Calcaneus (Heel Bone) Fractures-OrthoInfo - AAOS Copyright 2016 American Academy of Orthopaedic Surgeons Calcaneus (Heel Bone) Fractures A fracture of the calcaneus, or heel bone, can be a painful and disabling injury. This type of fracture commonly occurs during a high-energy event—such as a car crash or a fall from a ladder—when the heel is crushed under the weight of the body. When this occurs, the heel can widen, shorten, and become deformed. Calcaneus fractures can be quite severe. Treatment often involves surgery to reconstruct the normal anatomy of the heel and restore mobility so that patients can return to normal activity. But even with appropriate treatment, some fractures may result in long-term complications, such as pain, swelling, loss of motion, and arthritis. Anatomy Normal foot anatomy. The bones of the feet are commonly divided into three parts: the hindfoot, midfoot, and forefoot. Seven bones — called tarsals — make up the hindfoot and midfoot. The calcaneus (heel bone) is the largest of the tarsal bones in the foot.

It lies at the back of the foot (hindfoot) below the three bones that make up the ankle joint. 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. The subtalar joint allows side-to-side movement of the hindfoot and is especially important for balance on uneven surfaces. Top of page Description Calcaneus fractures are uncommon. Fractures of the tarsal bones account for only about 2% of all adult fractures and only half of tarsal fractures are calcaneus fractures. A fracture may cause the heel bone to widen and shorten. In some cases, a fracture may also enter the subtalar joint in the foot. When this occurs, damage to the articular cartilage covering the joint may cause long-term complications such as chronic pain, arthritis, and loss of motion. Severity The calcaneus is most often fractured during a: Fall from a height Twisting injury to the ankle Motor vehicle collision The severity of a fracture can vary.

For example, a simple twist of the ankle may result in a single crack in the bone. The force of a head-on car collision, however, may result in the bone being shattered (comminuted fracture). Similar fractures can result from different mechanisms. For example, if you land on your feet from a fall, your body's weight is directed downward. This drives the talus bone directly into the calcaneus. In a motor vehicle crash, the calcaneus is driven up against the talus if the heel is crushed against the floorboard. In both cases, the fracture patterns are similar. As a rule, the greater the impact, the more the calcaneus is damaged. In a high-energy fracture, other injuries, such as fractures of the spine, hip, or other heel, can occur. (Left) In some injuries, the talus is forced downward and acts like a wedge to fracture the calcaneus. (Right) This computerized reconstruction of a calcaneus fracture shows the amount of damage that can occur. Heel deformity Inability to put weight on the heel or walk With some minor calcaneus fractures, the pain may not be enough to prevent you from walking — but you may limp.

This is because your Achilles tendon acts through the calcaneus to support your body weight. If, however, your calcaneus is deformed by the injury, your muscle and tendon cannot generate enough power to support your weight. Your foot and ankle will feel unstable, and you will walk differently. Top of page Doctor Examination It is important that you tell your doctor the circumstances of your injury. For example, if you fell from a ladder, how far did you fall? It is also important that you tell your doctor if you have any other injuries or medical problems, such as diabetes, or if you take medications or smoke. Physical Examination After discussing your symptoms and medical history, your doctor will perform a careful examination. He or she will: Examine your foot and ankle to see if your skin was damaged or punctured from the injury. Check your pulse at key points of the foot to be sure that there is a good blood supply to the foot and toes. Check to see if you can move your toes, and can feel things on the bottom of your foot. Determine whether you have injured any other areas of your body by examining the rest of your injured leg, your other leg, pelvis, and spine.

Tests Imaging studies will help confirm the diagnosis of a calcaneus fracture: X-rays. This test is the most common and widely available diagnostic imaging technique. X-rays create images of dense structures, such as bone. An x-ray can show if your calcaneus is broken and whether the bones are displaced. Computed tomography (CT) scans. Because of the complex anatomy of the calcaneus, a CT scan is routinely ordered after a fracture has been diagnosed on x-ray. A CT scan will produce a more detailed, cross-sectional image of your foot and can provide your doctor with valuable information about the severity of your fracture. This information will help your doctor recommend the best plan for treatment. Your doctor may share both your x-rays and CT scans with you to help you better understand the nature and severity of your injury. Your doctor will consider several factors in planning your treatment, including: The cause of your injury Your overall health The severity of your injury The extent of soft tissue damage Because most calcaneus fractures cause the bone to widen and shorten, the goal of treatment is to restore the normal anatomy of the heel. In general, patients whose normal heel anatomy is restored have better outcomes. In most cases, recreating the normal heel anatomy involves surgery.

Your doctor will discuss the different treatment options with you. Nonsurgical Treatment Nonsurgical treatment may be recommended if the pieces of broken bone have not been displaced by the force of the injury. Immobilization. A cast, splint, or brace will hold the bones in your foot in proper position while they heal. You may have to wear a cast for 6 to 8 weeks — or possibly longer. During this time, you will not be able to put any weight on your foot until the bone is completely healed. Surgical Treatment If the bones have shifted out of place (displaced), your doctor may recommend surgery. Surgery to repair a calcaneus fracture can restore the normal shape of the bone but is sometimes associated with complications, such as wound healing problems, infection, and nerve damage. Nonsurgical treatment of some fractures, however, can also lead to long-term complications, such as pain, arthritis, and a limp. Your doctor will review the details of your injury and talk with you about the risks and benefits of surgical versus nonsurgical treatment. Timing of surgery. If the skin around your fracture has not been broken, your doctor may recommend waiting until swelling has gone down before having surgery.

Elevating your leg and keeping it immobilized for several days will decrease swelling. It will also give stretched skin a chance to recover. Waiting before the operation may improve your overall recovery from surgery and decrease your risk of infection. Open fractures, however, expose the fracture site to the environment and must be treated immediately. They require surgery to clean the wound and remove damaged tissue Early surgery is also often recommended for an avulsion fracture. Although uncommon, a piece of the calcaneus can be pulled off when the Achilles tendon splits away from the bone (avulsion). For this type of fracture, emergent surgery can decrease the risk of injury to the skin around the Achilles tendon. Surgical procedure. The following procedures are used for various types of calcaneus fractures: Percutaneous screw fixation. If the bone pieces are large, they can sometimes be moved back into place without making a large incision. Special screws are then inserted through small incisions to hold the fracture together. Open reduction and internal fixation. During this operation, an open incision is made to reposition (reduce) the bones into their normal alignment. They are held together with wires or metal plates and screws. (Left) A displaced fracture of the calcaneus.

(Right) The fracture has been reduced and the bones held in place with screws. In this x-ray, the bone fragments have been realigned and held in place with metal plates and screws. Top of page Recovery Bones have a remarkable capacity to heal. The more severe your injury, however, the longer your recovery may be. Patients with more severe fractures are also more likely to suffer some degree of permanent loss of function, regardless of treatment. Pain Management After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster. Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids. Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor.

As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery. Rehabilitation Whether your treatment is surgical or nonsurgical, your rehabilitation will be very similar. The time it takes to return to daily activities will vary depending on the type and severity of the fracture and whether you have other injuries. Some patients can begin weight-bearing activities a few weeks after injury or surgery; others may need to wait 3 months or more before putting weight on the heel. Most patients are able to begin partial weight bearing between 6 and 10 weeks after injury or surgery. Early motion. Many doctors encourage motion of the foot and ankle early in the recovery period. For example, you may be instructed to begin moving the affected area as soon as your pain allows. If you have had surgery, you may be instructed to begin moving the affected area as soon as the wound heals to your doctor's satisfaction. Physical therapy. Specific exercises can help improve the range of motion in your foot and ankle, and strengthen supporting muscles. Although they are often painful at the beginning and progress may be difficult, exercises are required in order for you to resume normal activities. Weight bearing.

When you begin walking, you may need to use crutches, a cane, or a walker and/or wear a special boot. It is very important to follow your doctor's instructions for walking on your foot. If you put weight on your foot too soon, the bone pieces may move out of place and you might require surgery. If you have had surgery, the screws might loosen or break and the bone may collapse. This may not occur the first time you walk on it but, if the bone is not healed and you continue to bear weight, the metal will eventually break. Six months after surgery, this patient's hardware has failed. Several screws have broken and the calcaneus has collapsed. This patient required major reconstruction, and today walks with a limp and has little motion in the foot. Complications Complications often occur with calcaneus fractures. Minor complications include: Small or temporary areas of delayed wound healing Nerve irritation around the incision Tendon irritation Failure of the wound to heal Infection Posttraumatic arthritis (with or without surgery) It is important to tell your doctor if you are a smoker. Smoking affects both bone and wound healing. With or without surgery, your bone may take longer to heal if you smoke.

Additional surgery is usually required in cases of infection or wound healing complications. If all attempts to resolve an infection or a wound healing complication fail, an amputation may be necessary. Top of page Outcomes If your injury is minor, such as a crack in the bone with little muscle damage, you may be able to resume normal activities from 3 to 4 months after surgery. If your fracture is severe, however, it may take from 1 to 2 years before recovery is complete. Despite the best efforts of the doctor and patient, normal foot and ankle motion is rarely regained after a severe fracture and patients do not typically resume their pre-injury level of function. A patient who is not very active might tolerate a foot that is not normal. On the other hand, a patient whose job or recreational activities require a lot of walking or climbing will notice more. Common Problems Top of page Improving Outcomes There is no universal agreement among experts as to the best treatment method for calcaneus fractures. No single method works the same for everyone. Patients whose x-rays show good healing and normal heel anatomy often have ongoing symptoms after treatment.

On the other hand, the calcaneus can look quite deformed on an x-ray, but the patient may have few, if any, symptoms. Studies have compared results in patients whose fractures were treated with and without surgery. Some studies show a significant benefit of surgery, while other studies show less benefit for certain patients. Researchers continue to look for ways to improve the outcomes of treatment for different types of calcaneus fractures, as well as for patients who smoke or have other health considerations. Your doctor will talk with you about the best treatment options in your case. Calcaneus Bone Anatomy, Definition & Function | Body Maps Your message has been sent. OK We're sorry, an error occurred. We are unable to collect your feedback at this time. However, your feedback is important to us. Please try again later. Close Calcaneus Located within the foot, the calcaneus is also known as the heel bone. It is situated in the back of the foot, just below the talus, tibia, and fibula bones of the lower leg. Of all of the bones in the foot, the heel bone is the largest. The calcaneus has a unique design and structure.

At the front, the heel bone features many curves to accommodate the talus and the many different tarsal bones, which lead to the metatarsals and phalanges that make up the front of the foot and toes. The back of the heel bone is not as complex, featuring a tuberosity and a medial process — landmark areas of the bone where muscles attach. The calcaneus provides insertion points for the abductor hallucis and the abductor digiti minimi muscles. At the back of the heel, the Achilles tendon inserts into the rough area located on the superior (upper) side. This fibrous connective tissue, as well as other ligaments and muscles, is necessary for standing, walking, and running. As such, a broken or fractured calcaneus will make these movements difficult. Calcaneus Fracture Imaging: Overview, Radiography, Computed Tomography Calcaneus Fracture Imaging Updated: Sep 30, 2015 Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Chief Editor: Felix S Chew, MD, MBA, MEd more... Share Overview Preferred examination CT imaging is the investigation of choice in calcaneus fractures .

[ 1 , 2 , 3 ] Coronal and axial views are generally taken. CT best defines the relationship of bone fragments. [ 4 , 5 , 6 ] MRI is increasingly being used to characterize ankle sprains, occult fractures, bone bruises, growth-plate injuries, and ligamentous/tendon injuries. MRI is the criterion standard for identifying peroneal tendon injury. This injury is identified by the high signal intensity in tendon on T2-weighted axial views. Tenography is useful for assessing large lesions of the tendons. Scintigraphy may be useful in occult fractures and in the differential diagnosis of pathologic fractures. Pathologic features may become apparent on scintigraphy a few weeks before they become apparent on plain radiographs because the increased osteoblastic activity associated with stress fractures is more easily detected with scintigraphy. [ 7 ] Physical examination usually is required to assess the integrity of tendons and ligaments. Approximately 75% of calcaneus fractures are intra-articular and involve the subtalar articular surface. Because these injuries are associated with a poor prognosis, it is important to identify patients with these fractures.

Conventional radiographs provide a benchmark for the diagnosis of fractures around the ankle in general, and they usually suffice for the diagnosis of the osseous component of the injury. [ 8 ] ; however, in most cases, supplemental imaging is needed to define characteristics fully, owing to the complex anatomy of this region. Comminuted fractures with fragment displacement of the calcaneus are common, and the relationship of the multiple fragments is difficult to appreciate on conventional radiographs. See Radiograph. The calcaneus is the most frequently fractured tarsal bone. Calcaneus fractures may occur as a result of falls from heights or from twisting injuries or through a pathologic process such as osteoporosis , cysts, and tumors. Os calcis fractures can be broadly classified into intra-articular and extra-articular types. The calcaneus functions as a lever arm for the gastrocsoleus complex, providing a foundation or vertical support for one's body weight and providing support for and maintaining the lateral column of the foot. Any fracture that impairs one of these functions substantially affects the person's gait if not restored. These fractures may remain undiagnosed clinically, as there may be no obvious deformity.

Often, a history of the patient falling from a height and landing on his or her heels is helpful, but radiographic examination is essential to confirm fracture. Management of these fractures depends on the type of fracture. Therefore, imaging plays a primary role. The management of calcaneus fractures and their associated soft tissue injuries are controversial. Open reduction and stable internal fixation with a lateral plate and without joint transfixation are established as standard therapy for displaced intra-articular fractures. Good to excellent results are achieved in two thirds to three quarters of all cases, as shown in large clinical series. Anatomic reduction of joint congruity and the overall shape of the calcaneus are important prognostic factors. The quality of joint reduction should be proved intraoperatively with the acquisition of Broden views, high-resolution fluoroscopy, or open subtalar arthroscopy. [ 9 , 10 , 11 , 12 , 13 ] See the images of calcaneus fractures below. Calcaneus, fractures. The Bohler angle.

In determining the Bohler angle, a line is drawn between the posterior superior aspect of the calcaneus and the highest point of the posterior subtalar articular surface; a second line, which intersects the first, is drawn from the highest point of the anterior process to the posterior margin of the subtalar surface. The angle that results from their intersection measures 20-40°. If the angle is reduced, a calcaneal fracture is present; however, a normal angle does not exclude a calcaneal fracture. View Media Gallery Calcaneus fractures resulting from falls onto the heels from heights are bilateral in 5-9% of patients; they are associated with compression fractures of the lumbar and/or dorsal spine in 10%. These fractures are complicated by a compartment syndrome in 10% of cases, with half of these involving development of clawing of the lesser toes or other chronic problems, such as stiffness and neurovascular dysfunction. Other fractures around the ankle and soft tissue injuries are encountered in a quarter of all cases of calcaneus fracture.

Soft tissue injuries include subluxation or dislocation of the peroneal tendons from the fibular sulcus, entrapment of neurovascular bundle, and interposition of the flexure hallucis longus tendon between bone fragments from sustentaculum tali. Limitations of techniques Conventional radiographs may be negative in cases involving subtle fractures, particularly in cases involving stress fractures. Comminuted fractures and displacement are common in fractures of the calcaneus, and the relationship of the multiple fragments is difficult to appreciate on conventional radiographs. CT is the modality of choice, especially in complex fracture patterns, although it is expensive and it imparts a relatively high dose of radiation; it should be used sparingly in young patients or in pregnant patients. It is noteworthy that CT tends to be somewhat overutilized in the United States; this tendency has increased in recent years. MRI is expensive and may cause problems in patients with claustrophobia. MRI is sensitive in the immediate documentation of stress changes in osseous structures. MRI is well known to show even minor stress changes (eg, after a marathon) that occur before the actual stress fracture.

A severe bone contusion is associated with multiple microfractures, whereas a stress fracture involves a linear component; the distinction between the 2 diagnoses may seem arbitrary. In the absence of a linear component, it may be difficult to distinguish an underlying severe stress reaction associated with a bone contusion from a stress fracture on MRI. Bone contusion associated with a stress fracture may be difficult to distinguish from red marrow. With MRI, it may be difficult to detect small intra-articular fragments—a fact that likely limits the use of MRI on a routine basis. Scintigraphy is sensitive in imaging bone trauma but lacks the specificity and the spatial resolution that MRI provides. A physiologic periosteal reaction, bone tumor, avascular necrosis, plantar fasciitis, or bone spur can cause false-positive findings. Next: Radiography Conventional radiography Conventional radiographic examination consists of axial and lateral views of the calcaneus and an anteroposterior (AP) view of the foot (see the images below). However, because of the complexity of the anatomy, multiple radiographic views are often necessary. Giannestras and Sammarco suggested that multiple views be used, including the oblique view.

[ 14 ] Radiographs of the dorsal and lumbar spine are also often indicated, because an associated fracture is seen in a vertebral body in 10% of all patients. Further fractures of the tibia and fibula are seen in 9% of patients. Calcaneus fractures are bilateral in 5% of patients. Calcaneus, fractures. Plain radiographs and CT scans in various projections and 3-dimensional rendering show the value of each modality. For the axial (Harris) view, see the images below. Calcaneus, fractures. Axial (Harris) view demonstrates a calcaneal fracture. View Media Gallery For Rowe type fractures, see the images below. Calcaneus, fractures. Avulsion fracture. Rowe type II beak/avulsion fracture of the Achilles tendon. Rowe classifies fractures into 5 groups. Groups I–III do not involve the subtalar joint. Groups IV and V involve the subtalar joint and represented almost 60% of the originally described series. For Essex-Lopresti fractures, see the images below. Calcaneus, fractures. Essex-Lopresti tongue-type calcaneal fracture.

The fracture line extends posteriorly to the tuberosity. View Media Gallery Normal variants of calcaneus fractures are shown in the images below. Calcaneus, fractures. Normal variants, complications, and differential diagnosis. Old calcaneal fracture. Dorsoposterior (DP) and lateral views of the foot demonstrate an old Essex-Lopresti depressed-type calcaneal fracture. The patient now has degenerative change at the subtalar joint. Essex-Lopresti describes 2 fracture types involving the subtalar joint. The depression type and the tongue type. Note flattening of the Bohler angle. View Media Gallery Lateral view and the Bohler angle The lateral view is the primary projection on which a diagnosis of a fracture is made, although some subtle fractures may be missed when reliance is placed on a lateral view only. Lateral views show the Bohler tuber angle and the crucial angle of Gissane clearly. Lorenz Bohler described the tuber-joint angle (the so-called Bohler angle).

In determining the Bohler angle, a line is drawn between the posterior superior aspect of the calcaneus and the highest point of the posterior subtalar articular surface; a second line, which intersects the first, is drawn from the highest point of the anterior process to the posterior margin of the subtalar surface. The angle that results from their intersection measures 20-40° (see the image below). Calcaneus, fractures. The Bohler angle. In determining the Bohler angle, a line is drawn between the posterior superior aspect of the calcaneus and the highest point of the posterior subtalar articular surface; a second line, which intersects the first, is drawn from the highest point of the anterior process to the posterior margin of the subtalar surface. The angle that results from their intersection measures 20-40°. If the angle is reduced, a calcaneal fracture is present; however, a normal angle does not exclude a calcaneal fracture. View Media Gallery In intra-articular fractures of the calcaneus, the subtalar joint is depressed, causing a decrease in the Bohler angle. The Bohler angle may also be decreased in some calcaneus fractures that do not involve the subtalar joint.

A flat Bohler angle is associated with intra-articular fractures; in such cases, the prognosis is poorer than it is in cases in which the angle is maintained. Axial view The axial view is used to evaluate the subtalar joint and the width of the calcaneus (see the images below). Normally, in an adult, the calcaneus measures 30-35 mm in width. A fracture may cause the calcaneus to increase in width; the expanded, fractured calcaneus may then impinge upon the fibula, causing entrapment of the peroneal tendons. AP view The AP view is essential for evaluating the calcaneocuboid joint (see the image below). This view also demonstrates avulsion fractures of the anterior lateral aspect of the calcaneus. Calcaneus, fractures. Anteroposterior (AP) and lateral radiographs of a patient following trauma demonstrate no apparent bony injury. View Media Gallery Oblique views Various oblique views have been advocated. These are valuable in demonstrating fracture extending into the joint and loss of parallelism of articular surfaces. Oblique views (ie, the Broden view) can define incongruity of the subtalar joint.

These images are obtained by internally rotating the foot 45°, with the heel resting on the radiographic plate; the beam is directed cephalad in angles varying from 10° to 40°. Peroneal tenography Peroneal tenography involves injecting iodinated contrast material into the peroneal tendon sheaths under fluoroscopic guidance. The contrast material then descends behind the lateral malleolus. Peroneal tenography helps in diagnosing abnormal conditions after calcaneus fractures or other trauma, such as peroneal tendon dislocation resulting from skiing accidents. Compression of the tendon sheath associated with partial or complete obstruction of the flow of contrast and tendon displacement may be depicted. Aspiration of the injected contrast material following use of a local anesthetic may relieve pain and help determine the source of the pain. Degree of confidence Conventional radiography is the primary imaging modality in cases of suspected ankle fractures. Radiography may be the only modality required, though it is not always capable of depicting the relationship of bone fragments to the joint and to each other. In complex fractures, CT scanning is used in addition to conventional radiography. Conventional radiography is inexpensive and is universally available.

It exposes the patient to a modest radiation dose. Study results are reproducible, and the images are easy to interpret. Measuring the various angles not only enables reliable diagnosis but also helps in determining the ultimate prognosis. False positives/negatives Various anatomic variants in the calcaneus may mimic fractures. Os subcalcis is a calcaneal apophysis seen in the adolescent on the posteroinferior plantar surface of the calcaneus, which is normally not visible on lateral radiographs. The unfused secondary ossification center for calcaneal tuberosity may produce a simulated fracture. Failed union of a portion of calcaneal apophysis in an adult may superficially mimic a fracture. Calcaneus secundarius is an accessory ossicle attached to the posterosuperior aspect of the calcaneus. The sustentaculum tali can produce a simulated fracture on the superior margin on lateral views. Prominent trabeculation can simulate a fracture on plain radiographs and CT scans. False-negative radiographic findings may occur when images show subtle fracture lines. These fractures may be confirmed with scintigraphy and/or MRI.

Previous Patients with type 1 injuries do well with nonoperative treatment; patients with injuries of types 2 and 3 may be treated effectively with open reduction and internal fixation; and type 4 injuries defy operative reduction. [ 17 ] Stress fractures CT is occasionally performed to diagnose stress fractures. CT is capable of demonstrating disruption of the bony cortex and periostitis in most individuals. Its sensitivity is higher than that of plain radiography. However, compared with MRI or bone scanning, CT has low sensitivity for stress reactions and fractures; this leads to a high rate of false-negative results. Soft tissue abnormalities Bradley and Davies studied soft tissue abnormalities occurring after calcaneus fractures [ 18 ] and determined that CT in both the immediate postfracture period and in the late phase may be used to detect and classify soft tissue changes. CT scans of 50 acute calcaneus fractures were compared with scans of 77 fractures in which the date of injury preceded the CT study by 6 months or more. The investigators found that 42 of the fractures (84%) in the acute group and 55 in the chronic group (71%) were classified as intra-articular; these fractures formed the basis of the study.

The alterations in the position of the peroneal tendons in the 2 groups were similar, with a 5% or smaller difference in each category. In the acute group, the peroneal tendons were of normal location in 40.4% of cases; in 11.9% of cases, the peroneal tendons were entrapped by bone; subluxation was evident in 33.3% of cases; and dislocations were present in 14.2% of cases. Structural abnormalities of the peroneal tendons and surrounding soft tissues were identified in 52.4% of patients in the acute group and in 61.1% of patients in the chronic group. The incidence of partial rupture of the peroneal tendons in the chronic group was approximately one third that in the acute group, but the low incidence of complete tendon rupture remained unchanged. The inference from these observations is that, in most cases, partial peroneal tendon rupture is reversible, whereas complete rupture is not.

Seven fractures were common to both series; from this limited group, the identification of hemorrhage around the peroneal tendons in the acute phase was shown not to be related to the subsequent development of chronic stenosing tenosynovitis. Various abnormalities of the medial tendons of the hindfoot were identified in 17% of patients in the acute group and in 18% of patients in the chronic group. Degree of confidence CT is the modality of choice for calcaneus fractures. Confidence in the diagnosis made on the basis of a positive CT scan of the affected area is high. Furey evaluated 30 calcaneus fractures to assess the degree of interobserver variability by using the Sanders classification system and found that the Sanders classification system achieved moderate agreement among users and was thus useful. [ 19 ] Thirty CT scans of calcaneus fractures taken over a 5-year period in 2 tertiary care centers were chosen randomly. Three orthopedic surgeons and 1 senior orthopedic resident reviewed the scans and classified the fractures. The results were analyzed by using a weighted kappa test that included the subcategories.

The weighted kappa value was 0.56, with a 95% confidence interval (CI) of 0.45-0.67. The subcategories of the classification were further combined, and a second analysis was performed to assess agreement between general classes. The weighted kappa value was 0.48, with a 95% CI of 0.37-0.59. Brunner et al conducted a study to evaluate the impact of 3-dimensional (3D) CT volume rendering on the interobserver and intraobserver reliability of 6 commonly used classification systems in the assessment of calcaneal fractures. In the study, 4 independent observers with different levels of clinical training evaluated 64 fractures according to the classifications of the Orthopaedic Trauma Association (OTA), Essex-Lopresti, Sanders, Crosby, Zwipp, and Regazzoni, using 2-dimensional CT scans with multiplanar reconstructions and 3D volume-rendering reconstructions. The results revealed that 3D reconstructions may have other benefits not evaluated in the presented study and may give useful information not captured by current classification systems.

[ 20 ] False positives/negatives In cases of stress fractures, a well-defined cortical discontinuity is suggestive of a fracture. However, the rate of false-negative results is high. Therefore, in the appropriate clinical setting, CT may be skipped, and either MRI or bone scanning may be performed. Repeat CT scanning is not an attractive alternative, though it may result in the correct diagnosis because of interval development of necrosis. Prominent trabeculation can simulate a fracture on CT. Previous View Media Gallery MRI is highly sensitive for the detection of bone marrow changes. Anatomic resolution is better with MRI than with radionuclide imaging. Bone contusions are also well depicted on MRI. On MRI, stress fractures typically appear as areas of low signal intensity on T1- and T2-weighted images. They often appear as a band of low signal intensity that arises from the cortex of the bone and extends perpendicular to the surface of the bone. If imaging is performed within 4 weeks of the injury, an area of high signal intensity often can be observed on T2-weighted images; this represents associated edema or hemorrhage. Fat-suppressed sequences are sensitive to bone marrow edema, which accompanies bone bruises and stress fractures.

MRI also has a place in the investigation of ligamentous and tendon injury in association with calcaneus fractures. Degree of confidence Confidence in the imaging findings is usually high in a patient who is believed on clinical grounds to have a stress fracture. MRI findings may be positive within 24 hours of the onset of symptoms. Stress fractures may take longer to become evident on radionuclide bone scans, particularly in patients with osteoporosis. MRI may be used to evaluate tendon and ligamentous injuries noninvasively. False positives/negatives Many pathologies can cause bone marrow edema; in patients with a history of trauma, the presence of edema may lead to an incorrect diagnosis of fracture. Pathologies associated with edema include osteomyelitis and neoplasm. The linear hypointensity is usually helpful in identifying stress fractures. Previous Calcaneus, fractures. CT scan. Calcaneus, fractures. CT scan. Calcaneus, fractures. Anteroposterior (AP) and lateral radiographs of a patient following trauma demonstrate no apparent bony injury. Calcaneus, fractures. Short-tau inversion recovery (STIR) sagittal MRI demonstrates high signal intensity at the anterior and middle processes.

This represents bony edema secondary to a fracture, which is not appreciated on the plain radiographs. Calcaneus, fractures. Technetium-99m diphosphonate bone scan depicts a stress fracture of the calcaneus, which was not apparent on plain radiographs. Calcaneus, fractures. Normal variants, complications, and differential diagnosis. Old calcaneal fracture. Dorsoposterior (DP) and lateral views of the foot demonstrate an old Essex-Lopresti depressed-type calcaneal fracture. The patient now has degenerative change at the subtalar joint. Essex-Lopresti describes 2 fracture types involving the subtalar joint. The depression type and the tongue type. Note flattening of the Bohler angle. Calcaneus, fractures. Normal variants, complications, and differential diagnosis. Achilles tendonitis calcification is a differential diagnosis in cases of suspected calcaneal fracture. Calcaneus, fractures. Normal variants, complications, and differential diagnosis. This patient presented with heel pain following trauma. Anteroposterior (AP) and lateral radiographs show features of plantar fasciitis. Note the calcaneal spur and calcification in the distribution of plantar fascia.

Calcaneus, fractures. Normal variants, complications, and differential diagnosis. Lateral radiograph of the calcaneus on the same patient as in Image 33 shows calcification of the plantar fascia. Calcaneus, fractures. Normal variants, complications, and differential diagnosis. This normal variant—an unfused secondary ossification center—must not be mistaken for a calcaneal fracture. Calcaneus, fractures. Normal variants, complications, and differential diagnosis. Calcaneal cysts are normal variants and should not be confused with pathology. Calcaneus, fractures. Normal variants, complications, and differential diagnosis. Calcaneal cysts are normal variants and should not be confused with pathology. Calcaneus, fractures. This patient presented following trauma to the calcaneus. Axial radiograph shows soft tissue swelling with amorphous calcification. Biopsy proved a malignant synovioma. Calcaneus, fractures. Normal variants, complications, and differential diagnosis. This patient presented following trauma to the calcaneus. Axial radiograph shows soft tissue swelling with amorphous calcification. Biopsy proved a malignant synovioma. (See also the previous image.) Calcaneus, fractures. Normal variants, complications, and differential diagnosis.

T2-weighted sagittal MRIs demonstrate fibrosis of the peroneal tendon sheath following a past calcaneus fracture, which is a recognized complication of calcaneal fractures. of 85 Calcaneus Fracture - Broken Heel Bone Calcaneus Fracture By Jonathan Cluett, MD - Reviewed by a board-certified physician. Updated February 06, 2016 The calcaneus is the bone in the heel of the foot, commonly referred to as the heel bone. This bone helps support the foot and is important in normal walking motions. The joint on top of the calcaneus, called the subtalar joint, is responsible for allowing the foot to rotate inwards and outwards. Calcaneus fractures are almost always the result of severe, high-energy injuries. They typically occur as a result of a fall from a height, such as falling from a ladder. Other causes of a calcaneus fracture include automobile crashes and sports injuries. The calcaneus can also sustain a stress fracture , an injury sometimes seen in athletes, such as long-distance runners. Signs of a Calcaneus Fracture Calcaneus fractures cause swelling and pain of the back of the foot.

Common signs of a calcaneus fracture include: Inability to walk Severe heel pain Most calcaneus fractures are closed injuries, meaning the skin is intact. When the skin around the calcaneus fracture is broken, this may represent an open fracture , also called a compound fracture. An open fracture of the calcaneus is an emergency that requires urgent surgery. Treatment of Calcaneus Fractures Calcaneus fractures may be treated in a cast or surgery may be recommended. If the calcaneus fracture is not out of position, noninvasive treatment will be recommended. Non-operative treatment is also recommended in patients who have poor circulation or diabetes; these patients are at especially high-risk for developing complications from surgery of the foot. Patients who are smokers also have a very high risk of complications related to surgery for a calcaneus fracture. Surgery must be carefully considered in these patients, and many doctors believe the risks are too high in smokers to consider surgery. Surgical treatment of calcaneus fractures usually involves making an incision over the outside of the foot, and placing a metal plate and screws into the broken heel bone. Your doctor will attempt to restore the normal alignment of the bone and return the cartilage surface as close to normal as possible.

Occasionally, if the broken calcaneus is two large pieces of bone (as compared to many small pieces) this surgery can be done with small incisions and no plate. Your doctor can recommend the appropriate treatment based on specific characteristics of your fracture. In the most severe calcaneus fractures, the calcaneus bone may be fused to the bone above the heel, the talus. In these situations, the chance of restoring joint function of the foot is unlikely, and the fusion procedure can allow a stable foot for walking. All patients with a calcaneus fracture must also be examined for other high-energy injuries. Studies have shown a large number of patients who have a calcaneus fracture will also have fractures of the lumbar spine (10 to 15 percent). Other injures commonly occur in patients who sustain a calcaneus fracture, including injuries to the head, neck, and other extremities. Stress fractures of the calcaneus can be treated with noninvasive treatment. Most often patients will have to be on crutches, and may even require a brief period of cast immobilization. Stress fractures sometimes take 3-6 months before athletes are able to return to sports following this injury.

Complications of Treatment Calcaneus fractures are generally severe injuries, and often lead to longstanding problems of the foot and ankle. Early complications of calcaneus fractures are most often due to the significant swelling that can occur with these injuries. Those patients who have surgery for a calcaneus fracture can develop healing problems as a result of this swelling. As mentioned, patients with diabetes, smokers, and those with poor circulation are especially prone to developing this complication. Late complications from a calcaneus fracture are most often due to chronic foot pain and arthritis. Arthritis of the hindfoot is common after a patient sustains a calcaneus fracture. The risk of developing arthritis as a result of the calcaneus fracture is generally related to the severity of the fracture. Patients often have problems with chronic foot pain , difficulty with certain types of footwear, and pain associated with walking, running, and prolonged standing. The recovery period of a calcaneus fracture is an important aspect in determining how well a patient will return to his pre-injury level of activity. Patients will be required to keep weight off of the foot for as long as three months. The other critically important aspect of treatment is controlling swelling, especially in patients who have had surgery.

The best ways to control swelling includes elevation, immobilization, and ice application. Sources: Barei DP, et al. " Fractures of the calcaneus " Orthop Clin North Am 2002 Jan; 33(1): 263-85. Juliano P, Nguyen HV " Fractures of the calcaneus " Orthop Clin North Am 2001 Jan; 32(1): 35-51. Continue Reading Calcaneal (Calcaneus) Fracture - footEducation footEducation Summary A typical depressed calcaneal fracture (Figure 1) is perhaps the most serious common foot injury. Depressed (crushed) calcaneal fractures occur when the heel is directly or indirectly loaded with excessive force, such as in a fall from a height or in a motor vehicle accident where the heel may be driven into the floorboard. There are both non-operative and operative treatments available for this injury. Operative treatment allows for the bone fragments to be repositioned so that they can heal in an improved position (it does not speed bone healing which usually takes 8-12 weeks).

However, surgery requires a high degree of skill and experience on the part of the surgeon. Surgical complications such as wound breakdown or deep infection are not uncommon, and can be extremely serious. Complications are higher in patients who are smokers, diabetics, have vascular disease, or who have excessive swelling. The long-term prognosis is somewhat guarded with both operative treatment and non-operative treatment, with some hindfoot stiffness and pain being common. Figure 1A: X-ray of foot showing a normal calcaneus from the side Figure 1B: X-ray of a depressed calcaneus fracture Clinical Presentation: Calcaneus Fractures Patients who have suffered a calcaneus fracture present with acute pain and a large amount of swelling over the heel. They are usually unable to bear weight on the involved foot. The fracture itself occurs when the the lower bone of the ankle (talus) gets driven into the upper part of the heel bone (calcaneus). This causes the calcaneus to break (Figure 2). Therefore falls from a height where the patient lands on their feet is a common mechanism leading to a calcaneus fracture. The calcaneal bone is somewhat analogous to a complicated shaped egg.

It has a hard shell (cortical bone) on the outside, and very soft, cancellous bone in the inside. When it breaks, there is a primary fracture line running from the inside distal part of the calcaneus to the outside hind part of the calcaneus (Figure 3) Figure 2A: Mechanism of Typical Calcaneal fracture – Side view Figure 2B: Mechanism of Typical Calcaneal fracture – Viewed from the back Figure 3: Primary Fracture line viewed from the top (also showing secondary fracture lines) In addition, there is often a series of other fracture lines. The calcaneus, in many ways, breaks the same way as an egg would break into a number of different pieces. The fracture pattern will vary for each patient and injury. Physical Examination related to Calcaneal Fractures In patients with calcaneus fractures the physical examination usually demonstrates tremendous swelling around the involved heel. In some patients, there will be a break in the skin, representing an open fracture. Open fractures constitute an orthopedic emergency. Usually, the sensation in the foot is intact. In addition, blood supply to the foot is usually intact, although this does need to be assessed following the injury.

It is also common to have other injuries, such as a fracture involving the ankle or another part of the foot. A Lumbar spine burst fracture will occur in about 10% of patients who suffer a calcaneal fracture. This is a fracture in the lower to mid back which essentially crushes one of the vertebras. The same mechanism that produces a calcaneal fracture will predispose a patient to having a lumbar burst fracture. Imaging Studies X-rays are helpful when a calcaneal fracture is suspected. Typically, a lateral x-ray demonstrating the foot from the side (Figure 4), as well as an axillary heel view showing an end-on view of the heel are taken. This allows the basic fracture pattern to be identified. Figure 4: X-ray of fractured calcaneus from the side To more thoroughly understand the fracture pattern, particularly if surgery is a possibility, a CT scan will be ordered (Figure 5). On the CT scan, the number of fracture lines extending through the posterior facet of the calcaneus is important.

Figure 5: CT scan of fractured calcaneus Treatment of Calcaneus Fractures Non-Operative Treatment Calcaneal fractures can be quite difficult to treat, and the recovery can be prolonged. It is not uncommon and, in fact, may be the norm to have some element of post-traumatic subtalar arthritis as a result of this injury. Non-operative management of calcaneal fractures does not mean NO treatment. Non-operative management includes a prolonged period of non-weight bearing to allow the fracture to heal. This typically needs 10-12 weeks to allow the calcaneal fracture to be healed enough to bare weight. During that time, the patient is treated with appropriate pain control. This includes elevation to limit swelling, ice to decrease the swelling and improve local symptoms, and narcotic pain medication. An important active part of non-operative management is early work to optimize range of motion. This means that after the initial swelling subsides (usually 7-14 days), the patient will be instructed to perform daily range of motion exercises aimed at optimizing the amount of motion in the ankle, subtalar, and transverse tarsal joints.

These exercises are often as simple as drawing out a figure-of-eight with the big toe, as well as using a towel over the toes to bring the foot up towards the shin (dorsiflexing the ankle). A large study has suggested that results of non-operative treatment are only marginally worse than the results of operative treatment, when all the patients are considered (Buckley et al JBJS Sept 2003). If a patient is at high-risk of operative complication, non-operative treatment should be employed as the risks of operative treatment for this injury can be quite severe. Patients who smoke, are diabetic, have vascular disease, have an active Worker’s compensation claim, or are older, are thought to have a higher risk of complications and/or poor outcome. Operative Treatment Operative treatment involves reconstructing the shattered calcaneus, essentially trying to return the calcaneus to the pre-injury shape. For each patient, this treatment needs to be individualized. The operative procedure is technically difficult, and can be associated with an unacceptably high complication rate. It is therefore important that the surgeon involved have confidence and experience with these types of fractures. Operating through excessively swollen tissue has been shown to significantly increase the risk of wound healing problems and infection.

For this reason, it is now standard practice to wait until the soft-tissues swelling has settled, often 10-14 or more days after the injury. The worst results of calcaneal fracture treatment occur when an operatively treated fracture is complicated by a bad, deep infection or a significant wound breakdown. It is not unheard of in these situations where the patient will eventually require an amputation. Operative treatment is performed usually through an incision on the outside of the heel. The fracture fragments of the calcaneus are systematically reduced back into the original position. If they cannot be anatomically reduced, this will significantly reduce the effectiveness of the surgery, often to the point where non-operative management should be undertaken. After the bones have been repositioned, they are fixated with a combination of screws and plates (Figure 6). The fixation is customized depending upon the fracture pattern. Figure 6: Calcaneus following surgical fixation With certain fracture patterns, it is possible to perform a percutaneous procedure. Percutaneous treatment (operating without making a large incision) involves skewering part of the fracture with a straight wire (K-wire), and manipulating it into an improved position. This is done through a few stab incisions.

Unfortunately, less than 10% of the calcaneal fractures fit into this category, and most require a large, open procedure if the bone fragments are to be adequately repositioned (reduced). Tongue-type fractures occur when the posterior facet remains in continuity with the posterior aspect of the calcaneus, forming what looks like a tongue. These are the types of fractures that would be potentially amenable to percutaneous repair. Figure 7: Calcaneus following percutaneous repair Following surgery, the recovery time is similar to that for non-operative treatment. Essentially, the patient needs 10-12 weeks of non-weight bearing to allow the fracture to heal. However, within 2 weeks of surgery some basic non-weight bearing range of motion exercises should be instituted, in order to limit the hindfoot stiffness. Surgical Complications Complications of operative treatment are not uncommon. The major complications include: Deep wound infection: Because of the tenuous skin over the outside of the heel, any type of wound infection commonly goes down to the bone potentially leading to osteomylelitis (bone infection). Wound healing can be an issue because the soft-tissue on the outside of the heel has a tenuous blood supply.

Meticulous wound closure is required to minimize the risk of this problem. Sural Neuritis: The sural nerve, which innervates the outside of the foot, is often stretched or injured in the surgical approach, and can become scarred or injured in the course of the surgery. Nonunion of the calcaneus is possible, although it is uncommon. Subtalar arthritis is not so much a complication as it is a common long-term effect of the injury, leading to pain and stiffness in the hindfoot. This will manifest itself with symptoms when the patient stands for a prolonged period of time, or walks on uneven ground. This could be a problematic symptom for patients that are on their feet a lot. For these patients, it may even be necessary to eventually perform a primary subtalar fusion. Talus Fractures-OrthoInfo - AAOS Copyright 2014 American Academy of Orthopaedic Surgeons Talus Fractures A talus fracture is a break in one of the bones that forms the ankle. This type of fracture often occurs during a high-energy event, such as a car collision or a high-velocity fall.

Because the talus is important for ankle movement, a fracture often results in significant loss of motion and function. In addition, a talus fracture that does not heal properly can lead to serious complications, including chronic pain. For this reason, many talus fractures require surgery. Anatomy The talus is the bone that makes up the lower part of the ankle joint (the tibia and fibula bones of the lower leg make up the upper part of the ankle joint). The talus sits above the heel bone (calcaneus). Together, the talus and calcaneus form the subtalar joint, which is important for walking, especially on uneven ground. The talus is the main connector between the foot and leg, helping to transfer weight and pressure forces across the ankle joint. It is largely covered by articular cartilage, the white slippery material that covers all joint surfaces. This cartilage allows the talus to move smoothly against its neighbor bones. The talus bone sits between the bones of the lower leg and the calcaneus (heel bone). Top of page Description Fractures occur in all parts of the talus bone.

Most commonly, the talus breaks in its mid-portion, called the "neck." The neck is between the "body" of the talus, located under the tibia, and the "head," located further down the foot. Another common site for talus fractures is along the outside of the bone where it juts out slightly. This area of the bone is called the "lateral process." Fractures of the lateral process often occur when the ankle is forced out to the side and are commonly seen in snowboarders. The talus often breaks in the mid-portion — or "neck" — of the bone. This illustration shows a displaced talus neck fracture. Reproduced and modified with permission from Fortin PT, Balazsy JE: Talus fractures: evaluation and treatment. J Am Acad Orthop Surg 2001; 9:114-127. Fractures are often classified according to the severity of the displacement — how much the pieces of bone have moved out of their normal position. Minimally displaced or stable fractures: This type of fracture is barely out of place. The broken ends of the bones line up almost correctly.

In a minimally displaced fracture, the bones usually stay in place during healing, and surgery to fix the bones into position is not usually required. Displaced fracture. When a bone breaks and the pieces move out of their anatomic position, it is called a displaced fracture. The amount of displacement relates to the amount of energy that caused the fracture. Fractures that are highly displaced are more likely to be unstable. Unstable displaced fractures of the talus often require surgery to restore correct alignment and to give the best chance for the return to normal movement of the foot and ankle. Open fracture: When broken bones break through the skin, they are called open or compound fractures. Open fractures often involve much more damage to the surrounding muscles, tendons and ligaments. In addition, open fractures expose the fracture site to the environment. They have a higher risk for complications and infection and take a longer time to heal. Top of page Cause Most talus fractures are the result of high-energy trauma such as a car collision or a fall from height. Injuries from sports, particularly from snowboarding, are another, less common, cause of talar injuries.

Top of page Doctor Examination Most people with talus fractures will go to an urgent care center or emergency room for initial treatment because of the severity of their symptoms. Physical Examination After discussing your symptoms and medical history, your doctor will do a careful examination. He or she will: Examine your foot and ankle carefully to see if there are any cuts from the injury. Check to see if you can move your toes, and can feel things on the bottom of your foot. In some cases, nerves may be injured at the same time that the bone is broken. Check your pulse at key points of the foot to be sure that there is good blood supply to the foot and toes. Check to see that pressure from fluids is not building up in the muscles of the foot, a condition called compartment syndrome. Compartment syndrome can result in loss of sensation and function, and requires emergency surgery once it is diagnosed. Determine whether you have received any other injuries by examining the rest of your injured foot and your legs, pelvis and spine. Imaging Tests Information from diagnostic imaging tests will help your doctor decide whether surgery is required and will be critical for surgical planning. X-rays. X-rays are the most common and widely available diagnostic imaging technique.

An x-ray can show if the bone is broken and whether there is displacement (the gap between broken bones). It can also show how many pieces of bone there are. An x-ray of a talus neck fracture. Reproduced from Johnson TR, Steinbach LS (eds): Essentials of Musculoskeletal Imaging. Rosemont, IL American Academy of Orthopaedic Surgeons, 2004, p. 605. Computed tomography (CT) scan. If your doctor still needs more information after viewing your x-rays, a CT scan may also be ordered. A CT scan shows a cross-sectional image of your foot. It can provide valuable information about the severity of the fracture by helping your doctor see the fracture lines more clearly. Top of page Treatment Immediate first aid treatment for a talus fracture, as with any painful ankle injury, is to apply a well-padded splint around the back of the foot and leg from the toe to the upper calf to immobilize the limb and protect it. Elevating the foot above the level of the heart helps to minimize swelling and pain. Specific treatment depends upon the severity and the type of fracture, so it is important to seek immediate medical attention.

Nonsurgical Treatment Only fractures that are well-aligned (stable) can be treated without surgery. This is very rare in a talus fracture, however, because of the high-energy force that causes the injury. Casting. A cast will hold the bones in your foot in place while they heal. You will have to wear a cast for 6 to 8 weeks. During this time, you will be asked to limit the amount of pressure you put on your foot. The goal is for the bone to heal enough for you to bear weight on it without the risk that it will move out of position. Rehabilitation. When the cast is removed, your doctor will give you exercises to help restore the range of motion and strengthen your foot and ankle. Surgical Treatment If the bones have shifted out of place (displaced), surgery to internally set and stabilize the broken pieces results in the best outcome and reduces the risk of future complications. Open reduction and internal fixation. During this operation, the bone fragments are first repositioned (reduced) into their normal alignment. They are then held together with special screws or metal plates and screws. (Left) This x-ray shows a talus fracture. (Right) The bone fragments are fixed in place with screws.

Reproduced with permission from Fortin PT, Balazsy JE: Talus fractures: evaluation and treatment. J Am Acad Orthop Surg 2001; 9:114-127. Top of page Recovery Bones have a remarkable capacity to heal. The more severe your injury, however, the longer your recovery may be. After surgery, your foot will be in a splint or cast from 2 to 8 weeks, depending on the nature of the injury and how well your doctor thinks it is healing. As your bones begin to heal, your doctor will likely order x-rays to ensure that everything is in alignment and healing properly. Pain Management After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster. Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery. Early Motion Many doctors encourage motion of the foot and ankle early in the recovery period, as soon as your pain allows. Patients who have had surgery are instructed to begin moving the affected area as soon as the wound heals. Patients who are treated without surgery will work on regaining motion in the foot and ankle after the cast is removed. Physical Therapy Specific physical therapy exercises can improve the range of motion in your foot and ankle, and strengthen supporting muscles. Weight-bearing When you begin walking, you may need to use a cane and wear a special boot. You will not be able to put all of your weight on your foot for up to two to three months. If you place too much weight on your foot too soon, the bone pieces may move out of place. Be sure to follow your surgeon's directions.

As your break heals and your pain improves, you will be allowed to put more pressure on your foot. Complications After Talus Fractures Avascular Necrosis (AVN) With unstable talus fractures, the blood supply to the bone can be disrupted at the time of the injury. Sometimes, the blood supply simply returns to the bone and normal healing begins. In other cases, however, the bone cells die without a blood supply, leading to a gradual and very painful collapse of the bone. This condition is called avascular necrosis (AVN) or osteonecrosis with collapse. When the bone collapses, the articular cartilage covering the bone also collapses. Without this smooth cartilage, bone rubs against bone, leading to increased pain, arthritis and loss of motion and function. The more severe the talus fracture, the more likely it is that AVN will occur. Even fractures that are treated appropriately, including those that are treated surgically, may develop AVN. Posttraumatic Arthritis Posttraumatic arthritis is a type of arthritis that develops after an injury. Even when your bones heal normally, the cartilage protecting the bones can be damaged, leading to pain and stiffness over time.

The majority of talus fractures result in some degree of posttraumatic arthritis. In cases of extreme arthritis that limits activity, additional surgery, such as a joint fusion or ankle replacement, may be the best option to relieve symptoms. Top of page Last reviewed: August 2014 AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist" program on this website. Copyright 2014 American Academy of Orthopaedic Surgeons Related Articles Calcaneus Heel Spur Causes and Symptoms | Heel That Pain What is Heel Pain and How Do I Treat it? Heel Pain Calcaneus Is heel pain interfering with your life? When calcaneal spurs get bad, they can make working on your feet extremely painful, interfere with your workout routine, and make you irritable or depressed. The pain may be sharp and stabbing, and may be worse when you walk on hard surfaces or in the morning after prolonged rest.

But here’s the good news: You’re not alone! One out of ten people have calcaneal heel spurs — and heel spur pain is easy and affordable to manage using stretching, icing, and orthotics . Causes Of Calcaneal Spurs When you step, your calcaneus has to support the weight of your body. For an average size person, that weight is approximately 20 times their own body weight. However, the pillow of fat under the foot softens this to help prevent injury. Unfortunately, it is easy to overload the heel bone even with the body’s natural protection. Neglecting to warm up properly when you work out, over-exercising by sharply increasing the intensity or duration of your workouts, or working long days on a hard surface can injure the muscles of the sole of the foot. This can cause inflammation of the sole muscles and sinew, and can sometimes crack the sinew. Once your sinew is cracked, an interesting process occurs. When you sit, the foot muscles will contract to help protect the damaged sinew. However, when you get up, the sinew will crack even more. The body will respond like it to repair a broken bone – basically by wrapping it up in a bone.

This results in a small bony projection on the calcaneus, causing heel pain and discomfort. Symptoms Of An Overloaded Sinew Or Calcaneul Spur In order to prevent this heel pain from getting out of hand, it is important to understand the symptoms. It is possible that you have an overloaded sinew or a calcaneal spur if you are experiencing the following: Sharp, stabbing pain under or on the inside of your heel Pain that disappears when you rest, but gets worse when you get up It is more painful in the morning The pain is worse when you walk on a hard surface or carry something heavy The pain is so severe that it is difficult to continue your daily work Who is At Risk for Calcaneal Spurs? While a variety of different people can develop heel pain on their calcaneus, certain people are more at risk. People who are overweight and middle-aged tend to suffer with these heel spurs the most. This is because the size of their fat pillow under their foot decreases and becomes less effective over time. Also, weekend athletes also suffer because they exercise sporadically. Additionally, those who have pronated feet (feet that roll inward while walking or running) are more at risk.

The #1 Treatment for Calcaneal Pain Most calcaneal spur and sinew injury solutions simply add padding to your shoe, slightly reducing the pressure put on your calcaneus. This can temporarily reduce pain, but is not a long-term solution for heel pain. Heel Seats are the #1 treatment for calcaneal pain because in addition to re-cushioning the fat pad of the heel, they also apply targeted acupressure to the plantar fascia ligament, reducing the strain on the calcaneus and sinew. Calcaneus Fracture Surgery Calcaneus Fracture Surgery Page Content What is a calcaneus fracture? The calcaneus is the heel bone. Fractures, or breaks, of the calcaneus commonly occur after a fall from a height or car accident. Treatment of these fractures may require surgery. What are the goals of calcaneus fracture surgery? The goal of surgery for a calcaneus fracture is to restore the shape of the calcaneus as close to normal as possible. ​ View of hardware placement Restoration of normal alignment and contour is considered the best way to restore function and minimize pain. What signs indicate surgery may be needed?

Surgery is recommended when a broken calcaneus has lost its alignment and contour. Identification of the fracture is typically made after a physical examination by obtaining standard foot and ankle X-rays. The specific type, pattern and classification of the fracture is best made by obtaining a CT scan. Your surgeon will review both X-rays and the CT scan to determine if your break would be best managed by surgery. When should I avoid surgery? There are several reasons why surgery may not be recommended for a calcaneus fracture. Patients with diabetes may be at increased risk for infection or wound healing problems. Patients with poor blood flow may also have difficulty healing properly. Elderly individuals may have difficulty with surgical rehabilitation. Surgery is often delayed due to the swelling that typically accompanies these injuries. The swelling may be severe enough to delay surgery for weeks or preclude it altogether. Surgery can more safely proceed when the skin at the surgical site at the lateral heel wrinkles, indicating the dangerous swelling has gone away. Medications such as immuno-suppressants or steroids may slow healing and may also preclude surgery. Smoking is generally considered harmful for wound and fracture healing. Quitting smoking prior to any planned surgery may diminish those risks.

General Details of Procedure The most common surgical techniques utilized to treat a broken calcaneus involve cutting through the skin to place the bone back together and using plates and screws to hold the alignment. A classic “open” procedure involves an incision over the lateral aspect of the heel. The incision is likened to a hockey stick or large “L” where the overlying nerve (sural) and tendons (peroneal) are moved out of the way. The fracture fragments are restored to the best possible position. Internal fixation refers to the placement of a plate and screws to hold the fracture in place. ​ Post-surgery X-ray of hardware in place The technique of “closed” reduction and percutaneus fixation can sometimes be utilized. Multiple small incisions are placed in critical areas around the heel. The broken fragments can be realigned without looking directly at the fracture.This is done with the help of X-rays in the operating room. Screws are then placed through the skin to hold the position. Specific Technique General anesthesia, used to put a patient to sleep during surgery, is commonly used in conjunction with a regional nerve block, which involves a local injection to help with pain control.

The addition of a regional block can provide 12 to 24 hours of pain control after surgery. Surgery can be a same-day procedure or planned with a hospital stay. A tourniquet is used to minimize bleeding and to ensure proper visualization of critical structures that are protected during the surgery. For the standard open approach, a hockey stick or “L” incision is made on the outside of the heel. The sural nerve and the peroneal tendons are moved out of the way and the skin is held back by placing wires is key positions. The bony fragments are then visualized. The general alignment of the heel is restored. The fragments are then placed into position. All fragments are temporarily held in position with small removable wires. The wires are then removed and a plate and screws are placed. The skin is then closed. Post-surgical dressings and a splint are applied. What happens after surgery? Expect a lengthy recovery after calcaneus fracture surgery. You will be given a splint or cast. You should not put weight on your foot for at least six to eight weeks until there is sufficient healing of the fracture. The foot remains very stiff and some permanent loss of motion should be expected.

Most patients have at least some residual pain despite complete healing. Everyone who sustains a malaligned break of the calcaneus, particularly involving the joint, should expect to develop some arthritis. If arthritis pain and dysfunction of the foot are severe, then further surgery may be required. These fractures are severe and can be life-changing. Potential Complications There are complications that relate to surgery in general. These include the risks associated with anesthesia, infection, ​ damage to nerves and blood vessels, and bleeding or blood clots. Complications from treatments for displaced calcaneus fractures can be severe. The most common early complications are in skin healing and nerve stretch. Most wound healing complications can be treated with wound care. Occasionally further surgical treatment may be required. The development of a deep wound infection often requires surgery and antibiotics. Nearly all nerve stretch complications will resolve over time. Frequently Asked Questions Do the plates and screws need to be removed? No, plates and screws do not need to be removed. If they are causing pain or irritation, your surgeon may consider removing them, but he or she will make sure there is enough fracture healing before proceeding. The American Orthopaedic Foot & Ankle Society (AOFAS) offers information on this site as an educational service.

The content of FootCareMD, including text, images and graphics, is for informational purposes only. The content is not intended to substitute for professional medical advice, diagnoses or treatments. If you need medical advice, use the "Find an Orthopaedic Foot & Ankle Surgeon" tool at the top of this page or contact your primary doctor.

Question: Where is the calcaneus bone?
Answer: Heel