possible subtalar fusion. Intra-articular calcaneal with subtalar joint depression. The calcaneus (also called the heel bone) is the largest tarsal bone of the foot. It is part of the hindfoot and sits directly below the three bones that make up the ankle joint. Most calcaneal fractures are occupational, and are caused by axial loading from a fall [ 2 ]. Subtalar osteoarthritis may result from surgical or nonsurgical treatment with an increasing number of patients with non-operatively treated displaced intra-articular calcaneus fractures requiring late subtalar fusion as a result of subtalar arthritis. The Journal of bone and joint surgery. Reduction and alignment should be verified with fluoroscopy and exchanged for definitive fixation and the wound should be closed in layers with many recommending drain placement. Surgical treatment tends to fall into one of two categories, the open extensile lateral approach, and minimally invasive techniques. These types of stress fractures are often misdiagnosed as Insertional Achilles Tendonitis. Physical Therapy can last for 4-6 weeks depending on the cause of injury. Calcaneus Fracture (Broken Heel) Treatment The calcaneus or heel bone is the largest bone in the foot and servers as the primary weight bearing structure in the heel. Peroneal tendon instability may result from displaced, intra-articular calcaneus fractures. Created by. 2019 Feb 2; [PubMed PMID: 30739765], Ankle Radiograph Lateral Calcaneus Fracture. Open calcaneal fractures require emergent irrigation and debridement and careful wound management. Clinical orthopaedics and related research. It allows for adequate visualization intra-operatively and allows for manipulation of the fracture to restore alignment and articular surfaces. Please note that narcotics in our practice are extremely restricted and are NOT a good long term solution. [16] Aldridge's group did recommend that definitive fixation not be performed at the time of initial irrigation and debridement. Calcaneus fractures are rare but potentially debilitating injuries. Elevation of the foot. Wound complications and infections can be as high as 37% and 20% respectively with operative intervention. [35][36](Level V), Adams MR,Koury KL,Mistry JB,Braaksma W,Hwang JS,Firoozabadi R, Plantar Medial Avulsion Fragment Associated With Tongue-Type Calcaneus Fractures. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Normal Bohlers and Gissane angles do not rule out a fracture. Usually due to a fall from a height at work or a road traffic incident, calcaneal fractures are often intra-articular and displaced, affecting primarily the subtalar joint. Bibek Adhya, Himmat Dhillon, Sidak Dhillon, Mandeep Singh Dhillon. Chronic pain is also a common complication, in many cases owing to post-traumatic subtalar arthritis, malalignment or stiffness resulting from the injury. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. Depending on the cause of your injury, your foot and ankle specialist may also examine you for an ankle or mid-foot injury, or refer you to another specialist to check for injuries beyond the foot. A clinical assessment by a Physical Therapist can identify the likelihood of a Calcaneus Fracture through clinical tests such as the Calcaneal Squeeze test.If this test is positive for pain, it is likely that you will be referred for an x-ray.If a Calcaneus Fracture is demonstrated on the x-ray, you may be referred for a CT scan for further clarity on the size and . Treasure Island (FL): StatPearls Publishing; 2022 Jan. Would you like email updates of new search results? 2014 Oct; [PubMed PMID: 25243849], Githens M,Shatsky J,Agel J,Bransford RJ,Benirschke SK, Medial external fixation for staged treatment of closed calcaneus fractures: Surgical technique and case series. 1. Calcaneal body fractures with significant varus or valgus malalignment, lateral impingement, loss of calcaneal height, or significant translation of the posterior tuberosity. Only 6% of the minimally invasive group had wound complications and none required additional surgery. British volume. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons. Splinting, ice and elevation will be helpful in improving tissue quality for later operative intervention. [21]Of note, there was no comparison of pre-operative fracture morphology and many authors contend that more severe patterns require the extensile approach and are also predisposed to a higher complication rate. Calcaneus fracture commonly occurs during a high-energy eventsuch as a car crash or a fall from a ladderwhen the heel is crushed under the weight of the body. Type I fractures: 1 nondisplaced or minimally displaced bony fragment. The majority are displaced intraarticular fractures (60 to 75 percent) [ 2 ]. official website and that any information you provide is encrypted Weight-bearing is often delayed 8-12 weeks (or more depending on the degree of comminution and progression of healing on radiographs). Foot Ankle Int. [14], Surgical intervention is typically recommended for the following indications:[15]. When this occurs, the heel can widen, shorten, and become deformed. This site needs JavaScript to work properly. Plantar ecchymosis extending through the plantar arch of the foot should raise suspicion significantly. Surgical management of calcaneal fractures. Long-term functional results in this cohort resulted in mild pain and some alterations in activities of daily living. A two year recovery, with a stiff, painful, deformed foot that will not fit into a normal shoe and osteoarthritis of the subtalar joint are common outcomes.1, Orthopaedic surgeons often fix these fractures internally to try to improve the final result. 2008 Aug [PubMed PMID: 18670282], Buckley R,Leighton R,Sanders D,Poon J,Coles CP,Stephen D,Paolucci EO, Open reduction and internal fixation compared with ORIF and primary subtalar arthrodesis for treatment of Sanders type IV calcaneal fractures: a randomized multicenter trial. A. Some surgeons will favor primary subtalar arthrodesis as it seems to reduce the need for subsequent procedures and the associated increased costs and lost time from work associated with those additional surgeries. Clinics in podiatric medicine and surgery. Subfibular impingement may result in lateral heel pain, particularly with eversion of the hindfoot. All participants of the study recovered very slowly from injury, most improvement plateaued at 18 months and most participants reported ongoing adverse effects from their injury at 2 years. Most extraarticular fractures are treated conservatively with 10-12 weeks of casting (true extra-articular fractures only account for roughly 20% of all calcaneal fractures). Access this article for 1 day for:30 / $37 / 33 (excludes VAT). The peak incidence occurs in younger males [ 2 ]. [18]The lateral calcaneus and joint surfaces can be well visualized and typically temporary retraction is created by the placement of Kirschner wires into the talus, fibula, and cuboid. Skin quality around the heel must be evaluated for tenting and/or threatened skin. Both groups had a 100% union rate and similar radiographic parameters with regards to Bohler's angle and the angle of Gissane. -. Severe heel bone fractures can extend into the ankle joint and fracture the cartilage that . The site is secure. Twenty-one fractures were included in this series and the authors found that calcaneal length, height, and axial alignment can be restored with an external fixator, Bohler's angle cannot be restored with external fixator and ligamentotaxis alone. Once you are allowed to bear weight on the foot, Dr. Perler usually sends you for physical therapy who will help you get back to full weight bearing and out of the boot over the following month. Certain Populations tend to have better results a well [27]: Due to the severe nature and the force required to sustain calcaneal fractures concomitant injuries must be considered. Surgical technique. Epub 2022 Mar 11. If you have recently experienced a trauma and are experiencing symptoms of a calcaneal fracture, visit your foot and ankle specialist. Rehabilitation Protocols for Calcaneus Fractures. Traditionally, there is a male predominance of injuries due to the industrial nature of the accidents. government site. and transmitted securely. Copyright 2015 - 2022 Adam D. Perler, DPM, FACFASSite Design by Swarm Interactive, Heel Bone Fractures (Calcaneal Fractures), Extensive swelling and bruising in the heel region. [18][14]. 2020 Jan [PubMed PMID: 28846249], Griffin D,Parsons N,Shaw E,Kulikov Y,Hutchinson C,Thorogood M,Lamb SE, Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. 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