Edit concept Question Editor Create issue ticket

Calcaneus Fracture

Calcaneus fractures describe the fracture of the calcaneus bone in the heel of the foot. They are sometimes called Lover's fracture or the Don Juan fracture.


Presentation

Patients usually present with a history of a fall from a significant height, a motor vehicle collision or injury subsequent to a similar scenario. A motor vehicle collision is especially suspicious for calcaneal fractures if the patient is sitting in the front because of a higher likelihood of contact with floorboards. Most patients suffer from intra-articular injuries and tend to be young males.

Other areas of pain should also be investigated. Sometimes the pain in the calcaneal region is so severe that the patient is not fully aware of other sources of pain or injuries. It is also important to look for vertebral compression fractures or compression fractures of the humerus which can occur in around 10% to 15% of all cases.

History taking should encompass past medical conditions such as cancer, peripheral vascular diseases or diabetes. Prior surgical history or placements of orthopedic hardware are especially important if they occurred close to the site of injury.

On physical exam, patients present with edema, ecchymosis, pain, heel and/or plantar arch deformities and difficulty bearing weight on the affected foot. Inspection of the injured area is important in detecting any open fractures, especially where lacerations can be found. Pain upon squeezing the heel in the palm of the hand is a characteristic feature of calcaneal fractures. The Mondor sign is another pathognomonic finding. It describes a specific pattern of ecchymosis that can be followed distally, to the sole of the affected foot. The physical exam should also target the vascular system, paying particular attention to distal capillary refill, dorsalis pedis and posterior tibial pulses. Pulses need to be compared on both sides. It is also important to rule out the development of compartment syndrome. The latter can be suspected by diminished pulses, swelling, pallor and sensory abnormalities (paresthesias).

The physical exam should also encompass the midfoot, the ankle and the knee. Positive findings should prompt imaging with X-ray to rule out any potential fractures. Other highly vulnerable areas that can be associated with calcaneal fractures are the malleoli (medial, posterior and lateral) and the base of the fifth metatarsal.

Up to 7% of all patients with calcaneal fractures may have bilateral fractures. This is perhaps not surprising given the associated mechanisms of injury, such as a fall from the height. It is important to thoroughly exam both sides in order to exclude bilateral injuries.

Constitutional Symptom
  • He denies constitutional symptoms. On examination, his body mass index is 22, he has a normal foot posture and can perform a single leg heel rise without difficulty.[orthobullets.com]
Military Personnel
  • A small minority of calcaneus fractures may be non-traumatic stress fractures due to repetitive axial loading, as seen in military personnel or long-distance runners. Ten percent of calcaneus fractures are bilateral.[orthopaedicsone.com]
Aspiration
  • Aspiration of the injected contrast material following use of a local anesthetic may relieve pain and help determine the source of the pain.[emedicine.medscape.com]
Vomiting
  • When I got out of surgery, I remember Rebecca telling me she had smoked after going under, but she vomited. I just kept thinking to myself, "I don't want to puke. I hate it".[bradgarrett.com]
Ulcer
  • Avoid trapping the fifth toe under the fourth (risk of ulcer) Other measures Close interval follow-up and evaluation for possible surgical repair DVT Prophylaxis (e.g.[fpnotebook.com]
Skin Lesion
  • No patient who underwent a minimally invasive reduction had skin lesions, but showed pain due to osteoarthritis lesions that appeared in the subtalar joint. 4 of them, who underwent open reduction and internal fixation had postoperative wound infections[ncbi.nlm.nih.gov]
Heel Pain
  • Symptoms Symptoms of a calcaneus fracture included swelling in the foot, significant bruising on the heel, being unable to put weight on the heel, and significant heel pain. The heel can be very sensitive to even the lightest of touches.[warren-law.com]
  • Traumatic fractures can include the following signs and symptoms: A sudden onset of heel pain and inability to put weight on the injured foot. Swelling in the heel area. Bruising of the heel and ankle.[feetfixer.com]
Limping Gait
  • In very mild forms of Calcaneus Fracture or Broken Heel, walking may not be affected to a large extent as the Achilles tendon comes to the rescue and supports the body weight but still the person may have a limping gait.[epainassist.com]
Small Foot
  • These three bones are the: Tibia — shinbone Fibula—smaller bone in the lower leg Talus—small foot bone that works as a hinge between the tibia and the fibula Together, the calcaneus and the talus form the subtalar joint.[orthoinfo.aaos.org]
Abnormal Gait
  • We present a case of malunited calcaneal fracture with a rare complication of an exostosis in the middle 3rd of the plantar surface of calcaneus which clinically produced a large bony swelling on the sole of the foot causing pain and abnormal gait .This[faoj.org]
Forgetful
  • I'll never forget going to the nearby hospital where they thought I was trying to trick them to get pain killers, and instead I was in agonizing pain for I had just shattered my heel bone.[bradgarrett.com]
Screaming
  • We are still in the hospital. he has not slept an the pain is unbearable to the point of him crying and screaming. The nurses jus look at him during this. What should we do? I understand and feel bad for all of you in this situation.[medhelp.org]

Workup

X-ray imaging is the principal diagnostic method. Generally, both lateral and axial views are taken. CT is sometimes done if the X-ray is inconclusive but clinical findings point to calcaneal fractures, if more detail about the fracture is necessary and if the Bohler angle is greater than 20°.

The Bohler angle is estimated by the intersection of two imaginary lines on lateral x-rays. The first line connects the superior part of the posterior calcaneal tuberosity with the superior subtalar articular surface. The second line links the superior subtalar articular surface with the superior part of the anterior calcaneal process. The Bohler angle normally measures between 20 and 40°. An angle smaller than 20° points to a calcaneal fracture.

Because calcaneal injuries can be associated with compression fractures of the spine, it is important to check for thoracolumbar injuries.

Treatment

Surgery is necessary for the treatment of calcaneal fractures. It is usually an open surgery, in which the bone is pieced back together or the fracture is fixed utilizing plates and screws to rectify the alignment. Open surgery is performed by cutting over the lateral part of the heel in a hockey stick or "L" formation, enabling the displacement of critical tendons and nerves for better access. When plates and screws are used to hold the bone together, the process is named "internal fixation".

A "closed reduction" is sometimes applicable in the treatment of calcaneal fractures. This procedures entails making several small cuts around the heal and putting the bone fragments together with the help of imaging procedures such x-rays without having to directly visualize the fractured bone pieces. The final position is then held with screws fixed through the skin. Recent evidence suggests that minimally invasive surgery is associated with lower morbidity than open reduction or closed reduction with internal fixation [8] [9].

Both general and local anesthesia are utilized in surgeries relating to calcaneal fractures. Local anesthesia is administered in the form an injected regional nerve block. The latter helps in controlling pain 12 to 24 hours after the surgery is performed. The surgery can be either done on the same day of admission or planned within a longer hospital stay.

Placement of a tourniquet aids in minimizing bleeding as well as in improving the visualization of important structures while the procedure is underway. After incisions are made and the sural nerve and muscle tendons are displaced, the skin is retracted through the use of metal wires. This then gives full access for the surgeons to the bone fragments, which are subsequently re-instated in the correct position. Metal wires are also used to temporarily fix the bone fragments in place, before permanently adjusting the positions of the bones with plates and screws. At the end of the surgery, the skin is closed and a splint is applied.

Prognosis

Prognosis is variable but studies done almost 50 years ago by Essex-Lopresti show that there is a much greater morbidity with intra-articular fractures relative to extra-articular calcaneal injuries.

Residual morbidity may be difficult to determine in the initial stages of the disease. It may take up to a year to accurately assess long-term damage subsequent to calcaneal fractures [6] [7].

Etiology

Causes of calcaneal fractures can be divided into intra and extra-articular. Intra-articular fractures are usually the result of excessive axial loading with subsequent transmission of tension into the plantar tuberosity of the calcaneus, situated on the lateral side of the axis of the lower extremity. The more prevalent causes of increased axial loading that ultimately manifest with calcaneal fractures include fall from heights above 6 feet, traffic accidents, impact during running or jumping, overuse injuries and stress fractures in athletes.

Extra-articular fractures, on the other hand, usually occur after a strong twist to the hindfoot. They may also follow blunt-force injuries and avulsion injuries of the Achilles tendon.

Epidemiology

Fractures of the calcaneus comprise 2% of all fractures that occur in adults. Around 30% are extra-articular and 30% are intra-articular, with young men being most commonly affected. The calcaneus is also the most commonly fractured tarsal bone, representing about 60% of all tarsal fractures [3] [4].

A calcaneal body fractures is the most frequent extra-articular fracture. Other extra-articular fractures include those targeting the anterior process, the superior tuberosity beak, the sustentaculum tali and avulsions. Anterior process fractures are the only fractures seen more commonly in women and make up about 10% to 15% of all extra-articular calcaneal injuries. Avulsions and superior tuberosity beak fractures represent 10-15% of extra-articular fractures. Sustentaculum tali injuries are not usually found in isolation.

Calcaneal fractures are mostly encountered as closed fractures and only 2% of all reported cases are open fractures.

Sex distribution
Age distribution

Pathophysiology

Calcaneal fractures generally result from excessive axial load on the talus, with subsequent transmission of the force in a lateral direction from the talus onto the calcaneus. The fracture line starts from the angle of Gissane and courses in the posteromedial direction, drawing an oblique fracture line. Multiple secondary fractures may then subsequently form from the initial fracture line. In 75% of the cases, there is involvement of the subtalar joint.

Calcaneal fractures can be generally classified into two types: tongue-type and joint depression fractures [5]. Tongue-type fractures are characterized by a secondary fracture line that extends in a direct posterior direction. The result is the formation of a posterior, superior and a lateral fragments. The inferior fragment completes the rest of the calcaneus. Joint depression fractures are more common and are characterized by a secondary fracture line that originates from the angle of Gissane and then courses in a posterior direction before exiting the bone on the posterior facet, after deviating dorsally. The major part of the posterior facet makes up the fracture fragment.

Prevention

Calcaneal fractures result most frequently from a combination of factors. Compressive forces, shearing stress and a rotational component are all necessary for the fracture to occur [10]. This takes place most commonly after a fall from a height, a motor vehicle incident or severe muscular tension that can ultimately result in trauma. It is important not to ignore chronic medical diseases such as osteoporosis and diabetes, that can also significantly increase the risk of calcaneal fractures.

There are very limited prevention measures that can be utilized in cases of motor vehicle accident and falls from a height. These usually correspond to common safety precautions. On the other hand, weight bearing and strength exercises can help prevent fractures that result from muscular tension and stress. The type of footwear worn can also have a significant impact on calcaneal fracture incidence. Inadequate footwear as well as the performance of intense sporting activities barefoot can increase the risk of stress fractures in general, and calcaneal fractures more specifically [11].

Summary

Calcaneal fractures represent 2% of all fractures in adults and 60% of tarsal fractures [1]. They most commonly occur after a fall from a height, a motor vehicle accident, excessive muscular tension and trauma.

Calcaneal fractures can be generally divided into two subtypes: intra and extra-articular. Intra-articular fractures are more common and occur largely because of axial stress that is slightly displaced to the lateral side. Extra-articular fractures result from trauma, particularly after a twisting of the hindfoot or avulsion injuries of the Achilles tendon. Patients usually present with pain, edema, ecchymoses and swelling over the injured site. It is important to rule out compartment syndrome that usually manifests with paresthesias, decreased pulses, swelling and pallor. Pathognomonic signs on physical exam include tenderness when the heel is compressed in the palm of the hand and a distinctive pattern of ecchymosis named the Mondor sign. It is usually necessary to examine the spine and other joints during the physical exam, especially since the condition is commonly associated with other injuries, particularly compression fractures of the thoracolumbar spine.

Diagnosis is established with x-ray imaging and can be further validated with CT if more detail is sought for. Surgery is the principal treatment modality. The surgeon usually performs an open surgery and fixes the bone fragments after retracting the overlying tendons and nerves [2]. A closed reduction may also be performed, with the help of imaging aids such x-ray. Calcaneal fracture surgery necessitates general anesthesia and a local nerve block that helps in limiting postoperative pain for up to 24 hours. Prognosis is variable, and morbidity can be properly assessed after a year from the date of the injury.

Patient Information

Calcaneal fractures are a type of bone fractures that affect a bone in the heel, called the calcaneus. They most commonly occur after a patient falls from a height above six feet, a motor vehicle accident in which the patient is sitting in front, due to excessive muscle strain or after direct trauma to the foot. Patients usually present with pain on the affected side, swelling and reddening of the skin around the location of the injury. The physician may perform a particular procedure during the physical exam, in which the heel is held in the palm of the hand and gently squeezed. The presence of pain on such a maneuver is a distinctive sign for calcaneal fractures. The condition is usually diagnosed with X-ray, although a CT can also be performed if more detail is needed. Treatment requires surgery, which can be done either by opening the skin, retracting the nerves and muscle tendons, and subsequently fixing the bone back together or by making small incisions in the skin and fixing the bone after visualizing it with X-ray. The doctor may need to administer both general anesthesia and a local nerve block. The latter helps in controlling the pain after the procedure is done. Prognosis is variable, and severity of the damage occurred may need a year to be accurately determined.

References

Article

  1. Lee P, Hunter TB, Taljanovic M. Musculoskeletal Colloquialisms: How Did We Come Up with These Names? Radiographics. 2004 Jul-Aug;24(4):1009-27.
  2. Grala P, Twardosz W, Tondel W, Olewicz-Gawlik A, Hrycaj P. Large bone distractor for open reconstruction of articular fractures of the calcaneus. Int Orthop. 2009 Apr 30.
  3. Daftary A, Haims AH, Baumgaertner MR. Fractures of the calcaneus: a review with emphasis on CT. Radiographics. 2005 Sep-Oct;25(5):1215-26.
  4. Badillo K, Pacheco JA, Padua SO et-al. Multidetector CT evaluation of calcaneal fractures. Radiographics. 2011 Jan-Feb;31(1):81-92.
  5. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis, 1951-52.Clin Orthop. 1993 May; 3-16.
  6. Potter MQ, Nunley JA. Long-term functional outcomes after operative treatment for intra-articular fractures of the calcaneus. J Bone Joint Surg Am. 2009 Aug; 91(8):1854-60.
  7. Besch L, Waldschmidt JS, Daniels-Wredenhagen M, et al. The treatment of intra-articular calcaneus fractures with severe soft tissue damage with a hinged external fixator or internal stabilization: long-term results. J Foot Ankle Surg. 2010 Jan-Feb; 49(1):8-15.
  8. Zhang T, Su Y, Chen W, Zhang Q, Wu Z, Zhang Y. Displaced intra-articular calcaneal fractures treated in a minimally invasive fashion: longitudinal approach versus sinus tarsi approach. J Bone Joint Surg Am. 2014 Feb 19; 96(4):302-9.
  9. Schuberth JM, Cobb MD, Talarico RH. Minimally invasive arthroscopic-assisted reduction with percutaneous fixation in the management of intra-articular calcaneal fractures: a review of 24 cases. J Foot Ankle Surg. 2009 May-Jun; 48(3):315-22.
  10. Soeur R, Remy R. Fractures of the calcaneus with displacement of the thalamic portion. J Bone Joint Surg Br. 1975 Nov;57(4):413-21.
  11. Salzler MJ, Bluman EM, Noonan S, Chiodo CP, de Asla RJ. Injuries observed in minimalist runners. Foot Ankle Int. 2012 Apr;33(4):262-6.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-07-11 21:25