10/21/2017

Calcaneal Fractures

Calcaneal Fractures

Fractures of the calcaneus (heel bone) is the most common tarsal bone fracture. Most calcaneal fractures occur as the result of a fall from a height more than 14 feet. Calcaneal fractures are common among roofers and mountain climbers. The second most common contributing cause to these traumatic fractures are automobile accidents. Calcaneal fractures are most commonly found in males age 30-50 y/o.

Calcaneal fractures have a track record of being difficult to deal with and have frustrated doctors for years. The issue for calcaneal fractures is in trying to rebuild the break in order that therapeutic may take place. The calcaneus is actually much like an egg; an outer firm shell and soft on the inside. As a result, the calcaneus usually shatters when broken. Calcaneal repair not only requires re-apposition of multiple break patterns, but also requires restoration of the subtalar joint. The particular subtalar joint is the interface between the calcaneus and also talus and is a major load bearing joint of the base. In some cases, further joint surfaces may be affected (the calcaneal cuboid joint) but are of lesser importance because of their limited weight bearing roles.

Two classifications are used for the classification of calcaneal fractures. The particular Rowe classification as well as the Essex-Lopresti classification both describe calcaneal fractures. TheEssex-Lopresti classification describes subtalar joint depressive disorder fractures (very severe fractures) in a bit more detail than the more commonly used Rowe group. Plain xrays and CT scans are often used to determine the extent and classification of calcaneal fractures.

Type 1a - Tuberosity fracture medial or lateral

Type 1c - Fracture of the anterior process of the calcaneus

Type 2b - Avulsion crack involving the insertion from the tendo-Achillles

Type 4 - Body crack involving the subtalar joint

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The Essex-Lopresti Category Of Calcaneal Fractures

Type a - Language Type

Type B - Joint depression type.

Stress Fractures of the Calcaneus

Stress fractures of the calcaneus are typically the result of a sudden abrupt injury but can occur without a history of trauma. The most common injury seen our practice is a fall from a height of more than 6 ft. A stress fracture of the calcaneus is a condition that is often overlooked as a differential diagnosis of heel pain. Plantar fasciitis (also called heel spur syndrome)is so common that many health care providers will defer to plantar fasciitis as a primary diagnosis when checking heel pain. A good patient history, as well as particularly one that notes the onset and character of the pain, is very important when distinguishing between plantar fasciitis and calcaneal stress fractures.

The diagnosis of calcaneal stress fractures can be difficult at times. Stress fractures, regardless of where they occur in the body, are different than what we would tend to think of when we go over fractures. The appearance of a stress fracture on x-ray are not always evident.. Quite often, the only x-ray findings that we'll see are those who show up on the end of the healing process, sometimes as long as several months after the damage. We don't actually visualize the fracture, but rather we see the calcification that occurs in the late phases of the healing process. Should the symptoms of heel pain not respond to treatment for plantar fasciitis, or initial clinical findings seem suggestive of a stress fracture, there are several tools that can be used to help differentiate between calcaneal stress fractures and each of the other common conditions considered in treating heel pain.

Plain x-rays may be able to see a calcaneal break, but quite often, due to the lack of disruption of the bone, plain films lack the ability to 'see' the fracture. As fractures heal, many times the healing process can be seen on plain x-ray films. The recovery process will increase the amount of calcium encircling the fracture. This process of calcification typically takes about 4-6 weeks to see on plain x-ray, therefore, periodic follow-up x-rays may aid in diagnosing a stress fracture of the heel.

Three phase technitium bone scan may help differentiate the location and degree of inflammation in the calcaneus thereby helping to diagnose a calcaneal stress fracture. Bone scans are a test the place where a radioactive nucleotide is injected into the patient and a scan is taken of the injured area three times over the course of three hours. Each of the scans show a different amount of inflammation based upon the increased blood flow to the painful area. In the case of a calcaneal break, a bone scan can help in many ways.

  • First, the scan will locate the area of the crack based upon the inflammation seen in fracture healing.
  • Second, the bone scan will help to differentiate between a number of other potential problems from the heel such as plantar fasciitis.
  • And lastly, a check might help to determine the acuteness of an injury.
  • For instance, we may see a questionable area on an x-ray but we will not be able to tell whether the thought injury is old or new.
  • The bone scan will help us in that a new injury will 'light up' on the check out due to its' current swelling.
  • An old injury on the other hand won't lighting up' on the scan due to its' insufficient current inflammation.
  • MRI's are also helpful in differentiating calcaneal fractures from plantar fasciitis.
  • MRI's can identify small areas of bone edema suggestive of a crack.

Treatment of Calcaneal Fractures

As previously mentioned, calcaneal fractures can be very difficult to manage. Closed reduction is a term used when doctors will manipulate the fracture under anesthesia without surgery. Closed reduction can be successful in treating calcaneal fractures in many cases based upon the stage of fracture. Open reduction (surgical reduction of the fracture) is not guaranteed to produce more successful outcomes. Calcaneal fractures can range from simple to explosive. Follow-up following reduction (whether close or open) may differ but will include a period of non-weight bearing, splinting or sending your line to allow for fracture healing.

  • Severe cases of joint depression fractures (Rowe type 4 and additional surgery may be required to fuse the subtalar joint.
  • If the subtalar joint is significantly damaged in the injury, blend of the stj is the only solution.
  • Most doctors will stage these methods, performing a subtalar fusion long after the immediate trauma of the injury.
  • Treatment of calcaneal stress fractures varies with the severity of the fracture as well as the degree of pain.
  • Several cases of calcaneal stress fractures are simply treated with rest and a decrease of activity.
  • Others may necessitate a walking cast or period of non-weight bearing.
  • Medical intervention is rarely indicated.
  • Healing of calcaneal stress cracks can be prolonged and may require a period of several months to be able to heal.

Nomenclature:

Calcaneus - The bone of the heel.

  • Subtalar Joint - (STJ) the joint between the two major bones of the rearfoot, the talus and calcaneus.
  • The STJ is a common site of residual osteoarthritis following calcaneal fractures.
  • Technitium - a radioactive substance that is attracted to area of inflamation.
  • Used as the active substance in bone scans.
  • Anatomy: The calcaneus is very firm upon its' outer surface but soft as well as spongy on the inside, much like a great egg.
  • It is an unusually shaped bone with numerous surfaces making in the support for the subtalar joint and the calcaneal cuboid joint.

Biomechanics:

The biomechanics of calcaneal stress fractures has not been defined. Due to the fact that most calcaneal stress fractures happen as a result of random traumatic incident, no defined pathway for the fractures has been proven. Symptoms: The diagnosis of a calcaneal stress fracture is usually based upon pain in which proceeds following an incident of trauma. Occasionally a calcaneal stress fracture will have an insidious onset, but most with have got an acute onset. Edema (swelling) and erythema redness) may or may not be present.

The most common symptom of a calcaneal stress fracture, and the one indicator that can help to differentiate anxiety fractures from fasciitis, is the nature of the pain. Stress fracture pain is constant. It hurts when a person's body weight is first applied and continues in order to hurt. Pain due to plantar fasciitis is sharp at the start of weight bearing yet soon subsides, in order to a qualification, above 5-10 minutes.

The Location of Pain is Also Important

Stress fracture pain will generally (and not always) be in the body of the calcaneus. Pressure to the medial and lateral walls of the calcaneus result in pain. Plantar fascial pain is specific to the bottom of the heel and is moderate with direct pressure, but sever with weight bearing.

Differential Diagnosis:

Baxter's nerve entrapment - a great entrapment of the recurrent branch of the posterior tibial nerve.

Gout - deposition of monosodium urate crystals (hyperuricemia)

Heel Spur Syndrome - See Plantar Fasciitis

Plantar fasciitis - a common condition of the heel that results in pulling by the plantar fascia and a tearing pain at the addition of the fascia on the bottom of the heel. Pain is serious with the first few steps out of bed in the morning or after a brief period of rest.

Gout

Retrocalcaneal bursitis (Albert's Disease) - this really is the development and swelling of a bursa behind the heel between the heel bone and Achilles tendon

Rheumatoid Arthritis

Rheumatic Fever.

Septic Arthritis

Sero-negative arthropathies like Reiter's Syndrome.

Sever's Disease - and inflammatory situation typically found in younger over weight boys age 10 to 15 years old

  • Tarsal Tunnel Affliction - also known as posterior tibial nerve neuralgia.
  • Tarsal Tube Syn. characteristically has pain that does not decrease with rest.
  • Also has numbness or 'tingling' with the toes

References:

Rowe CR, Sakellarides HT, Freeman PA, et al. Fractures of the operating system calcis: long term follow-up study of 146 patients. JAMA.

  • Hermann OJ. conservative remedy for fractures of the operatingsystem calcis.
  • J Bone Shared Surg 1963:45-A:865-867

Palmer I. The mechanism and also treatment of fractures of the calcaneus: open reduction with the use of cancellous grafts. JBone Joint surg 1948;30-A(1):2-8

About the Author:Jeffrey a

Oster, DPM, C.Ped is a board certified foot and ankle surgeon. Dr. Oster is also board certified in pedorthics. Dr. Oster is medical director of Myfootshop.com which is in active exercise in Granville, Ohio.

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Domenic GoldenDomenic Golden
Domenic is a head content marketing specialist at musclenstress.com, a collection of articles on health issues. In the past, Domenic worked as a post curator for a well-known health site. When he's not writing posts, Domenic enjoys drawing and rock climbing.