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

Clinically Relevant Anatomy

A sound understanding of the anatomy of the calcaneus is essential in determining the patterns of injury and treatment goals and options.
The bony architecture of the calcaneus is that of an irregularly shaped rectangle with four facets, one of which articulates anteriorly with the cuboid bone and three of which (the anterior, middle, and posterior facets) articulate superiorly with the talus. Level 2a

The superior surfaces articulate with the talus

• Posterior facet : Separated from the middle and anterior facets by a groove that runs posteromedially, know as the calacaneal sulcus. The canal formed between the calcanealsulcus and talus is called the sinus tarsi.
• Middle calcaneal facet : Supported by the sustenaculum tali and articulates with the middle facet of the talus.
• Anterior calcaneal facet :articulates with the anterior talar facet and is supported by the calcaneal beak.

The triangular anterior surface of the calcaneus articulates with the cuboid
The lateral surfaces

• The lateral surface is flat and subcutaneous, with a central peroneal tubercle for the attachment of the calcaneofibular ligament centrally. The lateral talocalcaneal ligament attaches antero-superiorly to the peroneal tubercle. 

These anatomic landmarks are important because fractures associated with these areas may cause tendon injury

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.

These fractures account for 2-3% of all fractures of the body and 60% of all tarsal fractures.

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%) 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 side

• 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> 
           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 instability

Diagnostic Procedures

• Pain - Most importantly pressure pain, or pain elicited when providing pressure to the calcaneus by holding the heel of the patient’s foot and gently squeezing
• Edema
• Ecchymosis - A hematoma or pattern of ecchymosis extending distally to the sole of the foot is specific for calcaneal fractures and is known as the Mondor sign
• Deformity of the heel or plantar arch - Widening or broadening of the heel is seen secondary to the displacement of the lateral calcaneal border outward and accompanying edema
• Inability to or difficulty weight-bearing on affected side
• Limited or absent inversion/eversion of the foot
• Decreased Bohler or “tuber-joint” angle - In normal anatomical alignment an angle of 25-40 degrees exists between the upper border of the calcaneal tuberosity and a line connecting the anterior and posterior articulating surfaces. With calcaneal fractures,this angle becomes smaller, straighter, and can even reverse.
• CT scan (both axial and coronal views) to classify the degree of injury to the posterior facet and lateral calcaneal wall
• X-rays or Radiographs:

1.  Axial - Determines primary fracture line and displays the body, tuberosity, middle and posterior facets
2. Lateral - Determines Bohler angle
3. Oblique/Broden’s view - Displays the degree of displacement of the primary fracture line
   

Medical management / Interventions

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

Operative care

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.

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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 

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.

Physical Therapy Management

After surgery

Both the progression of nonoperative and postoperative management of calcaneal fractures include traditional immobilization and early motion rehabilitation protocols. In fact, the traditional immobilization protocols of nonoperative and postoperative management are similar, and are thereby combined in the progression below. Phases II and III of traditional and early motion rehabilitation protocols after nonoperative or postoperative care are comparable as well and are described together below. Level 1b 

1. Phase I for Traditional Immobilization and Rehabilitation following Nonoperative and Postoperative Management: Weeks 1-4
a. Goals:
- Control edema and pain
- Prevent extension of fracture or loss of surgical stabilization
- Minimize loss of function and cardiovascular endurance
b. Intervention:
- Cast with ankle in neutral and sometimes slight eversion,
- Elevation
- Ice
- After 2-4 days, instruct in non-weight bearing ambulation utilizing crutches or walker
- Instruct in wheelchair use with appropriate sitting schedule to limit time involved extremity spends in dependent-gravity position
- Instruct in comprehensive exercise and cardiovascular program utilizing upper extremities and uninvolved lower extremity

2.Phase II for Traditional Immobilization/Early Mobilization and Rehabilitation following Nonoperative and Postoperative Management: Weeks 5-8

a. Goals:
- Control remaining or residual edema and pain
- Prevent re-injury or complication of fracture by progressing weight-bearing safely
- Prevent contracture and regain motion at ankle/foot joints
- Minimize loss of function and cardiovascular endurance

b. Intervention:
- Continued elevation, icing, and compression as needed for involved lower extremity
- After 6-8 weeks, instruct in partial-weight bearing ambulation utilizing crutches or walker
- Initiate vigorous exercise and range of motion to regain and maintain motion at all joints: tibiotalar, subtalar, midtarsal, and toe joints, including active range of motion in large amounts of movement and progressive isometric or resisted exercises
- Progress and monitor comprehensive upper extremity and cardiovascular program

3.Phase III for Traditional Immobilization/Early Mobilization and Rehabilitation following Nonoperative and Postoperative Management: Weeks 9-12

a. Goals:
- Progress weight-bearing status
- Normal gait on all surfaces
- Restore full range of motion
- Restore full strength
- Allow return to previous work status

b. Intervention:
- After 9-12 weeks, instruct in normal full-weight bearing ambulation with appropriate assistive device as needed
- Progress and monitor the subtalar joint’s ability to adapt for ambulation on all surfaces, including graded and uneven surfaces
- Joint mobilization to all hypomobile joints including: tibiotalar, subtalar, midtarsal, and to toe joints
- Soft tissue mobilization to hypomobile tissues of the gastrocnemius complex, plantar fascia, or other appropriate tissues
- Progressive resisted strengthening of gastrocnemius complex through use of pulleys, weighted exercise, toe-walking ambulation, ascending/descending stairs, skipping or other plyometric exercise, pool exercises, and other climbing activites
- Work hardening program or activities to allow return to work between 13- 52 weeks

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>