Introduction
Fractures of the calcaneus, often referred to as heel bone fractures, can lead to significant pain and disability. These injuries frequently occur as a result of high-energy incidents such as automobile accidents or falls from heights, where the heel bone is subjected to heavy loads that crush it. Such trauma can cause the heel to undergo deformation, resulting in a wider, shorter, and misshapen structure.
Calcaneus fractures can be serious, often requiring surgical intervention to restore the heel's anatomy and permit a return to normal mobility. Despite appropriate medical care, some fractures may lead to chronic issues such as pain, swelling, diminished range of motion, and arthritis. Individuals employed in physically demanding jobs often find it challenging to reintegrate into their work after sustaining a calcaneus fracture.
What is a calcaneus fracture?
Calcaneus fractures are relatively rare, accounting for only about 2% of all fractures occurring in adults, with calcaneus fractures representing roughly 50% of all tarsal fractures. These injuries can cause notable alteration in the heel bone’s structure, leading to a widening and shortening effect. In many instances, the fracture may also penetrate the subtalar joint (the joint above the heel bone and underneath you talus/ankle), potentially damaging the cartilage that lines the joint, which can contribute to long-term complications like persistent pain, arthritis, and restricted motion.
How bad can they be?
The extent of a calcaneus injury is influenced by various factors, including:
- The number of fractured segments.
- The size and quantity of the fractured pieces.
- The degree of displacement among the broken fragments; in minor cases, the broken bone ends may align closely, while in more severe fractures, considerable gaps or overlapping of fragments may occur.
- The extent of damage to the subtalar joint’s cartilage.
- Any injury to adjacent soft tissues, such as muscles, tendons, and skin.
Fractures that break through the skin or involve a wound reaching the bone are known as open fractures. These types of fractures often involve more extensive damage to surrounding soft tissues and extend the duration of recovery. Open fractures pose a heightened risk of infection for both the wound and the underlying bone, necessitating immediate medical intervention to cleanse the area.
How do they happen?
Calcaneus fractures are usually the result of a fall from height or collisions involving motor vehicles. The severity of a fracture can vary significantly, with many stemming from violent impacts. For instance, a simple ankle twist may lead to a minor fracture, while a head-on collision might result in a comminuted fracture wherein the bone disintegrates into multiple pieces.
Similar fracture mechanisms can yield different injury patterns; for example:
- Landing on one's feet after a fall exerts downward pressure, forcefully pressing the talus into the calcaneus.
- In vehicle accidents, the heel might be forcibly driven against the floorboard, impacting the calcaneus against the talus.
Higher impact forces typically lead to more severe damage to the calcaneus, and in high-energy injuries, other bodily injuries like fractures to the spine, hip, or opposite heel may occur.
What are the symptoms?
Individuals with calcaneus fractures commonly report:
- Pain
- Bruising
- Swelling
- Altered heel shape
- Inability to bear weight on the affected heel or walk
In some minor cases, individuals may experience insufficient pain to hinder walking but may exhibit limping. This occurs because the Achilles tendon connects through the calcaneus to support body weight. Conversely, if the calcaneus is misshaped from the injury, the muscle and tendon cannot sufficiently sustain weight, leading to instability in the foot and ankle.
What you should tell us during your examination
Detailing the specifics of your injury is crucial when consulting a doctor or practitioner. For example, it's important to communicate details such as the height of a fall and the type of surface you landed on. Additionally, informing your doctor/practitioner about any other injuries, medical conditions like diabetes, or if you smoke is vital.
Imaging
Imaging is essential to confirm or exclude the presence of a calcaneus fracture:
- X-rays are the standard diagnostic tool, visualising dense structures like bone. They can identify fractures and determine whether any bone displacement has occurred.
- Computed tomography (CT) scans may be ordered after initial X-rays, as they provide a more intricate view of the calcaneus, assisting in assessing fracture severity and informing treatment strategies.
Treatment
Your treatment plan will consider various factors, including:
- The injury's origin
- Your overall health
- The injury's severity
- The extent of soft tissue damage
Given that calcaneus fractures often lead to changes in the bone structure, the primary goal of treatment is to restore the heel's normal anatomy. Generally, a return to the typical heel configuration yields better outcomes, frequently necessitating surgical intervention. Your doctor or practitioner will present treatment options tailored to your specific case and may need to refer on to an orthopaedic surgeon.
Nonsurgical Treatment
If the broken bone fragments have not shifted out of alignment, a non-surgical approach may be recommended. This typically involves:
- Immobilisation: Fitting a cast, splint, or brace to keep the foot's bones in the correct position during recovery. A cast may be required for 6 to 8 weeks or even longer, during which weight-bearing on the foot will be limited until healing occurs.
Surgical Treatment
In the presence of fragmented or misaligned bones, surgery may be needed. Surgical intervention for a calcaneus fracture aims to restore the bone's proper shape, although associated risks exist, such as issues with wound healing, infections, and nerve impairment.
In some cases nonsurgical treatment may also lead to persistent complications like pain, arthritis, or limping may arise, prompting surgical options. Your orthopaedic doctor should provide detailed insights about the advantages and disadvantages of surgical versus nonsurgical options.
Rehabilitation
Regardless of whether surgical or nonsurgical treatment is applied, rehabilitation protocols remain largely similar. The duration for restoring normal activities may differ based on fracture strength and any concurrent injuries.
Some patients may commence weight-bearing activities within weeks post-injury or surgery; however, many need to wait roughly three months before resuming weight on the heel. Some may initiate partial weight-bearing within 6 to 10 weeks of injury or surgery.
- Early motion is often encouraged, with guidance to start moving the joint as pain permits. Post-surgery, movement may be initiated contingent on wound healing.
- Physical therapy is integral, with prescribed exercises to enhance foot and ankle mobility and strengthen supporting muscles. While initially uncomfortable, engaging in exercises is crucial for returning to everyday activities.
- Weight bearing might necessitate the use of crutches, a walking stick, or a walker, as well as a specialised boot. Adhering to your doctor's weight-bearing instructions is crucial; premature weight application can disrupt bone healing or cause metalwork failure post-surgery.
Complications
Complications frequently accompany calcaneus fractures. Minor complications may encompass:
- Temporary or minor delayed wound healing
- Nerve irritation in areas around surgical sites
- Tendon discomfort
- Joint stiffness
- Chronic pain
- Ongoing swelling
Serious complications may involve:
- Non-healing wounds
- Infections
- Post-traumatic arthritis (with or without surgical intervention)
Inform your physician if you smoke, as it can significantly hinder both bone and wound healing processes. Healing is typically slower amongst smokers. In cases of infection or wound healing complications, additional surgery may be necessary.
Common Problems
Persistent issues following recovery may include:
- Skin irritation from shoe friction affecting the previously injured areas.
- Altered gait, sometimes arising if the foot's natural shape is not adequately restored or if the Achilles tendon fails to heal as normal; this might result in difficulties on uneven surfaces
- Ongoing pain related to subtalar dysfunction, limited mobility, or structural issues from persistent fracture displacement or arthritis.
Further Treatment
For those experiencing chronic discomfort or complications, further intervention may be necessary:
- Orthotics may address chronic issues via shoe modifications, such as heel pads, lifts, or specially tailored footwear.
- Additional surgery may be required if bone healing has occurred in a misaligned position or if arthritis develops in the subtalar joint; fusion of these bones may be needed to alleviate pain, albeit at the cost of reduced mobility in the hindfoot.
Contact us here if this article has raised any concerns. Find Your Stride.
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