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 higher than 14 feet. Calcaneal fractures are common among roofers and rock and roll climbers. The second most common contributing cause to these kinds of traumatic fractures are vehicle accidents. Calcaneal fractures are most commonly found in males age 30-50 y/o.
Calcaneal fractures have a track record of being difficult to handle and have frustrated doctors for years. The issue in treating calcaneal fractures is in trying to rebuild the crack in order that healing may take place. The calcaneus will be 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 demands re-apposition of multiple fracture patterns, but also calls for restoration of the subtalar joint. The subtalar joint is the interface between the calcaneus as well as talus and is a primary load bearing joint of the base. In some cases, further joint surfaces may be affected (the calcaneal cuboid joint) but are of lesser importance because of their limited weight bearing functions.
Two classifications are used for the classification of calcaneal fractures. The Rowe classification as well as the Essex-Lopresti group both describe calcaneal fractures. TheEssex-Lopresti classification describes subtalar joint depression fractures (very extreme fractures) in a bit 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 perhaps lateral
Type 1c - Fracture of the anterior process of the calcaneus
Type 2b - Avulsion break involving the insertion with the tendo-Achillles
Type 4 - Body crack involving the subtalar joint
The Essex-Lopresti Category 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 may appear 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 checking heel pain. A good patient history, and also 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 shall see are the ones that show up towards 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 original 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 process of recovery will increase the amount of calcium surrounding the fracture. This process of calcification typically takes about 4-6 weeks to see on plain x-ray, consequently, 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 identify a calcaneal stress fracture. Bone scans are a test the place 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 scans show a different level of inflammation based upon the increased blood flow to the painful 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 crack based upon the inflammation seen in fracture healing.
- Second, the bone scan will help to differentiate between a number of other potential difficulties with the heel such as plantar fasciitis.
- Happening, a scan may help to determine the acuteness of an injury.
- For instance, we may see a questionable area on an x-ray but we shall not be able to tell whether the thought injury is old or new.
- The bone scan will help us in that a new injury will 'light up' on the check due to its' current inflammation.
- An old injury on the other hand is not going to light 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 crack under anesthesia without surgery. Closed reduction can be successful in treating calcaneal fractures in many cases depending 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 in order to explosive. Follow-up following reduction (whether close or open) may differ but will include a period of non-weight bearing, splinting or throwing to allow for fracture healing.
- Severe cases of joint depression fractures (Rowe type 4 and additional surgery may be required 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 immediate trauma of the injury.
- 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 intervention 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 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 osteoarthritis 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 upon its' outer surface but soft and spongy on the inside, similar to an 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 because of random traumatic incident, no defined pathway for the cracks has been established. Symptoms: The diagnosis of a calcaneal stress fracture is usually based upon pain which remains following an incident of trauma. From time to time a calcaneal stress fracture will have an insidious onset, but most 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 sign that can help in order to differentiate stress fractures from fasciitis, is the nature of the pain. Stress fracture pain is constant. It hurts when a person's body weight is first applied and continues to be able to hurt. Pain due to plantar fasciitis is sharp at the start of weight bearing however soon subsides, in order to a degree, more than 5-10 minutes.
The Location of Pain is Also Important
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 reasonable 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 organization and inflammation of a bursa at the rear of the heel between the heel bone and Achilles tendon
Sero-negative arthropathies for example Reiter's Syndrome.
Sever's Disease - and inflammatory situation typically found in youthful over weight boys age 10 to 15 years old
- Tarsal Tunnel Syndrome - also called posterior tibial nerve neuralgia.
- Tarsal Canal 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 os calcis: long term follow-up study of 146 patients. JAMA.
- Hermann OJ. conservative treatment for fractures of the os calcis.
- J Bone Combined Surg 1963:45-A:865-867
Palmer I. The mechanism and 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 exercise in Granville, Ohio.