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 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 treat and have frustrated doctors for a long time. The problem in treating calcaneal fractures is in trying to rebuild the break so that therapeutic may take place. The actual calcaneus is actually much like an egg; an outer firm shell and soft on the inside. As a result, the calcaneus usually shatters when broken. Calcaneal repair not only requires re-apposition of multiple fracture 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 the limited weight bearing roles.
Two classifications are used for the classification of calcaneal fractures. The actual Rowe classification as well as the Essex-Lopresti classification both describe calcaneal fractures. TheEssex-Lopresti classification describes subtalar joint depression 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 lateral
Type 1c - Fracture of the anterior process of the calcaneus
Type 2b - Avulsion crack involving the insertion with the tendo-Achillles
Type 4 - Body crack involving the subtalar joint
The Essex-Lopresti Group Of Calcaneal Fractures
Type a - Tongue Type
Type B - Joint depression type.
Stress Fractures With 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 feet. 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 most health care providers will defer to plantar fasciitis as a primary diagnosis when analyzing heel pain. A good patient history, as well as particularly one that notes the onset and character of the pain, is very important when distinguishing 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 will see are those that show up for the end of the healing process, sometimes as long as several months after the damage. We don't actually visualize the fracture, 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 recovery process will increase the amount of calcium surrounding the crack. This process of calcification typically requires 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.
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Three phase technitium bone scan might 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 reads show a different degree 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 fracture based upon the inflammation seen in fracture healing.
- Second, the bone scan will help to differentiate between a number of other potential difficulties from the heel such as plantar fasciitis.
- Happening, a check might 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 suspected injury is old or new.
- The bone scan will help us in that a new injury can 'light up' on the scan due to its' current swelling.
- An old injury on the other hand won't gentle up' on the scan due to its' not enough 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 may manipulate the break 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 casting 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.
- If the subtalar joint is significantly damaged in the injury, fusion of the stj is the only solution.
- Most doctors will stage these kinds of 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 fracture and the degree of pain.
- Several 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 treatment is rarely indicated.
- Healing of calcaneal stress fractures can be prolonged and may require a period of several months to be able to heal.
Calcaneus - The actual bone from the heel.
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- 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 scans.
- Anatomy: The calcaneus is very firm upon its' outer surface but soft as well as spongy on the inside, very similar to an 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 occur due to a random traumatic incident, no defined pathway for the cracks has been established. Symptoms: The diagnosis of a calcaneal stress fracture is usually considering pain in which proceeds following an incident of trauma. Occasionally a calcaneal stress break will have a great insidious onset, but most 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 symptom that can help in order 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 in order to hurt. Pain due to plantar fasciitis is sharp at the start of weight bearing however soon subsides, to a degree, above 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 from 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) - this really is the development and swelling of a bursa at the back of the heel between the heel bone and Achilles tendon
Sero-negative arthropathies like Reiter's Syndrome.
Sever's Disease - and inflammatory condition typically found in youthful over weight boys age 10 to 15 years old
- Tarsal Tunnel Syndrome - also referred to as posterior tibial nerve neuralgia.
- Tarsal Tube Syn. characteristically has pain that does not decrease with rest.
- Also has numbness or 'tingling' from the toes
Rowe CR, Sakellarides HT, Freeman PA, et al. Fractures of the operating system calcis: long term follow-up study of 146 patients. JAMA.
- Hermann OJ. conservative remedy for fractures of the os calcis.
- J Bone Combined 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 and is in active train in Granville, Ohio.