Fracture of the Calcaneus
The calcaneus or heel bone is the largest bone in the foot and is situated at the lower back part of the foot. The calcaneus forms the subtalar joint with the talus, which helps provide side-to-side movement of the foot. Fractures of the calcaneus reduce or prevent movement of the subtalar joint. Calcaneus fractures may lead to deformity of the heel and foot, irregularity of the subtalar joint, post-traumatic arthritis, and affect the surrounding tendons and nerves of the heel.
Based on the involvement of the subtalar joint, calcaneus fractures are divided into fractures that enter the joint (intra-articular fractures) or fractures that don’t enter the joint (extra-articular fractures). Intra-articular fractures involve the joint and any of the three subtalar articulating facets (the locations where the two bones meet). Extra-articular fractures may involve the calcaneal body and associated structures, but not the joint.
What are the causes of calcaneus fractures?
Calcaneus fractures are mostly high-energy injuries caused by forceful trauma, such as jumping from a height or motor vehicle accidents. More unusually, ankle sprains and stress fractures may also cause the heel bone to become fractured.
What are the signs and symptoms?
Signs and symptoms of calcaneus fractures include:
- Sudden heel pain
- Swelling around the heel area
- Bruised heel, sole of the foot and ankle
- Inability to bear weight on the injured heel
- Absent or limited inward and outward movement of the foot
How is it diagnosed?
After a history and examination of the foot and ankle, X-rays are ordered to evaluate the ankle and foot. Given the complex fracture patterns seen in calcaneus fractures, a CT scan is often ordered to fully evaluate the injury and plan treatment accordingly.
What are the treatment options?
The treatment approach for calcaneus fracture depends on the type and severity of injury.
Minimally displaced fractures, with well-aligned subtalar and calcaneocuboid joints, can be treated non-surgically. This involves casting of the leg and foot in a below-knee plaster for around 6 weeks, rest and elevation, and strict non-weightbearing.
Surgery is recommended for intra-articular or displaced calcaneal fractures. The goal of surgery is to restore the normal shape of the calcaneus, as well as to reconstruct the joint surface. Some fractures necessitate an open approach with a large L-shaped incision on the outside of the heel, whilst other fractures can be managed with a smaller incision just in front of the tip of the fibula. Some select fracture patterns can be treated in a minimally-invasive patterns, using only small cuts to manipulate the bone fragments and fix them with screws.
Ultimately, the idea behind restoring the normal shape of the bone and congruency of the subtalar joint with surgery is to restore normal movement to the ankle and hindfoot, and reduce the likelihood of developing post-traumatic arthritis, stiffness and pain.
How long does it take to recover?
Calcaneus fractures are severe injuries, and recovery can take many months. Patients are usually non-weightbearing for 8 to 12 weeks after the injury or surgery. Prolonged physiotherapy can be needed after this to maximise function. Swelling and stiffness is likely to be present for many months.
Long term pain and disability are not uncommon after this injury, even after excellent surgical treatment. Patients in manual labour jobs can take 6-12 months to return to work.
The biggest risk with intra-articular calcaneus fractures is stiffness of the subtalar joint, resulting in a loss of sideways movement in the foot. This makes it very difficult to accommodate walking on uneven ground. Ongoing pain and decreased mobility are also common complications from this injury. Further surgery can be required in the future to rebuild the calcaneus and fuse the subtalar joint.