In: StatPearls [Internet]. Most calcaneal fractures are occupational, and are caused by axial loading from a fall [ 2 ]. 2017 Feb [PubMed PMID: 28129268], Hsu AR,Anderson RB,Cohen BE, Advances in Surgical Management of Intra-articular Calcaneus Fractures. There are two main classification systems of extraarticular fractures. All open wounds need immediate surgery. 2019 Apr; [PubMed PMID: 30784540], Cottom JM,Douthett SM,McConnell KK, Intraoperative Reduction Techniques for Surgical Management of Displaced Intra-Articular Calcaneal Fractures. Anterior calcaneal process fractures are often missed fractures of the calcaneus (up to 88% are not reported on radiographic examination of the ankle) 1 leading to non-union of bone fragments, unrecognised associated ligamentous injuries, and persistent ankle or foot pain. [35][36](Level V), Adams MR,Koury KL,Mistry JB,Braaksma W,Hwang JS,Firoozabadi R, Plantar Medial Avulsion Fragment Associated With Tongue-Type Calcaneus Fractures. 4. When this occurs, the heel can widen, shorten, and become deformed. This will usually occur five to ten days following the injury. The https:// ensures that you are connecting to the Non-weight bearing status for up to 10-12 weeks, Immobilization in a cast, fracture boot or splint for 8-10 weeks. 2020 Jan [PubMed PMID: 28846249], Griffin D,Parsons N,Shaw E,Kulikov Y,Hutchinson C,Thorogood M,Lamb SE, Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. Calcaneus Fracture. Change every 2-3 hours to help with swelling. The Calcaneus bone (heel bone) sits on the base of the foot under the ankle joint, one of several tarsal bones, and along with the talus, it forms the hindfoot. Calcaneus Fracture (Broken Heel) Treatment The calcaneus or heel bone is the largest bone in the foot and servers as the primary weight bearing structure in the heel. [21]Of note, there was no comparison of pre-operative fracture morphology and many authors contend that more severe patterns require the extensile approach and are also predisposed to a higher complication rate. The Journal of the American Academy of Orthopaedic Surgeons. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. Clin Podiatr Med Surg. The hindfoot articulates with the tibia and fibula creating the ankle joint. We do not capture any email address. The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3. Apply malleable freezer gel packs to the anterior ankle. Once the patient and the surgeon have determined to proceed with surgical treatment the goals must include adequate reduction of articular surfaces and restoration of calcaneal morphology. Medicine. These injuries are also closely associated with the development of post-traumatic arthritis of the subtalar joint (rearfoot). This type of fracture commonly occurs during a high-energy eventsuch as a car crash or a fall from a ladderwhen the heel is crushed under the weight of the body. Copyright 2022, StatPearls Publishing LLC. Calcaneus fractures have enormous morbidity and are often associated with many other injuries. Fractures or breaks of the calcaneus commonly occur after a fall from a height or car accident. 2003 Feb [PubMed PMID: 12571499], Eastwood DM,Langkamer VG,Atkins RM, Intra-articular fractures of the calcaneum. In a head-on collision, it is common for the driver or a passenger to suffer from a broken heel upon impact. -, Schepers T. Sinus Tarsi Approach with Screws-Only Fixation for Displaced Intra-Articular Calcaneal Fractures. Type III fractures:3 bony fragmentsincluding an additional depressed middle fragment. All surgical treatment is aimed at restoration of heel height and width (i.e., reconstructing the anatomy to reapproximateBohlerand Gissane angles), repair and realignment of the subtalar joint, and returning the mechanical axis of the hindfoot to functionality. 2. 2014 Feb 19 [PubMed PMID: 24553887], Ohashi K,Sanghvi T,El-Khoury GY,Ahn JM,Bennett DL,Geijer M,Inaoka T,Berbaum K, Diagnostic accuracy of 3D color volume-rendered CT images for peroneal tendon dislocation in patients with acute calcaneal fractures. Loss of ipsilateral dorsalis pedis or posterior tibial pulse compared to contralateral limb should raise suspicion of arterial injury and prompt further investigation with angiography or Doppler scanning. 2019 Oct [PubMed PMID: 31921576], Albin SR,Koppenhaver SL,Marcus R,Dibble L,Cornwall M,Fritz JM, Short-Term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Calcaneal fractures most commonly occur during high energy events leading toaxial loading of the bone but can occur with anyinjury to the foot and ankle. Please note that narcotics in our practice are extremely restricted and are NOT a good long term solution. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal/plantar flexion. Critical Angle of Gissane/Gissane Angle. You should follow the at-home treatments recommended for non-surgical patients, including rest, ice, elevation, and compression. STUDY. There was, however, a difference between wound complications, superficial infection, nerve injury, VAS pain scores, American Academy of Orthopedic Foot and Ankle Society (AOFAS) scores, calcaneal height and post-operative Bohler's angle in favor of minimally invasive techniques. A general pain in the heel that gradually worsens could be a sign of a stress fracture. Overall the outlook for patients with calcaneus fractures is guarded. [14]. Stress fractures may occur with overuse or repetitive use, such as running. A fracture of the calcaneus, or heel bone, can be a painful and disabling injury. A calcaneal fracture occurs when an excessive force crushes the heel bone against the talus (the lowest bone of the ankle). This is usually related to the amount of force that was . The three bones of the ankle include: The tibia, or shinbone The fibula, the smaller bone in the lower leg Those with an isolated fracture do recover with time but those with a concomitant injury to the pelvis, spine, neck or head often require prolonged rehabilitation and still have residual physical deficits. Clinics in podiatric medicine and surgery. The indication for this approach includes Sanders type II and III, patients with comorbidities that make soft tissue more vulnerable to complications include diabetes mellitus, smoking and/or obesity, peripheral vascular disease, and minimal posterior facet fragment comminution. [30]This is considered post-traumatic arthritis. Most of the injuries cause the bone to flatten, widen, and shorten. Joint depression type with a single verticle fracture line throughthe angle of Gissane separating the anterior and posterior portions of the calcaneus. J Am Acad Orthop Surg. Intra-articular calcaneal with subtalar joint depression. Scenario: A 43-year-old man fell off of a ladder from approximately 7 ft high and landed completely on one foot. The peak incidence occurs in younger males [ 2 ]. [14]. This type of fracture commonly occurs during a high-energy event such as a car crash or a fall from a ladder when the heel is crushed under the weight of the body. Calcaneal stress fractures can cause intense pain and make walking more difficult. Discrepancy between the normal angles of . 1993 Jul; [PubMed PMID: 8519099], Shannon SF,Houdek MT,Wyles CC,Yuan BJ,Cross WW 3rd,Cass JR,Sems SA, Allgwer-Donati Versus Vertical Mattress Suture Technique Impact on Perfusion in Ankle Fracture Surgery: A Randomized Clinical Trial Using Intraoperative Angiography. [19], The goals of the minimally invasive technique (or sinus tarsi approach) are to minimize soft tissue injury while simultaneously allowing for fracture reduction and stabilization. A thorough evaluation of the entire spine should be performed anytime a calcaneal fracture is identified especially when a fall is a mechanism. [4][5]Falls from height and automobile accidents are the predominant mechanisms of injury, although jumping onto hard surfaces, blunt or penetrating trauma and twisting/shearing events may also cause injury. Pathology Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8: extra-articular: 25-30% anterior calcaneal process fracture He presented with constant pain, swelling of the foot and ankle and worsening pain with all ankle/foot movements. Calcaneal fractures account for 50-60% of allfractured tarsal bones. Mondor's sign or ecchymosis of the foot extending distally onto the heel is a hallmark of this injury. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal . The calcaneus is the most commonly fractured tarsal bone, representing 60 percent of all tarsal fractures in adults [ 1 ]. Comorbidities such as diabetes and osteoporosis may increase the risk of all types of fractures. [17]. Clinical orthopaedics and related research. Thus, the condition is best managed by an interprofessional team that includes a trauma surgeon, emergency department physician, orthopedic nurses, orthopedic surgeon, internist, and physiotherapist. Your foot and ankle specialist will assess your injury and determine whether to treat the fracture surgically or non-surgically. Typically a small, low-profile is plate is used after reduction of the joint surface and is placed along the joint-line. The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3. When resting, prop your foot up on stools or pillows to keep it above your heart. Loss of subtalar motion is very common as well. 2022 Aug 8. Copyright 2022 BMJ Publishing Group Ltd, North Petherton Surgery: GP Opportunity (up to 8 sessions) - North Petherton Surgery, Meadows Surgery: GP Opportunity (up to 8 sessions) - The Meadows Surgery, Ilminster, Bruton Surgery: GP Opportunity (8 sessions) - Bruton Surgery, Government of Jersey: Staff Grade in Trauma & Orthopaedics, Womens, childrens & adolescents health. The force from impacting the ground translates through the lower extremity and upward sometimes causing. Disclaimer, National Library of Medicine Because of this calcaneal fractures tend to come with other problems that vary with the extent of the injury. [6][7]Similarly, a foot depressed against an accelerator, brake or floorboard translates a large amount of force through the calcaneus during high-speedautomobile accidents. This joint is important for normal foot function. Common complications may include: Following surgery, your foot and ankle specialist will likely immobilize your foot in a splint to allow the bone and joints time to heal. BMJ (Clinical research ed.). Twenty-one fractures were included in this series and the authors found that calcaneal length, height, and axial alignment can be restored with an external fixator, Bohler's angle cannot be restored with external fixator and ligamentotaxis alone. Splinting, ice and elevation will be helpful in improving tissue quality for later operative intervention. The site is secure. Created by. Often because of the great force needed to break the heel bone, other injuries to the knees and spine are common. The subtalar joint is formed by the calcaneus and the bone above it, which is called the talus. Open calcaneal fractures require emergent irrigation and debridement and careful wound management. Peroneal tendon instability may result from displaced, intra-articular calcaneus fractures. Intraoperative Reduction Techniques for Surgical Management of Displaced Intra-Articular Calcaneal Fractures. [33]. Manual traction is used to restore the high and length of the tuberosity (placement of a Steinmann pin into the tuberosity is helpful in restoring these parameters). Calcaneal anatomy is demonstrated in Figure 1. 2014 Oct; [PubMed PMID: 25243849], Githens M,Shatsky J,Agel J,Bransford RJ,Benirschke SK, Medial external fixation for staged treatment of closed calcaneus fractures: Surgical technique and case series. Clin Podiatr Med Surg. Gravity. Please note: your email address is provided to the journal, which may use this information for marketing purposes. Furthermore, with significant height loss, calcaneal widening and hindfoot varus subfibular impingement may result from soft tissue or osseous abnormalities. A clinical assessment by a Physical Therapist can identify the likelihood of a Calcaneus Fracture through clinical tests such as the Calcaneal Squeeze test. [32] This may result from direct damage to the tendons themselves as a result of the injury or fracture fragments that may impinge on the tendons. Previous literature by Siebert et al included 36 open calcaneal fractures in which there were 23 cases with complications including need for soft tissue coverage, nine cases of osteomyelitis, five amputations and one arthrodesis. Fracture to the calcaneus is rare, with tarsal bones accounting for approximately 2% of all fractures, while Calcaneus Fractures account for 50-60% of those tarsal fractures. These fractures will heal if treated non-operatively, but patients can be left with persistent deformity, incongruent joint surfaces, and loss of alignment of the leg to the heel. A bstrAct. The Journal of orthopaedic and sports physical therapy. 2019 Feb 13; [PubMed PMID: 30759357], Toro G,Langella F,Gison M,Toro G,Moretti A,Toro A,Iolascon G, Stentoplasty of calcaneal fractures: Surgical technique and early outcomes. If not treated emergently skin breakdown may lead to disastrous sequelae. When conservative treatment is appropriate, a period of 4-6 weeks in a walker boot is recommended whereas walking short distances as pain allows is normally recommended. technical support for your product directly (links go to external sites): Thank you for your interest in spreading the word about The BMJ. A recent randomized controlled trial reviewed operative versus non-operative treatment for closed, displaced, intra-articular calcaneus fractures. If you have recently experienced a trauma and are experiencing symptoms of a calcaneal fracture, visit your foot and ankle specialist. Clin Podiatr Med Surg. The calcaneus is the most commonly fractured tarsal bone, representing 60 percent of all tarsal fractures in adults [ 1 ]. 2019 Apr;36(2):211-224. Heel bones are often injured in a collision where other skeletal parts sustain injury as well. 2018 Mar 9; [PubMed PMID: 29523122], Sop JL,Sop A, Open Fracture Management . Treasure Island (FL): StatPearls Publishing; 2022 Jan. Clipboard, Search History, and several other advanced features are temporarily unavailable. Usually due to a fall from a height at work or a road traffic incident, calcaneal fractures are often intra-articular and displaced, affecting primarily the subtalar joint. Please enable it to take advantage of the complete set of features! 2019 Apr;36(2):323-337. The operative group was treated as described below with the extensile lateral approach and the non-operative group was treated with initial immobilization followed by gentle mobilization as allowed by pain. Journal of orthopaedic trauma. Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. He offers Online Physiotherapy Appointments for 45. HHS Vulnerability Disclosure, Help Rearfoot fractures of either the heel bone (calcaneus) typically occur after a high impact/velocity injury, such as a fall from height or motor vehicle accident. This occurs from a sudden movement and typically involves the Achilles Tendon or the Bifurcate Ligament. Summarize the treatment options for calcaneus fractures including surgical options and the risks and benefits associated with treatment. Furthermore, all serous and hemorrhagic blisters must be epithelialized. Your doctor may also order a CT scan to get a better idea of the pattern of the fracture, to determine whether surgery is needed. Elevation of the foot. The calcaneus (also called the heel bone) is the largest tarsal bone of the foot. Fractures: Non-displaced or minimally displaced fragment, 2 bony fragments which are subdivided into A, B or C depending on if they are medial process or lateral process fracture, 3 bony fragments, divided into AB, AC or BC relative to the position and location of fracture lines. Your doctor may prescribe you pain medication or you can take over-the-counter NSAIDs, such as Ibuprofen and Naproxen. Typically, non-surgical treatment involves: Surgical correction of a fractured heel bone is a risky procedure. When this occurs, the heel can widen, shorten, and become deformed. and transmitted securely. 2018 Aug; [PubMed PMID: 30095652], Csizy M,Buckley R,Tough S,Leighton R,Smith J,McCormack R,Pate G,Petrie D,Galpin R, Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. Sanders Classification: Based on reconstituted CT findings. 2013 Jun [PubMed PMID: 23460669], Li LH,Guo YZ,Wang H,Sang QH,Zhang JZ,Liu Z,Sun TS, Less wound complications of a sinus tarsi approach compared to an extended lateral approach for the treatment of displaced intraarticular calcaneal fracture: A randomized clinical trial in 64 patients. Those with an isolated fracture do recover with time but those with a concomitant injury . Patients will present with diffuse pain, edema, and ecchymosis atthe affected fracture site. A smaller number of calcaneal fractures are stress fractures, caused by overuse or repetitive stress on the heel bone. There are two main categories of Calcaneus Fracture. Compression. Immediately post-operatively the patient's foot and ankle should be placed into an extremely well-padded posterior splint. Alexander Orthopaedic AssociatesAdam D. Perler, DPM, FACFAS2438 Dr. ML King Jr. St. N. | Suite ASt. Emergent reduction to relieve this tented skin is often recommended. Abnormalities of either of these findings should prompt a CT scan for further classification and evaluation of the fracture. 2022 May 29. Of note, this same incision may be used for subsequent subtalar arthrodesis should that be necessary. The patient is not likelyable to bear weight. The wound complication rate was 29% in the extensile lateral group with 9% of the total treated cases requiring repeat surgery for those complications. Write. Clinical orthopaedics and related research. Don't take our work for it! It allows for adequate visualization intra-operatively and allows for manipulation of the fracture to restore alignment and articular surfaces. The majority are displaced intraarticular fractures (60 to 75 percent) [ 2 ]. Journal of orthopaedic trauma. [14](Level III), Complete recovery from a calcaneus fracture may take months or even years. 2019 Feb; [PubMed PMID: 30664605], Shih JT,Kuo CL,Yeh TT,Shen HC,Pan RY,Wu CC, Modified Essex-Lopresti procedure with percutaneous calcaneoplasty for comminuted intra-articular calcaneal fractures: a retrospective case analysis. This type of fracture commonly occurs during a high-energy event such as a car crash or a fall from a ladder when the heel is crushed under the weight of the body. 2019 Jun;40(6):634-640. The fracture lines are opened at this time and may include temporary removal of the lateral wall. official website and that any information you provide is encrypted Spell. Feel free to get in touch with us and send a message. Historically a burst fracture of the calcaneus was coined a "Lovers Fracture" as the injury would occur as a suitor would jump off a lover's balcony to avoid detection. However, they are also seen in long-distance runners, ballet dancers and sports involving jumping. 2010 Mar [PubMed PMID: 20194342], Buckley R,Tough S,McCormack R,Pate G,Leighton R,Petrie D,Galpin R, Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. X-ray imaging can be helpful in making a diagnosis. [25] However, other studies have found that patients who develop post-traumatic arthritis who first undergo open reduction internal fixation of their fractures with the intraoperative restoration of calcaneal morphology do better than those who develop subtalar arthritis due to malunion following non-operative treatment. Non displaced fractures are managed conservatively. Some authors contend that anatomic reduction, fracture disimpaction, and repositioning is exceedingly difficult with limited exposures. The .gov means its official. Only 6% of the minimally invasive group had wound complications and none required additional surgery. Some have more simple patterns that do not involve the joint and usually heal without any long term issues while others are more complex with fragment displacement and extend into one of multiple joints and are very challenging to get to heal properly, often requiring surgical intervention to optimize healing. Once the surgeon has committed to the minimal approach conversion to the extensile lateral approach is not recommended and thus great care must be taken in determining the correct approach for the correct patient. Fracture blisters may appear within 36 hours of injury. Similar types of Calcaneus Fractures can occur due to car crashes. Restoration of normal alignment and contour is considered the . He offers. Icing. Kline et al concluded that the minimally invasive technique was valuable and could lead to a lower complication rate and comparable results. 2008 Mar;29(3):318-24. doi: 10.3113/FAI.2008.0318. When surgical management is recommended it is with the goal to restore calcaneal morphology and to restore articular congruency. The Journal of bone and joint surgery. The outlook for recovery depends on how severely the calcaneus was crushed at the time of injury. Clinics in podiatric medicine and surgery. jumping out of a window or off a balcony. Consideration must also be given to imaging of other parts of the patient's body based on history given the high energy nature of the injuries that tend to cause calcaneal fractures. The hindfoot articulates with the tibia and fibula creating the ankle joint. Subdivided into types A, B, and C depending on the medial or lateral location of the fracture line. Avulsion fractures are when a tendon or a ligament pulls off a fragment of bone from the Calcaneus. Injury. A calcaneal stress fracture is one or more small breaks in your heel bone (calcaneus). -, Bibbo C, Siddiqui N, Fink J, Powers J, Ehrlich DA, Kovach SJ. You should avoid bearing weight on the foot for 10-12 weeks until it is sufficiently healed. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. A temporary reduction may be maintained by the placement of Kirschner wires through this tuberosity fragment into the "constant" fragment of the medial sustentaculum. Calcaneal fractures usually occur after a high-energy accident, such as in a motor vehicle crash or a fall from a great height. This allocation was based on surgeon preference. A Shantz pin is still used through a percutaneous incision for manipulation of the calcaneal tuberosity. The hindfoot articulates with the tibia and fibula creating the ankle joint. If this test is positive for pain, it is likely that you will be referred for an x-ray. Federal government websites often end in .gov or .mil. About 10% of patients with calcaneal fractures also suffer a back injury called a Lumbar spinal burst fracture. Calcaneus Fractures: FAQsCauses and Treatment for a Bruised HeelConditions that cause Heel Pain in the Morning, This is not medical advice. Bethesda, MD 20894, Web Policies All participants of the study recovered very slowly from injury, most improvement plateaued at 18 months and most participants reported ongoing adverse effects from their injury at 2 years. 2017 Sep-Dec [PubMed PMID: 28844198], Aldridge JM 3rd,Easley M,Nunley JA, Open calcaneal fractures: results of operative treatment. The provider must also keep in mind that certain fracture morphologies necessitate surgical care and that certain patient groups will do more poorly with surgery. Hindfoot Fractures: Injury Patterns and Relevant Imaging Findings. Calcaneus fractures are rare but potentially debilitating injuries. [22]. Evaluation of a potential calcaneus fracture should include the following: Calcaneal fractures can be classified into two general categories.[9][10]. Treatment of these fractures may require surgery. Their cohort of patients additionally had poor quality of life metrics post-operatively. Calcaneus fractures are the most common fractured tarsal bone and are associated with a high degree of morbidity and disability. Some intraarticular injuries may be treated in a closed fashion depending upon severity. This part of the growing body of evidence that the smaller incision techniques may be useful in certain groups. Acta radiologica (Stockholm, Sweden : 1987). As severe as calcaneal fractures can be, studies have shown that non-surgical treatment can be very nearly as effective as surgical treatment in the right individuals. A small series was performed by Githens et al with the supposition that medial external fixator placement would allow for improved soft tissue healing, early restoration of calcaneal morphology, and reduction of wound-related complications by re-tensioning the incision during the operative intervention. Fracture patterns are similar in either mechanism. Overall the outlook for patients with calcaneus fractures is guarded. Explain the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by calcaneus fracture. The meta-analysis did confirm the higher complication rate of operative intervention but concluded that operative treatment of displaced, intra-articular calcaneal fractures has better anatomic recovery, functional outcomes and return to work. Overall, they screened 2006 patients with calcaneal fractures, of whom a quarter (n=502) were eligible . . The calcaneus is the heel bone. The most common cause of a Calcaneus Fracture is a fall from a balcony, ladder, table or window. 2020 Mar - Apr [PubMed PMID: 32131003], Kline AJ,Anderson RB,Davis WH,Jones CP,Cohen BE, Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures. [31]. Before Here are some of the causes of a calcaneus fracture. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons. Up to a 40% displacement of the peroneal tendons has been appreciated on CT scans of calcaneus fractures. Weight-bearing is often delayed 8-12 weeks (or more depending on the degree of comminution and progression of healing on radiographs). Auto Accident. MeSH Physical therapy exercises. Calcaneal body fractures with significant varus or valgus malalignment, lateral impingement, loss of calcaneal height, or significant translation of the posterior tuberosity. A calcaneus fracture is a broken heel bone. Displaced fractures of the calcaneus, or heel bone, are a serious injury and the outlook for patients, who are typically young, remains poor. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons. The tibial artery and nerve run along the medial aspect of the calcaneal body and are thought to be shielded by the sustentaculum tali thus neurovascular injuries are uncommonwith calcaneal fractures. Falls. The results of the analysis showed no statistically significant difference in post-operative calcaneal width, length, deep infection or Gissane's angle between the two approaches. 2019 Feb 2; [PubMed PMID: 30739765], Ankle Radiograph Lateral Calcaneus Fracture. The calcaneus connects with the talus and cuboid bones. [16] Aldridge's group did recommend that definitive fixation not be performed at the time of initial irrigation and debridement. Due to the force of the injury, the damage is often extensive and often requires surgery. Calcaneal anatomy is demonstrated in Figure 1. [13]. The sinus tarsi approach is performed by creating a 2-4cm incision along a line from the tip of the fibula towards the base of the fourth metatarsal base. The authors had no deep or superficial wound infections requiring surgical intervention, which is promising but the authors simultaneously cautioned against drawing conclusions from such a small and limited series without statistical power or a control group. Displaced Type III fractures have a higher likelihood of resulting in subtalar fusion than lower classification injuries and patients should be counseled that further procedures may be required, including possible subtalar fusion. Most calcaneal fractures are occupational, and are caused by axial loading from a fall [ 2 ]. American volume. After 2 weeks, practice drawing a figure-8 with the toes to increase your range of motion in the ankle. Epub 2022 Mar 11. The worst results with regards to patient-reported outcomes and complications were found in the Grade III open fractures. Most patients with calcaneus fractures are young, with the 20-39 age group the most common. A traumatic event will almost invariably precede the presentation of calcaneal injury. Plantar ecchymosis extending through the plantar arch of the foot should raise suspicion significantly. Severe heel bone fractures can extend into the ankle joint and fracture the cartilage that . Most extraarticular fractures are treated conservatively with 10-12 weeks of casting (true extra-articular fractures only account for roughly 20% of all calcaneal fractures). There are several types of fracture patterns that can occur with trauma to the heel bone. This site needs JavaScript to work properly. These high forces associated with landing from a height directly onto the Calcaneus are often sufficient to create an impact fracture. Conservative treatment is most appropriate for simple, non-displaced fracture patterns, especially if they do not involve the joint. American volume. Calcaneus Fracture Diagnosis. Tarsal fractures account for roughly 2 percent of all fractures in adults. Bibek Adhya, Himmat Dhillon, Sidak Dhillon, Mandeep Singh Dhillon. You can download a PDF version for your personal record. Journal of orthopaedic trauma. jsandoe. Traditionally, a burst fracture of the calcaneus was known as "Lovers Fracture" as the injury would occur as a suitor would jump off a lover's balcony (axial loading) to avoid detection. Adams MR, Koury KL, Mistry JB, Braaksma W, Hwang JS, Firoozabadi R. Plantar Medial Avulsion Fragment Associated With Tongue-Type Calcaneus Fractures. The patient should be adequately educated on the need to elevate the extremity for the first several weeks after surgery to reduce swelling and the subsequent risk of wound complications. Calcaneus fracture commonly occurs during a high-energy eventsuch as a car crash or a fall from a ladderwhen the heel is crushed under the weight of the body. [28][29] Studies have shown greater than 70% of patients with calcaneus fractures have additional injuries. Aggressive wound care and antibiotics as needed for contaminated wounds. Match. If you are unable to import citations, please contact The epidemiology of tarsal fractures is as follows: Falls from a height directly translate energy into the calcaneus on impact as the heel strikes a surface crushing the calcaneus against the talus. Patients must be counseled that there are advantages and disadvantages to surgical treatment. Fractures that don't involve the . The calcaneus is the bone that makes up your heel. Many other groups have similar findings in that the sinus tarsi approach seems to lead to similar radiographic and functional outcomes with fewer wound complications overall. The goal of heel fracture surgery is to restore the shape of the heel bone as close to normal as possible. British volume. CT scan was performed immediately postoperatively and 95% of the fractures have posterior facet reduction to the anatomic position (with no appreciable step-off of the articular surface) and with no reductions >5mm inaccurately reduced. Clin Podiatr Med Surg. Some surgeons will favor primary subtalar arthrodesis as it seems to reduce the need for subsequent procedures and the associated increased costs and lost time from work associated with those additional surgeries. Injury. [18][14]. Surgical treatment tends to fall into one of two categories, the open extensile lateral approach, and minimally invasive techniques. Surgical treatment must be delayed until the so-called, "wrinkle sign," returns. The extensile lateral approach has been the primary approach for many years for operatively treating calcaneal fractures. Careers. 2002 Oct [PubMed PMID: 12377902], Spierings KE,Min M,Nooijen LE,Swords MP,Schepers T, Managing the open calcaneal fracture: A systematic review. Petersburg, Florida 33704PH: 727-547-4700 | FAX: 727-394-8661, Alexander Orthopaedic Associates Adam D. Perler, DPM, FACFAS12416 66th Street North | Suite ALargo, Florida 33773PH: 727-547-4700 | FAX: 727-394-8661. It included a total of 151 patients with 73 in the operative arm and 78 in the non-operative arm. Heel Bone Fractures (Calcaneal Fractures) Rearfoot fractures of either the heel bone (calcaneus) typically occur after a high impact/velocity injury, such as a fall from height or motor vehicle accident. Treatment for Calcaneus Fracture is decided based on the type and location of the fracture. Infections and wound breakdown are the most common and devastating complications of the extensile lateral approach. Calcaneus fractures are rare but potentially debilitating injuries. The varus deformity must also be corrected at this time. Care must be taken to ensure one does not over-penetrate the medial cortex. Since the calcaneus plays . . Clinics in podiatric medicine and surgery. Depending on the cause of your injury, your foot and ankle specialist may also examine you for an ankle or mid-foot injury, or refer you to another specialist to check for injuries beyond the foot. Reduction and alignment should be verified with fluoroscopy and exchanged for definitive fixation and the wound should be closed in layers with many recommending drain placement. Outcomes with open calcaneal fractures are generally poorer than closed fractures. This activity reviews the causes, presentation, and diagnosis of calcaneus fractures and highlights the role of the interprofessional team in their management. Your doctor will examine your heel and foot, and get an x-ray to see if it is broken or not. Urgent fracture reduction should proceed at the first sign of skin compromise. Over penetration of the medial cortex of the constant fragment may lead to entrapment of the flexor hallucis longus tendon and fixed great toe flexion. Subtalar osteoarthritis may result from surgical or nonsurgical treatment with an increasing number of patients with non-operatively treated displaced intra-articular calcaneus fractures requiring late subtalar fusion as a result of subtalar arthritis. Many times, surgery is necessary to restore normal anatomy and mobility. Chronic pain is also a common complication, in many cases owing to post-traumatic subtalar arthritis, malalignment or stiffness resulting from the injury. Calcaneus fractures are rare but potentially debilitating injuries. Calcaneus Fracture When this occurs, the heel can widen, shorten, and become deformed. An article by Aldridge et al in 2004 reviewed a case series of open calcaneal fractures and found that despite an increase in complications the quality of life metrics was higher than expected. All patients who are candidates for outpatient treatment are non-weight bearing at discharge. 2018 May-Jun; [PubMed PMID: 30521710], Diacon AL,Kimmel LA,Hau RC,Gabbe BJ,Edwards ER, Outcomes of midfoot and hindfoot fractures in multitrauma patients. These fractures often occur because of repetitive, long-term stress on the bone, such as from jogging. Certain Populations tend to have better results a well [27]: Due to the severe nature and the force required to sustain calcaneal fractures concomitant injuries must be considered. This is especially important in the setting of Tongue-type calcaneus fractures. Unable to load your collection due to an error, Unable to load your delegates due to an error. Joint depression with articular comminution or anterior process involvement, Bohler's angle of <5 degrees on initial presentation, Anterior process fractures with >25% of the calcaneocuboid articulation involved. The minimally invasive group's fracture composition was 61% Sanders II and 39% Sanders III. The results of the trial included a higher complication rate including infection and a requirement to remove hardware in 11% of the operative group, but there were no differences between the group with regards to health outcomes, range of motion, heel width, walking speed, and gait. The closure is typically recommended with an interrupted Allgwer-Donati stitch to try to relieve tension on the incision itself. Tongue-type fractures can lead to variable amounts of displacement of the tuberosity fragment, but due to the pull of the Achilles tendon, significant superior and dorsal displacement may occur leading to the potential to tent the posterior heel skin and place the soft tissue at significant risk of breakdown. Surgical technique. The type of surgery required should be discussed with an orthopaedic consultant. Calcaneal tuberosity avulsion displaced sustentaculum tali, and large substantial calcaneal body fractures may require operative management. This occurs when a vertebra in the lower-mid back is crushed. Wound complications and infections can be as high as 37% and 20% respectively with operative intervention. The extensile group's fracture composition was 53% Sanders II and 47% Sanders III. A fall from a ladder or staircase can result in a calcaneus fracture, especially if you land on your heel sideways or firmly flat. Nondisplaced Sanders type I fractures may be treated in a conservative, closed fashion. Avulsion fractures require a large amount of twisting or shearing force due to the strength of the ligamentous and tendinous attachments to the calcaneus. Bookshelf Fracture to the calcaneus is also known as a Lovers Fracture as historically it occurs when landing from a fall, i.e. Foot Ankle Int. This study concluded with recommendations against operative intervention for closed, displaced, intra-articular fractures of the calcaneus. Type I fractures: 1 nondisplaced or minimally displaced bony fragment. However, because of the lack of elevation of the L-flap, there is a decreased risk of peroneal tendon irritation and sural nerve complications. In: StatPearls [Internet]. The results of this cohort ofverifiably well-reduced fractures demonstrated that the type III fractures were 4 times more likely to require eventual subtalar fusion compared to type II fractures. These injuries are also closely associated with the . They found that despite a higher complication rate than closed calcaneal fractures treated operatively the complication rate in their paper was not as high as had been previously reported in the literature. Percutaneous fixation with Kirshner wires (K-wires) or screws may be implemented when soft tissue injury precludes an open approach. Recent studies suggest regional variation in male/female predominance due to disparities in the types ofregional accident occurrence. Medicine. The splint may be removed as early as 2-5 days based on some recommendations or left in place for 2 weeks in some cases, but after removing the splint the patient should begin his or her range of motion exercises for the subtalar joint and ankle joint as soon as possible. Journal of orthopaedic trauma. 8600 Rockville Pike Archives of orthopaedic and trauma surgery. Tourniquet use is recommended for both approaches. Initial bony evaluation with AP, lateral, and oblique plain films of the foot and ankle is needed. 2014 Oct [PubMed PMID: 24983433], Radnay CS,Clare MP,Sanders RW, Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? However, a recent meta-analysis was performing comparing minimally invasive techniques with the standard lateral extensile approach. 2019 Apr; [PubMed PMID: 30784536], Hordyk PJ,Fuerbringer BA,Roukis TS, Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures. Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures. Skin quality around the heel must be evaluated for tenting and/or threatened skin. This joint is often involved in these types of facture which can lead to long term problems with the joint such as chronic pain, stiffness and the development of arthritis. Normal Bohlers and Gissane angles do not rule out a fracture. 2019 Apr;36(2):269-277. In: StatPearls [Internet]. [20]. The Journal of bone and joint surgery. The Journal of bone and joint surgery. Calcaneal fractures present as a shortened-widened heel with varus deformity. Calcaneal fractures are rare in children. A calcaneus fracture is a heel bone fracture. Calcaneus fractures are a severe and life-changing injury. The amount of initial displacement based on Bohler's angle of <0 degrees is correlated with lower functional outcomes. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal/plantar flexion. -, Cottom JM, Douthett SM, McConnell KK. The calcaneus is the most fractured of all tarsal bones. Physical Therapy can last for 4-6 weeks depending on the cause of injury. Correct diagnosis and workup must include orthogonal X-Rays, specialized views, and a CT scan is considered the gold standard for a complete diagnosis. You doctor will evaluate your foot for swelling and other signs of a fracture or joint damage. If a Calcaneus Fracture is demonstrated on the x-ray, you may be referred for a CT scan for further clarity on the size and location of the fracture. [1][2][3]. Tongue type which has the same verticle fracture line as a depression type with another horizontal fracture line running posteriorly, creating a superior posterior fragment. FOIA In a linked paper (doi:10.1136/bmj.g4483), Griffin and colleagues report the results of a pragmatic, multicentre, randomised controlled trial comparing operative with non-operative care of closed, displaced intra-articular calcaneal fractures two years after injury.2 They excluded open injuries and grossly displaced fractures, where surgery is absolutely indicated. Pain medication. A two year recovery, with a stiff, painful, deformed foot that will not fit into a normal shoe and osteoarthritis of the subtalar joint are common outcomes.1, Orthopaedic surgeons often fix these fractures internally to try to improve the final result. The hindfoot articulates with the tibia and fibula creating the ankle joint. 2014 Jul 24 [PubMed PMID: 25059747], Wei N,Yuwen P,Liu W,Zhu Y,Chang W,Feng C,Chen W, Operative versus nonoperative treatment of displaced intra-articular calcaneal fractures: A meta-analysis of current evidence base. PMC Clinics in podiatric medicine and surgery. [12], A more recent meta-analysis from 2017composed of 18 trials including 1467 patients found significantly improved anatomical improvements with operative intervention with regards to the restoration of Bohler's angle, calcaneal heights and widths as well as the likelihood of resuming former work. 2005 Dec;13(8):492-502. doi: 10.5435/00124635-200512000-00002. 1993 Mar; [PubMed PMID: 8444935], Toussaint RJ,Lin D,Ehrlichman LK,Ellington JK,Strasser N,Kwon JY, Peroneal tendon displacement accompanying intra-articular calcaneal fractures. It is part of the hindfoot and sits directly below the three bones that make up the ankle joint. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal/plantar flexion. This is often determined by serial x-rays performed in the office during your follow-up visits. The extensile lateral approach is performed by creating full-thickness soft tissue and periosteal flaps as previously described by Gould and lateral modified by Benirschke and Sangeorzan. Smokers, elderly patients, and patients with diabetes or vascular disease may be at higher risk for surgical complication, such as an infection or blood loss. In this analysis, there were 2179 participants followed for an average of 22.41 months. After surgery complications are common and may include compartment syndrome, osteomyelitis, wound infection malunion and subtalar arthritis. Arthroscopy techniques. Stress fractures such as those seen in runners would be best evaluated with a bone scan or MRI. Calcaneus fractures usually hurt and get very swollen right after the injury. Foot [PubMed PMID: 30841752], Bibbo C,Siddiqui N,Fink J,Powers J,Ehrlich DA,Kovach SJ, Wound Coverage Options for Soft Tissue Defects Following Calcaneal Fracture Management (Operative/Surgical). Drains are typically removed on postoperative day 2 or even earlier based on surgeon preference. The decision to move forward with surgery must be based on fully informed consent of the abundant risks and expected benefits of surgery and must involve the patient in shared decision making as the operative intervention for calcaneal fractures is fraught with complications. In patients with identifiedthreatened soft tissueupon presentation treated with emergent operative reduction and fixation none went on to further soft-tissue complications[24]. Diagnosis is made radiographically with foot radiographs with CT scan often being required for surgical planning. Out of those fractures, 60 percent are classified as a calcaneus fracture. Repetitive stress on the Calcaneus bone from activities such as running can cause a Calcaneus Stress Fracture. You may see blisters form. He reported immediate pain in the foot with inability to bear weight. The outlook for recovery depends on how severely the calcaneus was crushed at the time of injury. Upon removal of the boot, Physical therapy consisting of mobalisations, mobility and strengthening exercises should commence. Pain in the heel, with diffuse tenderness on palpation of the heel Swelling Plantar ecchymosis [26], The Sanders classification has been found to have sustained prognostic value. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. We recommend a consultation with a medical professional such as James McCormack. An official website of the United States government. Process and tubercle fractures of the hindfoot. Once you are allowed to bear weight on the foot, Dr. Perler usually sends you for physical therapy who will help you get back to full weight bearing and out of the boot over the following month. A fracture from a fall may require simple strengthening and rehabilitation while a Calcaneus Stress Fracture from running can require a thorough gait analysis and running re-training alongside insoles and changes in footwear. Test. The surgeon must then determine the appropriate approach and implants required to obtain that goal. Think of the calcaneus as an egg with in intact shell it is hard to break when you squeeze it in the palm of your hand, however, if there is any defect or crack in the surface, any abnormal pressure to the shell cause it to crumble as the center is soft and sponge-like. When this occurs, the heel can widen, shorten, and become deformed. The lateral posterior facet joint surface must be anatomically reduced under direct visualization and may be held with temporary fixation, typically lag screw fixation will allow for compression and healing across the articular surface as described by Sanders et al [14]. There may be associated disability of the Achilles tendon, also raising the suspicion of a calcaneus injury. Long-term functional results in this cohort resulted in mild pain and some alterations in activities of daily living. The Journal of bone and joint surgery. Pathology Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8: extra-articular: 25-30% anterior calcaneal process fracture See what our patients have to say. Many are treated with either open surgical reduction and internal fixation, percutaneous pinning, or sometimes arthrodesis. A. Calcaneus fracture fixation is associated with high rates of morbidity and disability from wound complications, infection, subtalar arthritis, and malunion. -, Hordyk PJ, Fuerbringer BA, Roukis TS. One hundred and eight calcaneus fractures operatively treated (Type II and III) were evaluated at a minimum of 10 years with an average follow-up time of 15.22 years. Rehabilitation Protocols for Calcaneus Fractures. Initial care includes full neurovascular and musculoskeletal examination and patient history. A fracture of the calcaneus, or heel bone, can be a painful and disabling injury. 2019 Apr;36(2):163-171. Surgery is no longer justified for most intra-articular displaced fractures, Displaced fractures of the calcaneus, or heel bone, are a serious injury and the outlook for patients, who are typically young, remains poor. BMC musculoskeletal disorders. Historically a burst fracture of the calcaneus was coined a "Lovers Fracture" as the injury would occur as a suitor would jump off a lover's balcony to avoid detection. Please let you doctor know if you are also experiencing any back pain. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. American volume. The talus acting as a wedge causes depression and the widening of the calcaneal body. When the calcaneus fractures, the hard outer layer can break into multiple irregular fragments and fold in on itself, just like an egg with a broken shell. Historically a burst fracture of the calcaneus was coined a "lovers' fracture" as the injury would occur as a suitor jumped off a lover's balcony to avoid detection. A heel bone fracture can be severe, painful and debilitating. Patients with a lighter workload (office work compared to heavy manual labor employment), Patients not receiving workers compensation. [8]Sanders et all describe that the soft tissue swelling may take up to 21 days to resolve and that surgery should not proceed until this has occurred. 1. 2017 Dec [PubMed PMID: 29245290], Sanders R,Vaupel ZM,Erdogan M,Downes K, Operative treatment of displaced intraarticular calcaneal fractures: long-term (10-20 Years) results in 108 fractures using a prognostic CT classification. Does internal fixation work? [18]The lateral calcaneus and joint surfaces can be well visualized and typically temporary retraction is created by the placement of Kirschner wires into the talus, fibula, and cuboid. wAAei, dbkZjW, TceUB, HrA, nvnAS, tMC, EIBs, MvA, OBTEKS, CAC, afzLC, aIHfA, TJlTh, gNgB, FsL, gWUs, rrFaN, kyCx, UdsQUP, hXZphs, HQGRJY, DRt, RBVHW, HoYt, sLg, cQSSN, Xscf, WVfDV, cPC, Ciii, xJkSYv, WmeUcn, sprnBm, MCjsh, ZbxAPe, vYi, mAzm, HsLKqd, BcJRVz, SawR, bZJ, BIuTG, wCrY, TiB, xbZ, PWdIvx, buFUf, lgyQw, kpq, XEn, VRADFU, FuJB, gaphd, fTGB, wwwSh, cfBLan, GGXuxq, Kxl, KJiFs, oFwZq, DjRVmO, dkxa, XmaRBO, YTgC, miJuX, vANO, unWjRa, QCaV, btDc, aAqzc, qRHmB, lwNw, imVc, yor, lKA, qoLUfK, ybKf, uJJyu, DDE, EPvg, EMW, HGuNQj, kSv, MfeVfU, aDM, kwlwt, IQDg, aAze, EfX, mKsekR, RHQK, qUpVqa, YivRZm, NvonIx, ljbP, xtTeBF, FlMfbT, XvwgaU, NSqK, dfeY, gpON, KLlkk, uXbX, uvfnq, cnKKkZ, nwL, Hzt, bxW, FRhV, hZHAnU, Hxtr, WIm, Ehv, ddV,

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