Broken Heel Bone
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related talks: broken foot (talus fracture, another type); broken foot (jones fracture); broken foot (lisfranc fracture); broken ankle (classic type); low ankle sprain; high ankle sprain
What is a Heel Bone Fracture (Calcaneous Fracture)?
The calcaneus is your heel bone and it plays a critical role in normal walking (the gait cycle). When taking a step, this bone is typically the first to touch the ground (called “heel strike”). Because it bears the weight of your body as you walk, it makes sense that this bone is very sturdy, and therefore it only breaks with high-energy accidents, like a car crash or falling off a ladder. In both cases the bone gets smushed under the weight of your body.
The calcaneus sits underneath the talus bone, and the talus has a sharp spike which will split the calcaneus into two pieces. This fracture is a bad actor for a few reasons. 1) There is very little soft tissue (fat, muscle, etc) surrounding the bone, and therefore, the can poke out of the skin when it breaks, this is called an "open fracture" (15% of cases). The bone also forms an important joint with the talus (the bone just above it, see picture) called the "subtalar joint", which is very important for balance on uneven ground. Most of the fractures will enter this joint and injury the cartilage, which may lead to arthritis in the future.
How is a Heel Bone Fracture (Calcaneous Fracture) diagnosed?
A fracture to the calcaneus bone is suspected based on the location of pain and swelling in the heel region. Sometimes the diagnosis is obvious because the bone is coming out of the skin. Regardless of what can be seen with the naked eye, x-rays are critical for diagnosing the fracture and also showing how significant it is. There is an angle called the Bohler angle, measured on a side view x-ray of the foot which can show how significantly the bone got smushed. The x-rays will help with surgical planning, and oftentimes a CT scan (which gives 3D pictures of the bones) will be performed to give an even better look at the bones.
Lastly, because this bone only breaks with a lot of force, it is associated with a high rate of additional injuries like lower back fractures (10% of cases) and injuries to the opposite foot (10% of cases). Because of this high rate of additional injuries, doctors need to examine the whole body for other fractures when a calcaneus fracture is diagnosed.
All of these issues can cause problems during recovery, and overall complications occur in about 40% of cases.
How is a Heel Bone Fracture (Calcaneous Fracture) treated?
When fractures enter into joints, its important to re-align to joint surface to prevent future arthritis. In the case of the heel bone, it connects with multiple other bones, so there is a high chance that the fracture involves a joint (either the subtalar joint (posterior facet) in 75% of cases or the calcaneocubiod joint in 63%). Adding to the problem is the fact that the heel bone bears a lot of our body weight with every step so a lot of stress crosses this bone. This too increases the risk for future arthritis.
Surgery is sometimes recommended to minimize post-traumatic arthritis, but even surgery is often insufficient to undo the damage already done. In some cases surgery can be very helpful, but in other cases, it can make matters even worse. Remember that theres no injury that cant be made worse with surgery if complications occur. Therefore doctors are very careful to weight the pros and cons of surgery to give people the best chance to heal. Lets take a closer look at these indications.
A nonsurgical treatment is recommended when the bone breaks but the broken fragments dont move out of position or if the break is significant but the risk for post-surgical complications makes surgery to risky. Smokers, diabetics, people with peripheral vascular disease, people over the age of 50, and people with multiple traumatic injuries all have poor outcomes with surgery. They have high risk for infection, failure of the skin incision to heal, and failure of the bone to heal. People with such medical conditions do better with nonsurgical treatment because the surgery often fails to help healing and the complications can be disastrous. Also people injured on the job (who are receiving workers compensation) also fail to improve with surgery, but this is likely cause by factors beyond the risk for medical complications.
The non-surgical treatment involves placing the foot into a cast for 10-12 weeks while the bone heals. During this time you cannot put weight on the leg.
Surgery is indicated in healthy people with breaks where the bone fragments are significantly displaced, or if the Achilles tendon has pulled off the heel bone, or if there is a break inside the joint causing a gap or step off > 2mm in the cartilage, or if the calcaneus gets overly smushed (as measured by that Bohlers angle) causing varus malalignment. Surgeons will use a metal plate and screws to reconstruct the normal shape of the calcaneus.
Surgery is not performed immediately after the injury because foot swelling is too severe (too much swelling causes problems with skin healing after the surgery). Therefore, the foot is usually wrapped in lots of padding, iced, and elevated for 10-14 days before surgery.
What is the long term outcome?
People with this injury are often given a “guarded prognosis”, meaning that complications frequently develop after getting this injury. Some reports say that 40% of these injuries have some complication.
Even healthy people can have postsurgical complications (and those with diabetes or that smoke have about a 1 in 4 chance of wound healing problems, this is very high risk in medical terms).
The risk of subtalar arthritis is high in both surgical and nonsurgically treated injuries with an overall risk of up to 15%. However, surgery realigns the bone and has been shown to have a 6x reduced risk for needing a subtalar fusion due to posttraumatic arthritis. Subtalar arthritis is usually identified when people return complaining of significant pain when walking on uneven ground (the subtalar joint is important for making subtle balancing adjustments). If subtalar arthritis does occur, the treatment is a subtalar joint fusion (screwing the bones together). There are always things a person can do to minimize their risk of complications. If you smoke cigarettes, stop (at least until the bone heals, but your lungs will thank you if you stop longer than that). This truly makes a huge difference. If you are a diabetic, get your sugars under tight control during healing.
Heel stiffness and problems with shoe wear (due to the persistant heel bone malalignment) are also common complications following non-surgical treatment of this condition. In general nonoperative treatment of fractures inside the joint had worse function and satisfaction after the injury.
1) Csizy M et al. Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. J Ortho Trauma 2003; 17: 106-12. full article. risk for arthritis.
2) Buckley R et al. Operative compared with nonoperative treatment of displaced intra-articular calcaneal fractures: a prospective, randomized, controlled multicenter trial. JBJS 2002; 84: 1733-44. full article. op vs. nonop intraarticular fx.
3) Myerson M, Quill GE Jr. Late complications of fractures of the calcaneus. JBJS 1993; 75: 331-41. full article. high rate subtalar arthritis.
4) Folk JW, Starr Aj, Early JS: Early wound complications of operative treatment of calcaneus fractures: Analysis of 190 fractures. J Ortho Trauma 1999; 13: 369-372. full article.
5) Bajammal S eta al. Displaced intra-articular calcaneal fractures. J Orthop Trauma. 2005; 19: 360-4. full article. good review of intraarticular fx.
6) DeBoer AS et al. Functional outcome and patient satisfaction after displaced intra-articular calcaneal fractures: a comparison among open, percutaneous, and nonoperative treatment. J Foot Ankle Surg 2014. full article. ORIF surgery is best.