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 rock and roll climbers. The second most common contributing cause to these traumatic fractures are car 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 problem for calcaneal fractures is in trying to rebuild the crack in order that recovery may take place. The particular calcaneus is actually much like an egg; an outer firm shell and soft on the inside. As a result, the calcaneus often shatters when broken. Calcaneal repair not only calls for re-apposition of multiple crack patterns, but also demands restoration of the subtalar joint. The particular subtalar joint is the interface between the calcaneus as well as talus and is a primary load bearing joint of the foot. In some cases, extra joint surfaces may be affected (the calcaneal cuboid joint) but are of lesser importance due to 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 category both describe calcaneal fractures. TheEssex-Lopresti classification describes subtalar joint depression fractures (very serious fractures) in a little more detail than the more commonly used Rowe category. 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 fracture involving the insertion from the tendo-Achillles
Type 4 - Body break involving the subtalar joint
The Essex-Lopresti Group Of Calcaneal Fractures
Type a - Language Type
Type B - Joint depression type.
Stress Fractures from the Calcaneus
Stress fractures of the calcaneus are typically the result of a sudden abrupt injury but can happen 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, 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 discuss fractures. The appearance of a stress fracture on x-ray are not always evident.. Quite often, the only x-ray findings that we will see are those who show up for 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 preliminary 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 healing 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, as a result, periodic follow-up x-rays may aid in diagnosing a stress fracture of the heel.
Three phase technitium bone scan might help differentiate the location and degree of inflammation in the calcaneus thereby helping to diagnose 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 tests show a different level of inflammation based upon the increased blood flow to the swollen area. In the case of a calcaneal crack, 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.
- And lastly, a check may 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 may 'light up' on the check out due to its' current irritation.
- An old injury on the other hand will not lighting 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 break.
Treatment of Calcaneal Fractures
As previously mentioned, calcaneal fractures can be very difficult to manage. Closed reduction is a term used when doctors can 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 be able 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 necessary to fuse the subtalar joint.
- When the subtalar joint is significantly damaged in the injury, fusion of the stj is actually the only solution.
- Most doctors will stage these kinds of procedures, performing a subtalar fusion long after the immediate trauma of the injury.
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- Treatment of calcaneal stress fractures varies with the severity of the crack and 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.
- Surgical treatment is rarely indicated.
- Healing of calcaneal stress bony injury can be prolonged and may require a period of several months to heal.
Calcaneus - The actual bone with the heel.
- Subtalar Joint - (STJ) the joint between the two major bones of the rearfoot, the talus and calcaneus.
- The actual STJ is a common site of residual joint disease 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 about its' outer surface but soft and spongy on the inside, very similar to a great egg.
- It is really an unusually shaped bone with numerous surfaces making up 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 as a result of random traumatic incident, no defined pathway for the bony injury has been proven. Symptoms: The diagnosis of a calcaneal stress fracture is usually based upon pain that remains following an incident of trauma. From time to time a calcaneal stress fracture will have a great insidious onset, but many with have a serious onset. Edema (swelling) and erythema redness) may or may not be present.
The most common symptom of a calcaneal stress fracture, and the one symptom that can help to differentiate tension 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 be able to hurt. Pain due to plantar fasciitis is sharp in the beginning of weight bearing however soon subsides, to be able to a diploma, above 5-10 minutes.
The Location of Pain is Important Too
Stress fracture pain will usually (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 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 from the plantar fascia and a tearing pain at the connection of the fascia on the bottom of the heel. Pain is severe with the first few steps out of bed in the morning or after a brief period of rest.
Retrocalcaneal bursitis (Albert's Disease) - this is the organization and irritation of a bursa behind the heel between the heel bone and Achilles tendon
Sero-negative arthropathies like Reiter's Syndrome.
Sever's Disease - and inflammatory problem typically found in younger over weight boys age 10 to 15 years old
- Tarsal Tunnel Predicament - also known as posterior tibial nerve neuralgia.
- Tarsal Tube 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 operatingsystem calcis: long term follow-up study of 146 patients. JAMA.
- Hermann OJ. conservative treatment for fractures of the operating system calcis.
- J Bone Joint Surg 1963:45-A:865-867
Palmer I. The device 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 practice in Granville, Ohio.