Calcaneal Fractures

Original Editor - De Poorter Lisa as part of the <a href="Vrije Universiteit Brussel Evidence-based Practice Project">Vrije Universiteit Brussel's Evidence-based Practice project</a>

Top Contributors -     Hajar Abdelhadji, Roxann Musimu , Dylan Van Calck    

Definition / Description

<img src="/images/thumb/6/60/Subtalar_joint.png/200px-Subtalar_joint.png" _fck_mw_filename="Subtalar joint.png" _fck_mw_location="right" _fck_mw_width="200" _fck_mw_type="thumb" alt="Subtalar Joint Showing Calcaneus" class="fck_mw_frame fck_mw_right" />

A calcaneus fracture is a heel bone fracture. The calcaneus, also called the heel bone, is the largest of the tarsal bones. It is situated at the lower and back part of the foot, forming the heel.
Together with the talus, the calcaneus forms the subtalar joint. This joint allows inversion and eversion of the foot. The midtarsal joint is comprised of two joints: The talocalcaneonavicalar and the calcaneocuboid joint.

The calcaneus has four important functions:
1. Acts as a foundation and support for the body’s weight
2. Supports the lateral column of the foot and acts as the main articulation for inversion / eversion
3. Acts as a lever arm for the gastrocnemius muscle complex
4. Makes normal walking possible

Epidemiology/Ethiology

Calcaneal fractures are uncommon, but serious injuries and they frequently occur in young adult men.

The annual incidence of fracture was 11.5 per 100.000. It occurred 2.4 times more frequently in males than females. In males, the incidence was 16.5/100000/year, with a peak incidence between 20-29 years of age (21.6/100000/year). In females, the overall incidence was 6.26/100000/year, with a gradual increase in incidence towards the post-menopausal years.Mitchell MJ, McKinley JC, Robinson CM. The epidemiology of calcaneal fractures. Royal Infirmary of Edinburgh, 2009 Dec;19(4):197-200. (Level Of Evidence: B)

These fractures account for 2-3% of all fractures of the body and 60% of all tarsal fractures. http://xnet.kp.org/socal_rehabspecialists/ptr_library/09FootRegion/31Foot-CalcanealFracture.pdf

Mechanism of Injury / Pathological Process

Calcaneal fractures are mostly the result of a traumatic incident and high impact situation. The greater part of fractures (71,5%)Mitchell MJ, McKinley JC, Robinson CM. The epidemiology of calcaneal fractures. Royal Infirmary of Edinburgh, 2009 Dec;19(4):197-200. (Level Of Evidence: B) are sustained in falls from a height. The small amount of 18.8% of fractures occurred in the workplace. Calcaneal fractures can also occur with less severe accidents like an ankle sprain or a stress fracture.

Mostly, the injuries occur in isolation. Most seen concomitant injuries were lower limb (13.2%) or spinal injuries (6.3%).

These calcaneal fractures can be intra-articular or extra-articular. Involving one or more of the three subtalar articulating facets, 75% of all calcaneal fractures are intra-articular. These fractures have a poorer prognosis. Fractures of the calcaneal body, anterior process, sustentaculum tali, and superior tuberosity are known as extra-articular fractures and don’t involve the joint.

Characteristics / Clinical Presentation

<img src="/images/thumb/e/e8/Calcaneus_Fracture.jpg/300px-Calcaneus_Fracture.jpg" _fck_mw_filename="Calcaneus Fracture.jpg" _fck_mw_location="right" _fck_mw_width="300" _fck_mw_type="thumb" alt="Calcaneal Fracture on X-ray" class="fck_mw_frame fck_mw_right" />

There are certain characteristics of a calcaneal fracture:

• Sudden pain in the heel, most importantly pressure pain.

• Swelling in the heel area

• Bruising of the heel and ankle

• Generalized pain in the heel area that usually develops slowly (over several days to weeks): typically for stress fractures

• Edema

• A hematoma or pattern of ecchymosis extending distally to the sole of the foot.

• Deformity of the heel or plantar arch: Secondary to the displacement of the lateral calcaneal border outward, there is a possible widening or broadening of the heel.

• Inability or difficulty to bear weight on affected sideB. Kienast B, Gille J, Queitsch C, Kaiser MM, Thietje R,Juergens C and Schulz AP. Early Weight Bearing of Calcaneal Fractures Treated by Intraoperative 3D-Fluoroscopy and Locked-Screw Plate Fixation. The Open Orthopaedics Journal, 2009, 3, 69-74 69. (Level Of Evidence: A2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738828/pdf/TOORTHJ-3-69.pdf

• Limited or absent inversion / eversion of the foot
• Decreased Böhler or “tuber-joint” angle
• CT scan: Diverse views, both axial and coronal views can classify the degree of injury to the posterior facet and lateral calcaneal wall.
• <a href="http://www.physio-pedia.com/index.php5?title=X-Rays">X-rays</a> or Radiographs:
           o Axial x-ray: Determines primary fracture line and displays the body, tuberosity, middle and posterior facets
           o Lateral x-ray: Determines <a href="http://www.physio-pedia.com/index.php5?title=Bohler_angle">Böhler angle</a>Grala P, Machyñska-Buæko Z, Kierzynka G. Surgical treatment of articular calcaneal fractures. Ortopedia Traumatologia Rehabilitacja Medsportpress, 2007; 1(6); Vol. 9, 89-97. (Level Of Evidence: A2) 
           o Oblique / Broden’s view: Determines the degree of displacement of the primary fracture line
• Heel tenderness
• Difficulty walking:
           o Inability to walk
           o Inability to move the foot

Differential Diagnosis

• Heel pain
• Baxter's nerve entrapment: An entrapment of the recurrent branch of the posterior tibial nerve
• <a href="http://www.physio-pedia.com/index.php5?title=Calcaneal_Spurs">Calcaneal spurs</a>
• <a href="http://www.physio-pedia.com/index.php5?title=Plantarfasciitis">Plantar fasciitis: </a>Plantar fascial pain is specific to the bottom of the heel. An MRI can be used to differentiate a calcaneal fracture from plantar fascitis.
• Retrocalcaneal bursitis: This is the formation and inflammation of a bursa at the back of the heel between the heel bone and achilles tendon. Also called Albert's Disease.
• Rheumatoid Arthritis
• Septic Arthritis
• <a href="http://www.physio-pedia.com/index.php5?title=Tarsal_Tunnel_syndrome">Tarsal Tunnel Syndrome</a>: The pain of this syndrome doesn’t decrease with rest. Other symptoms are numbness or tingling of the toes.
• Ankle instabilityhttp://www.eorif.com/AnkleFoot/CalcaneousFx.html#Anchor-Associated-44867

Medical management / Interventions

Treatment of calcaneal fractures depends on the type of fracture and the extent of the injury.

Operative careGrala P, Machyñska-Buæko Z, Kierzynka G. Surgical treatment of articular calcaneal fractures. Ortopedia Traumatologia Rehabilitacja Medsportpress, 2007; 1(6); Vol. 9, 89-97. (Level Of Evidence: A2)

For the majority of patients, surgery is the correct form of treatment. The goal of surgery is to restore the correct size and structure of the heel. Intra-articular fractures are often treated operatively. This is possible by performing an open reduction and internal fixation of the fracture. These procedures are performed through an incision on the outside of the heel. The calcaneus is put together and held in place with a metal plate and multiple screws. This procedure decreases the possibility of developing arthritis and maximizes the potential for inversion and eversion of the foot.
Extra-articular fractures are generally treated conservatively.

<img class="FCK__MWTemplate" src="http://www.physio-pedia.com/extensions/FCKeditor/fckeditor/editor/images/spacer.gif" _fckfakelement="true" _fckrealelement="11" _fck_mw_template="true"> Shajil K. CALCANEUM FRACTURE ORIF VIDEO . Available from: http://www.youtube.com/watch?v=gngTOOFmgJM [last accessed 09/02/13]

<img class="FCK__MWTemplate" src="http://www.physio-pedia.com/extensions/FCKeditor/fckeditor/editor/images/spacer.gif" _fckfakelement="true" _fckrealelement="7" _fck_mw_template="true">Legal Animations. Open Reduction Internal Fixation Calcaneus Fractures . Available from: http://www.youtube.com/watch?v=UTo0c_6YTK4 [last accessed 09/02/13]

Non-operative care

Nonoperative management is preferable when there is no impingement of the peroneal tendons and the fracture segments are not displaced (or are displaced less than 2 mm). Nonoperative care is also recommended when, despite the presence of a fracture, proper weight-bearing alignment has been adequately maintained and articulating surfaces are not disturbed. Extra-articular fractures are generally treated conservatively. Patients who are over the age of 50 years old or who have pre-existing health conditions, such as diabetes or peripheral vascular disease, are also commonly treated using nonoperative techniques. Patients receiving nonoperative management. Level 1A Buckley, Richard, et al. "Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures." J Bone Joint Surg Am 84.10 (2002): 1733-1744Griffin, Damian, et al. "Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial." (2014): g4483

R.I.C.E.:

• Rest: The affected foot must rest and the patient is not allowed to use the foot. This is to allow the fracture to heal.
• Ice: Several times a day the patient has an ice treatment to reduce inflammation, swelling and pain. 
• Compression: Bandage / Compression stocking
• Elevation: The initial management is to reduce the swelling with rest in bed with the foot slightly above heart level.

Immobilisation:
Partial or complete immobilisation is used if the fracture has not displaced the bone. Usually a cast is used to keep the fractured bone from moving. In the cast, the ankle is in neutral position and sometimes in slight eversion.
To avoid weight bearing, crutches may be needed.

Resources

http://ezinearticles.com/?Rehabilitation-After-Calcaneal-Fractures&id=4082480
http://orthopedics.about.com/od/footanklefractures/a/calcaneus.htm
http://xnet.kp.org/socal_rehabspecialists/ptr_library/09FootRegion/31Foot-CalcanealFracture.pdf
http://www.healthstatus.com/articles/Calcaneal_Fractures.html

Presentations

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<a href="http://prezi.com/htzzh_lneqpu/calcaneal-fractures/">Calcaneal Fractures</a> This presentation, created by Alice Thompson, provides an interactive insight into presentation, causes and types of calcaneal fractures as well as the evidence base for treatment options. <a href="http://prezi.com/htzzh_lneqpu/calcaneal-fractures/">Calcaneal Fractures/ View the presentation</a>

References

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<a _fcknotitle="true" href="Category:Ankle">Ankle</a> <a href="Category:Musculoskeletal/Orthopaedics">Orthopaedics</a>