Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Calcaneus Fracture

Basics
Description
  • Calcaneus fractures affect the calcaneus (heel bone) and the subtalar joint (between the talus and calcaneus).
    • Often high-energy injuries with substantial bony comminution and soft-tissue swelling
    • As such, often very difficult to treat
  • Calcaneus fractures may be intra-articular, involving the subtalar joint, or extra-articular.
    • Extra-articular fractures have better outcomes and can be treated nonoperatively.
    • Intra-articular fractures have a worse prognosis and can be associated with severe heel widening, shoe wear problems, gait abnormalities, foot stiffness, and chronic pain.
Epidemiology
Incidence
Uncommon, but the calcaneus is the most commonly fractured tarsal bone.
 
Risk Factors
  • Osteoporosis
  • Jumping activities
  • Work at heights
Pathophysiology
  • Fracture patterns depend on the following:
    • Force of impact
    • Orientation of the heel
    • Geometry of the calcaneus
Etiology
Fall from a height
 
Associated Conditions
  • Spinal fractures
  • Ankle fractures
  • Foot compartment syndrome
Diagnosis
Signs and Symptoms
  • Extreme hindfoot pain and tenderness
  • Gross heel widening
  • Soft-tissue ecchymosis
History
Patients typically are involved in high-energy trauma, such as a fall from a height or a motor vehicle crash.
 
Physical Exam
  • Check for the following:
    • Skin integrity
    • Heel ecchymosis
    • Extreme heel tenderness
    • Ankle tenderness
    • Heel widening
    • Soft-tissue swelling about the heel
    • Possible spinous process tenderness in the lower spine (if an associated lower spinal fracture is present)
  • Perform a comprehensive neurologic examination, looking for signs and symptoms of compartment syndrome.
Tests
Imaging
  • Radiography:
    • AP, lateral, and oblique views of the foot
    • AP, lateral, and mortise views of the ankle
    • A calcaneal axial view (Harris view)
  • CT:
    • Useful in determining whether a calcaneal fracture is intra-articular and in classifying intra-articular injuries.
    • It is very important that the CT scan be ordered as a CT scan of the calcaneus.
    • The foot is placed in neutral and the beam is oriented at a 30° oblique angle from the coronal plane.
  • The Sanders classification system is used for surgical planning and is based on the CT images of the posterior facet (1).
    • Type 1: Nondisplaced
    • Type 2: 2-part fractures of the posterior facet
    • Type 3: 3-part fractures with 2 fracture lines
    • Type 4: 4-part fractures with severe comminution
Diagnostic Procedures/Surgery
  • Patients with extreme swelling or pain may have compartment syndrome.
  • Pressure measurement may be necessary to differentiate severe pain from swelling and the injury from that of a compartment syndrome of the hindfoot.
Differential Diagnosis
  • Subtalar dislocation
  • Talar fracture
  • Ankle fracture
  • Severe ankle sprain
Treatment
General Measures
  • Closed calcaneal fractures can be managed initially in a bulky soft dressing and plaster splint; this dressing must be well padded and is fabricated as follows:
    • Several layers of cast padding wrapped around the foot, ankle, and leg
    • Next, a layer of bulky cotton dressing (commonly called rolled cotton, Red Cross cotton, bulky Jones dressing).
    • Then, a posterior plaster slab and stirrup U-shaped plaster slab are placed around the foot and leg and wrapped with an Ace wrap.
  • Strict elevation for several days after the fracture reduces swelling.
  • Admission to the hospital for pain control and monitoring for compartment syndrome may be indicated for more severe fractures.
  • A foot pump may be placed within the dressing to reduce soft-tissue swelling.
  • Nondisplaced fractures can be treated with splinting initially, followed by cast immobilization and nonweightbearing.
  • Open calcaneal fractures are operative emergencies.
  • Compartment syndrome occurs in 10% of calcaneal fractures.
    • Monitor patients for severe pain or neurologic deficits, and have a low threshold for foot compartment pressure measurement.
    • Patients with compartment syndrome may require emergent fasciotomy.
Activity
Activity is nonweightbearing until the fracture has healed (a minimum of 6 weeks).
 
Special Therapy
Physical Therapy
  • Gait training is indicated for nonweightbearing on the affected side until it is healed.
  • After immobilization, therapy should address ankle and foot motion.
Medication
First Line
Narcotic analgesics frequently are required for pain management.
 
Surgery
  • The decision to operate is individualized based on the severity of the fracture and the patient profile.
    • Smokers, patients >50 years old, laborers, and those involved in workers compensation claims tend to have poorer outcomes after surgery.
    • Diabetic and vasculopathic patients also are poorly served by surgery and may have better results from nonoperative treatment.
    • Conversely, younger patients with good soft-tissue viability and displaced intra-articular fractures usually have better outcomes with surgical treatment.
  • Reconstruction of the calcaneus:
    • Performed through a lateral incision
    • The lateral border of the calcaneus is exposed subperiosteally, and a pin is placed in the posterior fragment to improve exposure of the fracture and to facilitate reduction.
    • A plate is placed laterally after the fracture has been reduced, and fixation is provided by placing screws into a stable fragment, commonly the sustentaculum tali.
    • Residual bony defects may require bone grafting.
    • The incision is closed primarily, and the foot is placed into bulky cotton dressing with a posterior splint postoperatively.
  • Open fractures of the calcaneus should be treated with operative debridement.
    • The condition of the soft tissue guides subsequent treatment.
    • Early soft-tissue coverage is important, and a plastic surgeon should be consulted.
    • The soft-tissue coverage drives the ultimate outcome.
    • If coverage can be achieved, reduction and fixation may be accomplished.
Follow-up
Disposition
Issues for Referral
  • All patients with a calcaneus fractures should be referred to an orthopaedic surgeon.
  • All patients who have signs or symptoms of compartment syndrome should be seen in the emergency room by an orthopaedic surgeon.
Prognosis
  • Nondisplaced, extra-articular fractures have an excellent prognosis.
  • Patients with displaced intra-articular fractures may develop posttraumatic arthritis.
  • Intra-articular fractures are life-changing events, with long-term pain and loss of function.
Complications
  • Subtalar arthritis
  • Heel widening, preventing normal shoe wear
  • Gait difficulties
  • Foot stiffness
  • Peroneal tendinitis
  • Sural nerve irritation
  • Loss of soft-tissue viability
  • Postoperative wound infection
Patient Monitoring
Serial radiographs are obtained every 6 weeks to monitor healing.
 
Miscellaneous
Codes
ICD9-CM
  • 825.1 Open calcaneus fracture
  • 825.2 Closed calcaneus fracture
Patient Teaching
Intra-articular fractures can lead to subtalar arthritis and the late onset of pain.
 
Activity
  • The activity level of patients with intra-articular calcaneus fractures usually does not return to normal.
  • Patients often have stiffness of the ankle, preventing them from ladder use or heavy loading.
  • Patients may require additional surgery to fuse the ankle and subtalar joints.
Prevention
Prevention involves avoiding falls from height and high-energy trauma.
 
FAQ
Q: Will I return to my job?
A: Patients with high-energy calcaneus fractures and extensive intra-articular involvement rarely return to running, jumping, or climbing activities.
 
Q: Should I have surgery for my calcaneus fracture?
A: Some patients, including those who have diabetes or who smoke, are at high risk for wound infections. Patients with heel widening or articular step-off may benefit from surgery.

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