Although each individual fracture will be unique, calcaneus fractures tend to be grouped into one of two types of fractures. In today’s blog, we take a closer look at each type of heel fracture and discuss how each is typically treated.

The Two Types Of Calcaneus Fractures

Your calcaneus is the large bone that forms the foundation of the rear part of your heel. It connects with the talus and cuboid bones, and this connection forms the subtalar joint, which is a crucial joint for a variety of foot functions. The calcaneus is oftentimes compared to a hard boiled egg, in that a softer middle is protected by an thin outer shell. Excess trauma to the heel can cause this protective layer to break and a larger section of the bone to collapse and fragment. Fragmented bones and potential damage to an important joint mean that these heel fractures can be quite severe.

When a calcaneus fracture occurs, it typically develops in one of two forms. There is the intra-articular fracture and the extra-articular fracture, and we’ll take a closer look at both.

Intra-Articular Calcaneus Fracture – An intra-articular calcaneus fracture is the more severe of the two types of fractures. Not only does it involve a fracture of the calcaneus, but there is also damage to surrounding cartilage and the subtalar joint. Essentially, not only is the bone itself fragmented and damaged, but so are nearby areas that serve as crucial joint junctures and surfaces. These areas are unlikely to heal ideally on their own, which is why surgery is more common for the intra-articular calcaneus fracture.

Extra-Articular Calcaneus Fracture – An extra-articular calcaneus fracture is a fracture that does not involve damage to nearby joints or joint surfaces. This type of fracture can be the result of an avulsion injury (where a piece of bone is pulled off the calcaneus), or due to repetitive stress and overuse, like what an athlete or amateur runner might experience as they increase their workload. The majority of extra-articular heel fractures can be managed with the help of conservative treatments like rest, activity avoidance, physical therapy and a gradual return to higher impact activities, but some will still need to be addressed with a surgical procedure depending on their severity or how well they respond to non-operative treatment.

When surgery is necessary, it’s oftentimes performed using what’s known as the ORIF technique, which stands for Open Reduction Internal Fixation. The surgeon will use hardware like plates and screws to reposition bone fragments and secure them in place so that healing can occur as planned. You’ll then remain non-weight bearing for weeks while healing begins to run its course. Eventually you will transition to partial weight bearing and physical therapy around the 8-week month, and many patients are back to normal daily activities by around three months post-op. That said, severe fractures and more ambitious surgeries may require the patient to progress through a more extensive rehabilitation period, and maximum recovery may take anywhere from six months to two years to acheive.

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As we tell each patient that we consult online, it’s best to get a diagnosis from a specialist in your area, but it may be a good idea to head into a clinic for x-rays because a number of different issues could be going on. At a minimum, you’re probably dealing with what’s known as a heel or stone bruise. As we described in this post on identifying and treating heel bruises, the fat pad on the underside of the heel can be damaged after hard trauma to the heel. It can lead to a contused, partially disrupted or completely disrupted fat pad.

The good news is that heel bruises and fat pad disruptions typically heal well with conservative care techniques. This means treatments like rest, ice, compression and elevation. Anti-inflammatory pain relievers can also help provide relief. One of the most important things about treating a heel bruise is that you give your feet enough time to heal. If you try to rush back into activity too quickly, you’re only going to be stressing your heel with every step you take, and it’s never going to heal properly. Athletes are notoriously bad at rushing back too quickly following a heel bruise, but try to find other ways to exercise that still allows your feet to avoid activity.

Calcaneal Fracture Treatment

If you suffer severe enough trauma, the calcaneus, or heel bone, can actually fracture. Things get a little trickier if you’re dealing with a calcaneal fracture because non-operative treatment has some downfalls. Without surgery, your heel can widen, poor healing can negatively affect your peroneal tendon, arthritis and joint stiffness can develop or fibula disruption can occur. That’s why we talked about the problem with avoiding surgery if you have a calcaneal fracture.

For most calcaneal fractures, surgery is the preferred treatment route. Surgery to address the fracture has three main goals:

• Fuse the fracture to prevent arthritis
• Narrow the heel to reduce peroneal tendon disruption
• Adjusting the fracture and joint to ensure proper healing

This is a difficult procedure that takes precise work from a skilled surgeon, but it’s one of Dr. Silverman’s favorite procedures to perform. Getting the fracture to heal in just the right location is rewarding for both patient and provider. Rehab after surgery follows the same path of a heel bruise in that RICE and slowly returning to activity are your best courses of action.

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They went on to chastise operative care for heel fractures, saying:

• “[There was] no symptomatic or functional advantage after two years.”

• “The risk of complications was higher after surgery.”

• “We had anticipated benefit in at least some of these measures, but there were no differences in patient reported general health, quality of life, or ability to return to work. Ranges of movement of the injured hind foot were no different between treatment groups, and even heel width (a commonly suggested reason for surgery, to facilitate shoe fitting) was the same. Walking speed and five different metrics of gait also showed no difference at two years after injury.”

Worst of all, they concluded by saying, “There is no justification to continue with this surgery for closed displaced intra-articular calcaneal fractures without severe displacement. Patients and their surgeons can choose safer but equally effective non-operative care. “

Why They’re Wrong

This study and the research on it is poorly presented, but this is typical of a group trying to please a universal health plan, not trying to fret out the truth in care. In essence. they basically compared an out of date surgical technique to non-surgical technique.

Since 2005, I have not performed an open reduction and internal fixation using the technique described in the article. That surgery has a high rate of wound complications and infection, which they make a particular point in noting. This technique often requires prolonged immobilization in a cast and forces the patient to be non-weight bearing for 10 weeks (just as in non surgical treatment).

Instead, I have been using minimally invasive procedures using one or two small incisions. I achieve the same strength of fixation alignment without any wound problems. Instead of waiting up to three weeks for the skin and the tissues to be ready to handle the insult from the large classical L-shaped incision, surgery can proceed safely within the first week of the injury. Instead of patients placed on their side, the surgery can be done with patients lying supine on their backs, a safer position for anesthesia. Patients are removed from the cast after two weeks and begin weight bearing at six weeks. Their recovery from injury is more than twice as fast, the incision becomes invisible and the pain and swelling are greatly reduced.

When you compare a minimally invasive operation to fully open surgery, the differences are so large you can see why I so vehemently disapprove of this study!

The variety of options for minimally invasive technology have been developed over the last 4-6 years. Studies like this do a discredit to surgery and to surgeons, confuse the public, make insurance communications a hassle at best, and can block the top care for patients at the worst.

I am sure this paper will be discussed at next weeks combined IFFAS/AOFAS: International Federation of Foot and Ankle Societies and American Orthopedic Foot and Ankle Society meeting in Chicago. It’s an honor for the US to host the event. I am excited to go and learn from surgeons around the world. I can’t wait to let my patients benefit from all the shared information.

Related source: Reuters

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Below, we’ll examine the signs, symptoms and prevention tips of for dealing with a calcaneal fracture.

My Heel Hurts

People injure their calcaneal in several different ways, but they all result from the heel absorbing a great deal of force or rotational stress. Oftentimes I see an uptick in the number of calcaneal fractures during the fall season for a variety of reasons. The fall weather tends to make the ground more slippery, which means runners and athletes may injure themselves more easily if they can’t keep their footing.

Falls from a great height are the most common way a person fractures their calcaneal. Although your heel is padded, it is not designed to take a large amount of force at once.

Symptoms of a Calcaneal Fracture

Symptoms will vary based on the severity of the fracture. Some people will be able to walk or limp after suffering the injury, while others won’t be able to place weight on the foot. Regardless of the severity, most patients with a calcaneal fracture have to deal with:

• Pain

• Bruising

• Swelling

If left untreated, patients may eventually develop a permanent deformity of their foot or a widening of their heel. Non-surgical treatment used to be the preferred method for treating calcaneal fractures, but the fracture never completely heals without surgery, so many patients were left to deal with minor discomfort for the rest of their lives. Today, nearly all non-displaced calcaneal fractures are treated surgically. We’ll dive into the specifics in our follow-up post.

Preventing Calcaneal Fractures

Preventing calcaneal fractures can be a little tricky, since nobody plans to fall out of a tree or off a ladder, but steps can be taken to minimize your risk. If you plan on climbing a ladder, be sure you have another person holding the bottom of the ladder for support. If you’re a hunter, consider investing in a lightweight hunter safety harness so you don’t fall out of the stand in the event you doze off for a second.

Next week, we’ll examine the treatment and rehabilitation options for dealing with calcaneal fractures.

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• Falling out of a deer stand
• Jumping off a roof
• Slipping off a ladder

In the past, non-surgical treatment was considered safest as the risks from wound healing were so problematic and infection rates so high. However, without surgery, the heel widens and the foot cannot fit inside a normal shoe, the subtalar joint becomes arthritic, uneven ground becomes painful to walk on, and eventually the tendon will tear. And that’s just the beginning! Eventually the ankle and hindfoot joints will develop arthritis from the excessive stress. Today, almost all but non-displaced fractures are treated surgically to decrease these complications.

In the past, surgeons used to keep the patient in a splint for 10-21 days after the fracture before doing surgery. Following the procedure, patients were kept casted and non-weight bearing for 10 weeks.

Using the minimally invasive approach, I can safely fix these fractures within a few days of the injury. Using small incisions I align the fracture fragments and the joint surface to recreate the shape of the heel bone. Then I gently slide plates underneath the skin and place screws to rigidly stabilize the bone. The wound healing rates are phenomenal and patients marvel at how small the incision is. Patients are kept in a splint for only 2 weeks and then transitioned to a removable cast boot. Because fractures heal faster with minimally invasive techniques, I let my patient bear weight after only 6 weeks. Rehabilitation is faster, easier, and the results are simply better.

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