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Fracture of the Heel Bone (Calcaneus)
Fractures of the calcaneus can be
debilitating injuries. Usually these fractures occur when tremendous
forces impact the foot and damage the heel. Examples are falls from
heights or motor vehicle accidents. Imagine standing on an orange
and seeing it widen and squash flat. This is essentially what happens
to the calcaneus.
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These are CAT scan images of fractures
of the calcaneus. The terrible injury on the left has
multiple small fragments of bone. The one on the right
is more deformed but there are fewer and larger pieces
of bone. |
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The joint between the calcaneus and the talus
is called the subtalar joint. This joint is responsible for the inward
and outward movements of the foot, otherwise called inversion and
eversion. When the calcaneus is fractured the movement of inversion
and eversion is commonly decreased or lost completely. The upward
and downward movement of the ankle (dorsiflexion and plantarflexion)
is not usually affected by fractures of the calcaneus.
There are numerous problems associated with fractures of the calcaneus.
One is the widening and deformity of the bone itself. Another is irregularity
of the subtalar joint that leads to arthritis. Fractures to the calcaneus
may also cause injuries to the heel cushion (the heel pad) and to
the nerves and tendons surrounding the heel.
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On the left is
a picture of a foot that suffered a bad calcaneus fracture
and was treated without surgery. Compare the shape of
the flattened out heel on the left with the normal heel
on the right. |
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The ideal goal of treatment is to restore the dimensions of the heel
as accurately as possible. This is always difficult because of the
multiple fragments of bone that are commonly present. It is almost
like trying to piece together a jigsaw puzzle.
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These are images
of a fracture of the calcaneus. The image on the left
is a CAT scan. The image on the right is an x-ray. This
is a relatively minor fracture with only two or three
major fragments. |
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For the majority of patients, surgery is the correct form of treatment.
The goal of surgery is to restore the correct size and structure of
the heel. This is done by performing what is called an open reduction
and internal fixation of the fracture. The open reduction and internal
fixation procedure is performed through an incision on the outside
of the heel. The bone is put together and held in place with a metal
plate and multiple screws. This procedure decreases the likelihood
of arthritis developing and maximizes the potential for inward and
outward movement of the foot.
There are times, however, when the bone is so severely smashed and
fractured that, in addition to the open reduction and internal fixation,
the heel joint (the subtalar joint) needs to be fused. This is done
to decrease the chances of developing painful arthritis. Although
the inversion and eversion movement of the foot is lost after a subtalar
fusion, there is a more rapid return to activities and functions after
this type of surgery.
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This is the inside
of the foot during surgery. There are many pieces of the
calcaneus. In the right hand picture, some of the bone
pieces are shown with the white cartilage surface broken. |
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The fracture has been repaired with
a plate and multiple screws. Note that the overall shape of
the heel (calcaneus) has been very nicely restored. |
The ideal time to perform surgery is when there is minimal swelling
of the skin. We will often use a foot pump device applied to the foot
for a few days to decrease the swelling. This allows us to perform
the surgery as soon as possible.
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This fracture
of the calcaneus above has been fixed with screws that
have been inserted through skin punctures instead of large
skin incisions. |
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The x-ray on the
left shows the foot prior to surgery. The x-ray on the
right shows the foot after the procedure. Note that the
height and shape of the calcaneus have been perfectly
restored. |
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Following surgery, no walking on the foot is permitted for approximately
3 months. A bandage is applied to the leg after surgery. After the
stitches are removed, movement exercises and therapy are started to
try to maximize the function of the foot. It typically takes approximately
six months to recover from this type of injury.
Following a fracture of the calcaneus, there
are many potential problems which can occur. To some extent, this
depends on the type of treatment provided. The problems which occur
commonly are as follows:
- Pain in the back of the heel on the outside
of the ankle. This is present in the heel joint (the subtalar
joint), and is usually because of arthritis in this joint.
- Stiffness in the subtalar joint. Regardless
of the type of treatment, there is always some limitation of the
in and out movement of the foot. This is called inversion and
eversion. The problem occurs because of damage to the cartilage
surface of joint, which is often associated with arthritis.
- Widening of the back of the heel and difficulty
with wearing shoes. This problem occurs predominantly when surgery
is not performed initially, and the heel remains wide and deformed.
- Pain on the outside of the heel and the outside
of the ankle occurs due to injury to the tendons (the peroneal
tendons). This is a more common problem when surgery is not performed
initially, and is because of widening of the heel bone. The peroneal
tendons can be torn in the process.
- Pain under the pad of the heel. This is unfortunately
a permanent problem, since the specialized fatty cushion under
the heel can be permanently damaged with injury. This can only
be treated with correct cushioning and padding of the heel.
- Burning pain on the inside of the ankle. This
can occur as a result of widening of the inside of the heel on
the inside of the ankle, which causes irritation of the tibial
nerve (called a tarsal tunnel syndrome)
- Pain in the ankle, which occurs in severe forms
of fracture which are not treated with surgery. The heel bone
is severely crushed, which leads to jamming of the front of the
ankle.
Arthritis of the heel joint will lead to pain
in the outside of the ankle, and stiffness of the back of the foot.
Walking on uneven ground surfaces is difficult since the inversion
and eversion movement of the subtalar joint is missing. The treatments
can consist of anti-inflammatory medication, injection of the subtalar
joint with cortisone, special arch supports and heel cushions, and
surgery. We have reported in the literature that when surgery is
necessary to correct the problem, that the longer it takes to perform
this surgery after a fracture of the calcaneus, the longer it will
take to return the individual back to a more normal lifestyle, in
particular heavy work. There are many different types of surgery
which can be performed, and this is determined by the severity of
the deformity, the presence of arthritis, and other problems such
as tearing of tendons, pain in the ankle, and widening of the heel.
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The heel in the picture on the left
is severely deformed following a fracture of the calcaneus
which was not treated with surgery. The heel bone is
flattened and collapsed. Look at the picture of the calcaneus
on the right, where the arch and the height of the heel
is normal. This picture on the right is of a patient
who also sustained a fracture of the calcaneus, but although
arthritis of the joint occurred, there was minimal deformity
present. |
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When the deformity of the heel is not severe, and there is minor
arthritis, then all that may need to be done is to remove the excess
bone under the outside of the ankle. The problem here is called
impingement where bone from the broken calcaneus rubs on the under
side of the ankle causing pain.
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In these pictures, this is an operation
to remove excess bone on the outside of the heel after
a calcaneus fracture. You cannot see the heel joint (subtalar
joint) on the left picture. After removal of the excess
bone, it is now possible to see the white grisel surface
of the top of the subtalar joint. The long white structure
is the peroneal tendon which was caught and stuck as
a result of the extra bone on the side of the heel. |
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This picture is a CAT scan of the back
of the heel. The very irregular surface represents the
arthritis of the subtalar joint. The treatment for this
condition is to fuse or glue together the joint surfaces
to eliminate the arthritis and decrease pain. This operation
is called a subtalar fusion. |
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This is a typical picture of arthritis
and minor deformity of the heel following fracture of
the calcaneus. It has been corrected with an arthrodesis
(fusion) of the subtalar joint with screws. |
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When the deformity of the heel is more severe,
a fusion of the subtalar joint is not sufficient, and a piece of
bone (called a bone graft) is place into the joint to restore the
more normal dimension of the heel.
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In both of these pictures the deformity
of the heel is severe, and the heel is very flat. The
height of the heel must be restored, and this can be
done with a fusion of the subtalar joint, but a block
of bone graft must be used for this surgery. |
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In the picture on the left, the heel
has been opened, and a piece of bone is used from the
bone bank. It is never necessary to use bone from your
pelvis for this type of surgery. On the right hand picture,
two screws have been used and it is easy to see the difference
in the shape of the heel compared to the pictures above. |
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The picture on the left is of a patient
who had been treated with surgery five times after a
fracture of the calcaneus. A fusion of the subtalar joint
had been attempted without success, and the screw that
had been used to secure the fusion is loose. The foot
is very deformed and flat. This is extremely difficult
surgery, which was done as shown on the picture on the
right hand side, with repeat fusion using bone graft
and multiple screws. It is easy to see the improved shape
and position of the heel in the picture on the right
hand side. |
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