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Calcaneus (Heel Bone) Fractures
Definition:
The calcaneus is the heel bone at the rear of the foot. It connects with the talus bone of the ankle, and the cuboid bone in the mid-foot. The joint between the talus and calcaneus bones (the subtalar joint) is important for normal foot function.
The calcaneus bone has a hard exterior shell and a spongy, softer bone interior. This structure means that, if fractured, the bone tends to fragment. A fracture is therefore a serious injury with potential for the development of chronic pain and arthritis.
A calcaneal fracture may or may not involve the subtalar or surrounding joints. Intra-articular fractures (those that do involve a joint or joints) are more serious than extra-articular fractures because the articular cartilage between the bones is also damaged. Extra-articular calcaneal fractures can be stress fractures, caused by gradual injury or overuse, avulsion fractures, when part of the calcaneus is broken off when the Achilles tendon is torn away, or crush injuries that cause fragmentation of the bone.
Calcaneal fractures are also described by type and severity. A stable fracture is a fracture where the bones remain properly aligned. A displaced fracture describes the misalignment of the broken bones, and will usually require surgical repair. An open fracture, otherwise known as a compound fracture, is when a broken bone has protruded through the skin, while a closed fracture describes broken bones that have not broken the skin, but may involve damaged soft tissues. A comminuted fracture is a fracture that has resulted in the fragmentation of the bone.
Causes:
The majority of calcaneal fractures occur as a result of a trauma such as a fall from a height, a twisting injury, or a car accident.
Other causes are, as described above, overuse, repetitive stress, and ankle sprains that may tear away a piece of bone.
Symptoms:
Symptoms may vary according to the type of fracture that has been sustained.
A traumatic fracture may produce a sudden and severe pain in the heel, the inability to put any weight on the heel, and swelling and bruising of the heel and ankle. There may be visible deformity of the heel.
The symptoms of a stress fracture may include swelling of the heel area with pain that develops over a period of days to weeks. Initially the pain may merely cause you to limp slightly.
Diagnosis:
Your doctor will take a general medical history from you and ask questions specifically relating to your symptoms, any previous foot injuries, and the circumstances relating to your current injury. Your foot and leg will be physically examined and compared with your unaffected leg.
Depending on the circumstances of the injury, your spine and pelvis may also be examined.
X-rays will be taken to view the calcaneus and other bones of the foot and ankle. You may have a bone scan, which involves having a small amount of radioactive material injected intravenously. The radioactive material accumulates in areas of activity (for instance where a fracture is healing); pictures taken will highlight these areas. It is likely that a CT (computed tomography) or MRI (magnetic resonance imaging) scan will also be done as these imaging tests show the soft tissues of the body more clearly than X-rays can.
Treatment:
Treatment for a calcaneal fracture will depend entirely on the type and severity of your injury. The goal of treatment is to restore the heel to its proper structure and function.
Fractures caused by a traumatic event will probably require surgery to repair the bone (and joints if involved), or to fuse bones together. Surgery is often necessary for avulsion fractures, and immediate surgery is always required for an open fracture. During surgery the pieces of bone will be repositioned and fixed together with screws, pins, or plates to hold them in the correct position while they heal.
For some fractures, conservative (non-surgical) treatments may be sufficient. These treatments would include:
- Rest: keeping weight off the heel allows the bone to begin to heal. Using crutches when walking helps to achieve this.
- Ice, crushed in a bag and wrapped in a towel before being applied to the skin, helps to relieve pain and swelling. Ice should be applied several times a day, for as long as is comfortable, during the acute stage of the injury.
- Compression: Wrapping the ankle and heel in a compression bandage provides some relief from pain and swelling.
- Elevation: Raising the foot above the level of your heart helps to relieve swelling.
- It might be necessary to wear a walking boot or cast for up to 8 weeks, in order to avoid any movement of the heel bone.
Physiotherapy:
You will be encouraged to begin moving the foot and ankle as soon as possible during the recovery period. You will be shown specific exercises that will increase foot function by enlarging the range of motion. Exercises will also help strengthen the supporting muscles. Gradually you will begin to put weight on the foot, but it is important to follow medical advice as too much weight on the foot too early may cause further damage and require surgery to correct. Initially you will probably wear a walking boot, and use crutches or a cane to limit the amount of weight placed on the foot.
Prognosis:
A calcaneal fracture is a serious injury that may lead to long-lasting problems. There is an increased risk of developing arthritis in the affected joint, with the associated pain and stiffness. A permanent loss of range of motion in the ankle is possible, and if the heel bone fragmented, there may be a discrepancy in the length of the legs, causing you to walk with a limp. Subsequent surgery is often necessary. You may need to use an arch support in your shoe, or a brace, on a permanent basis.
If the original injury was mild you will probably be able to resume normal activity about 3 months after surgery. If, however, the injury was severe, it may take up to 2 years, and it is likely that there will be some permanent damage and loss of normal function.
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