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 greater than 14 feet. Calcaneal fractures are common among roofers and rock climbers. The second most common contributing cause to these types of traumatic fractures are vehicle 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 a long time. The situation in treating calcaneal fractures is in trying to rebuild the break to ensure that therapeutic may take place. The particular calcaneus is much like an egg; an outer firm shell and soft on the inside. As a result, the calcaneus frequently shatters when broken. Calcaneal repair not only calls for re-apposition of multiple break patterns, but also demands restoration of the subtalar joint. The actual subtalar joint is the interface between the calcaneus as well as talus and is a main load bearing joint of the feet. In some cases, extra joint surfaces may be affected (the calcaneal cuboid joint) but are of lesser importance because of their limited weight bearing tasks.
Two classifications are used for the classification of calcaneal fractures. The Rowe classification and also the Essex-Lopresti category both describe calcaneal fractures. TheEssex-Lopresti classification describes subtalar joint depressive disorders fractures (very serious fractures) in much 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 even lateral
Type 1c - Fracture of the anterior process of the calcaneus
Type 2b - Avulsion fracture involving the insertion of the tendo-Achillles
Type 4 - Body break involving the subtalar joint
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 a lot of health care providers will defer to plantar fasciitis as a primary diagnosis when evaluating heel pain. A good patient history, and particularly one that notes the onset and character of the pain, is very important when differentiating 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 the ones that show up towards the end of the healing process, sometimes as long as several months after the injury. We don't actually visualize the break, 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 for heel pain.
Plain x-rays may be able to see a calcaneal crack, 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 process of recovery will increase the amount of calcium around the break. This process of calcification typically requires about 4-6 weeks to see on plain x-ray, consequently, 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 identify a calcaneal stress fracture. Bone scans are a test 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 swollen 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 break based upon the inflammation seen in fracture healing.
- Second, the bone scan will help to differentiate between many other potential difficulties with the heel such as plantar fasciitis.
- Not only that, a check can 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 diagnosed injury is old or new.
- The bone scan will help us in that a new injury will 'light up' on the scan due to its' current inflammation.
- An old injury on the other hand will not gentle up' on the scan due to its' lack of 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 fracture.
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 dependant on 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 in order to explosive. Follow-up following reduction (whether close or open) differs but will include a period of non-weight bearing, splinting or throwing to allow for fracture healing.
- Severe cases of joint depression fractures (Rowe type 4 and additional surgery may be necessary to fuse the subtalar joint.
- When the subtalar joint is significantly damaged in the injury, fusion of the stj will be the only solution.
- Most doctors will stage these procedures, performing a subtalar fusion long after the particular immediate trauma of the injury.
- Treatment of calcaneal stress fractures varies with the severity of the crack and also the degree of pain.
- Many 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.
- Operative involvement is rarely indicated.
- Healing of calcaneal stress bony injury can be prolonged and may require a period of several months in order to heal.
Calcaneus - The particular bone with 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 arthritis pursuing calcaneal fractures.
- Technitium - a radioactive substance that is attracted to area of inflamation.
- Used as the active substance in bone reads.
- Anatomy: The calcaneus is very firm on its' outer surface but soft and spongy on the inside, very similar to a good egg.
- It is really an unusually shaped bone with numerous surfaces making in the support for the subtalar joint and the calcaneal cuboid joint.
The biomechanics of calcaneal stress fractures has not been defined. Due to the fact that most calcaneal stress fractures happen due to a random traumatic incident, no defined pathway for that fractures has been established. Symptoms: The diagnosis of a calcaneal stress fracture is usually based on pain in which continues following an incident of trauma. From time to time a calcaneal stress crack will have a good insidious onset, but many with have 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 be able to differentiate anxiety fractures from fasciitis, is the nature of the pain. Stress fracture pain is constant. It hurts when you weight is first applied and continues to hurt. Pain due to plantar fasciitis is sharp in the beginning of weight bearing however soon subsides, in order to a degree, more than 5-10 minutes.
The Location of Pain is Also Important
Stress fracture pain will typically (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.
Baxter's nerve entrapment - a good 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 through the plantar fascia and a tearing pain at the connection 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.
Retrocalcaneal bursitis (Albert's Disease) - that is the development and irritation of a bursa at the back of the heel between the heel bone and Achilles tendon
Sero-negative arthropathies such as Reiter's Syndrome.
Sever's Disease - and inflammatory problem typically found in younger over weight boys age 10 to 15 years old
- Tarsal Tunnel Syndrome - also called posterior tibial nerve neuralgia.
- Tarsal Canal Syn. characteristically has pain that does not decrease with rest.
- Also has numbness or 'tingling' of the toes
Rowe CR, Sakellarides HT, Freeman PA, et al. Fractures of the os calcis: long term follow-up study of 146 patients. JAMA.
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- Hermann OJ. conservative remedy for fractures of the operating system calcis.
- J Bone Joint Surg 1963:45-A:865-867
Palmer I. The device as well as 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 and it is in active practice in Granville, Ohio.