Calcaneal fracture

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Calcaneal fracture
Other namesHeel bone fracture, [1] lover's fracture, Don Juan fracture
CalFrac.png
X-ray of a fractured calcaneus
Specialty Orthopedics, emergency medicine
Symptoms Pain, bruising, trouble walking, deformity of the heel [1]
Complications Arthritis, decreased range of motion of the foot [1]
CausesLanding on the feet following a fall from a height, motor vehicle collision [2] [1]
Diagnostic method Based on symptoms, X-rays, CT scan [1]
Treatment Casting, surgery [1]
Medication NSAIDs, opioids [1]
Prognosis 3 month to 2 year recovery [1]
Frequency~2% of fractures [2]

A calcaneal fracture is a break of the calcaneus (heel bone). [1] Symptoms may include pain, bruising, trouble walking, and deformity of the heel. [1] It may be associated with breaks of the hip or back. [1]

Contents

It usually occurs when a person lands on their feet following a fall from a height or during a motor vehicle collision. [2] [1] Diagnosis is suspected based on symptoms and confirmed by X-rays or CT scanning. [1]

If the bones remain normally aligned treatment may be by casting without weight bearing for around eight weeks. [1] If the bones are not properly aligned surgery is generally required. [1] Returning the bones to their normal position results in better outcomes. [2] Surgery may be delayed a few days as long as the skin remained intact. [1]

About 2% of all fractures are calcaneal fractures. [2] However, they make up 60% of fractures of the mid foot bones. [2] Undisplaced fractures may heal in around three months while more significant fractures can take two years. [1] Difficulties such as arthritis and decreased range of motion of the foot may remain. [1]

Signs and symptoms

The most common symptom is pain over the heel area, especially when the heel is palpated or squeezed. Patients usually have a history of recent trauma to the area or fall from a height. Other symptoms include: inability to bear weight over the involved foot, limited mobility of the foot, and limping. Upon inspection, the examiner may notice swelling, redness, and hematomas. A hematoma extending to the sole of the foot is called "Mondor Sign", and is pathognomonic for calcaneal fracture. [3] [4] The heel may also become widened with associated edema due to displacement of lateral calcaneal border. Soft tissue involvement should be evaluated because of the association with serious complications (see below). [5] [6]

Complications

Evaluating soft-tissue involvement is the most important aspect of the clinical examination because of its association with patient outcome. [6] [7] Skin blisters may become infected if medical attention is delayed, which can lead to necrotizing fasciitis or osteomyelitis, causing permanent damage to muscle or bone. Ligament and tendon involvement should also be explored. Achilles tendon injury can be seen with posterior (Type C) fractures. Since calcaneal fractures are related to falls from height, other concomitant injuries should be evaluated. Vertebral compression fractures occur in approximately 10% of these patients. [8] A trauma-focused clinical approach should be implemented; tibial, knee, femur, hip, and head injuries should be ruled out by means of history and physical exam.[ citation needed ]

Cause

Calcaneal fractures are often attributed to shearing stress adjoined with compressive forces combined with a rotary direction (Soeur, 1975 [7] ). These forces are typically linked to injuries in which an individual falls from a height, involvement in an automobile accident, or muscular stress where the resulting forces can lead to the trauma of fracture. Overlooked aspects of what can lead to a calcaneal fracture are the roles of osteoporosis and diabetes.[ citation needed ]

Unfortunately, the prevention of falls and automobile accidents is limited and applies to unique circumstances that should be avoided. The risk of muscular stress fractures can be reduced through stretching and weight-bearing exercise, such as strength training. In addition, footwear can influence forces that may cause a calcaneal fracture and can prevent them as well. A 2012 study conducted by Salzler [9] showed that the increasing trend toward minimalist footwear or running barefoot can lead to a variety of stress fractures including that of the calcaneus.[ citation needed ]

Osteoporosis

Bone mineral density decreases with increasing age. Osteoporotic bone loss can be prevented through an adequate intake of vitamin C and vitamin D, coupled with exercise and by being a non-smoker. A study by Cheng et al. in 1997, [10] showed that greater bone density indicated less risk for fractures in the calcaneus.

Diabetes

In 1991, Kathol [11] conducted a study which showed a correlation between calcaneal insufficiency avulsion fractures (a fracture in which the Achilles tendon removes a portion of the bone as it rescinds) and diabetes mellitus. The diabetic population is more susceptible to the risks of fracture and potential healing complications and infection that may lead to limb amputation. Diabetes can be regulated and prevented through diet and exercise. [12]

Diagnosis

A fractured calcaneus as seen on CT CalcanealfractCT.png
A fractured calcaneus as seen on CT

Conventional radiography is usually the initial assessment tool when a calcaneal fracture is suspected. Recommended x-ray views are (a) axial, (b) anteroposterior, (c) oblique and (d) views with dorsiflexion and internal rotation of the foot. However, conventional radiography is limited for visualization of calcaneal anatomy, especially at the subtalar joint. A CT scan is currently the imaging study of choice for evaluating calcaneal injury and has substituted conventional radiography in the classification of calcaneal fractures. [13] Axial and coronal views are obtained for proper visualization of the calcaneus, subtalar, calcaneocuboid and talonavicular joints.[ citation needed ]

Classification

Bohler's angle Bohler's angle (raster).jpg
Bohler's angle
Gissane's angle Gissane.jpg
Gissane's angle

The calcaneus, also known as the heel bone, is the largest of the tarsal bones and articulates with the cuboid bone anteriorly and the talus bone superiorly. It is responsible for transmitting the majority of the body's weight from the talus bone to the ground.[ citation needed ]

Calcaneal fractures are categorized as intra-articular or extra-articular on the basis of subtalar joint involvement. Intra-articular fractures are more common and involve the posterior talar articular facet of the calcaneus. The Sanders classification groups these fractures into four types based on the location of the fracture at the posterior articular surface. Extra-articular fractures are less common and may be located anywhere outside the subtalar joint. [13] Extra-articular fractures are categorized depending on whether the involvement of the calcaneus is anterior (Type A), middle (Type B) or posterior (Type C). [15]

The Angle of Gissane, or "Critical Angle", is the angle formed by the downward and upward slopes of the calcaneal superior surface. On a lateral radiograph, an angle of Gissane > 130° suggests fracture of the posterior subtalar joint surface. Böhler's angle, or the "Tuber Angle", is another normal anatomic landmark seen in lateral radiographs. It is formed by the intersection of 1) a line from the highest point of the posterior articular facet to the highest point of the posterior tuberosity, and 2) a line from the former to the highest point on the anterior articular facet. Böhler's angle is normally 25° to 40°. [14] It is named after Austrian physician Lorenz Böhler. [16] A decreased angle is indicative of a calcaneal fracture.

The Sanders classification system is the most commonly used system for categorizing intra-articular fractures. There are 4 types:[ citation needed ]

  1. Type I fractures are non-displaced fractures (displacement < 2 mm).
  2. Type II fractures consist of a single intra-articular fracture that divides the calcaneus into 2 pieces.
    • Type IIA: fracture occurs on lateral aspect of calcaneus.
    • Type IIB: fracture occurs on central aspect of calcaneus.
    • Type IIC: fracture occurs on medial aspect of calcaneus.
  3. Type III fractures consist of two intra-articular fractures that divide the calcaneus into 3 articular pieces.
    • Type IIIAB: two fracture lines are present, one lateral and one central.
    • Type IIIAC: two fracture lines are present, one lateral and one medial.
    • Type IIIBC: two fracture lines are present, one central and one medial.
  4. Type IV fractures consist of fractures with more than three intra-articular fractures.

Extra-articular fractures include all fractures that do not involve the posterior facet of the subtalar joint.

Treatment

Non-surgical treatment is for extra-articular fractures and Sanders Type I intra-articular fractures, provided that the calcaneal weight-bearing surface and foot function are not compromised. Physicians may choose to perform closed reduction with or without fixation (casting), or fixation alone (without reduction), depending on the individual case. Recommendations include no weight-bearing for a few weeks followed by range-of-motion exercises and progressive weight bearing for a period of 2–3 months.[ citation needed ]

Displaced intra-articular fractures require surgical intervention within 3 weeks of fracture, before bone consolidation has occurred. Conservative surgery consists of closed reduction with percutaneous fixation. This technique is associated with less wound complications, better soft tissue healing (because of less soft tissue manipulation) and decreased intraoperative time. However, this procedure has increased risk of inadequate calcaneal bone fixation, compared to open procedures. [17] Currently, open reduction with internal fixation (ORIF) is usually the preferred surgical approach when dealing with displaced intra-articular fractures. Newer, more innovative surgical techniques and equipment have decreased the incidence of intra- and post-operative complications. [18] An updated (2023) systematic review found with limited confidence that surgery may lead to improved functional outcomes but at the risk of unplanned second surgeries. [19] With the growing prevalence of minimally invasive surgeries further studies are needed to better determine if these newer surgical interventions offer improved outcomes. [19]

Rehabilitation

Calcaneal fracture neutral position Calcaneal fracture neutral lposition.jpg
Calcaneal fracture neutral position
Leg Stand Leg Stand.jpg
Leg Stand

Rehabilitation for a calcaneal fractures is dependent on whether surgery was required or not. Both types of rehabilitation require three phases in which only the first phase is different.[ citation needed ]

Exercises that can be used for the range of motion phase can include eversion and inversion of the ankle, flexion and extension of the ankle, and a combination of the two motions to create a circular foot motion. Exercises that allow slight to full body weight to be used in the final phases include stepping forward then back, side-stepping, and leg stand.[ citation needed ]

Phases

The first phase of the rehabilitation after surgery includes keeping the foot elevated and iced for the first 2 days after the operation. After those 2 days, using crutches or a wheelchair in which there is no weight applied to the affected foot is recommended to getting around. If no operation was performed, the foot should be submitted to frequent range of motion exercises. [20] The second phase occurs 6 weeks after and consists of keeping the foot elevated and iced while resting and performing exercises in which only slight weight is applied to the affected area for the next two weeks, others recommend six weeks of this phase. [21] In this phase, range of motion exercises should be implemented if surgery was needed for the fracture. The third and final phase of rehabilitation of calcaneal fractures is to allow the full body weight to be used and use crutches or a cane if needed, between 13 weeks to a year the patient is allowed to resume normal activities. [17]

Society and culture

The name lover's fracture is derived from the fact that a lover may jump from great heights while trying to escape from the lover's spouse. [22]

Related Research Articles

<span class="mw-page-title-main">Foot</span> Anatomical structure found in vertebrates

The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws and/or nails.

<span class="mw-page-title-main">Ankle</span> Region where the foot and the leg meet

The ankle, or the talocrural region, or the jumping bone (informal) is the area where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joint. The movements produced at this joint are dorsiflexion and plantarflexion of the foot. In common usage, the term ankle refers exclusively to the ankle region. In medical terminology, "ankle" can refer broadly to the region or specifically to the talocrural joint.

<span class="mw-page-title-main">Achilles tendon</span> Tendon at the back of the lower leg

The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcaneus (heel) bone. These muscles, acting via the tendon, cause plantar flexion of the foot at the ankle joint, and flexion at the knee.

<span class="mw-page-title-main">Calcaneus</span> Bone of the tarsus of the foot

In humans and many other primates, the calcaneus or heel bone is a bone of the tarsus of the foot which constitutes the heel. In some other animals, it is the point of the hock.

<span class="mw-page-title-main">Pes cavus</span> Medical condition

Pes cavus, also known as high arch, is a human foot type in which the sole of the foot is distinctly hollow when bearing weight. That is, there is a fixed plantar flexion of the foot. A high arch is the opposite of a flat foot and is somewhat less common.

<span class="mw-page-title-main">Bone fracture</span> Physical damage to the continuity of a bone

A bone fracture is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a comminuted fracture. A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

<span class="mw-page-title-main">Plantar fasciitis</span> Connective tissue disorder of the heel

Plantar fasciitis or plantar heel pain is a disorder of the plantar fascia, which is the connective tissue which supports the arch of the foot. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. Pain is also frequently brought on by bending the foot and toes up towards the shin. The pain typically comes on gradually, and it affects both feet in about one-third of cases.

<span class="mw-page-title-main">Flat feet</span> Deformity in which the foot arches contact the ground

Flat feet, also called pes planus or fallen arches, is a postural deformity in which the arches of the foot collapse, with the entire sole of the foot coming into complete or near-complete contact with the ground. Sometimes children are born with flat feet (congenital). There is a functional relationship between the structure of the arch of the foot and the biomechanics of the lower leg. The arch provides an elastic, springy connection between the forefoot and the hind foot so that a majority of the forces incurred during weight bearing on the foot can be dissipated before the force reaches the long bones of the leg and thigh.

<span class="mw-page-title-main">Distal radius fracture</span> Fracture of the radius bone near the wrist

A distal radius fracture, also known as wrist fracture, is a break of the part of the radius bone which is close to the wrist. Symptoms include pain, bruising, and rapid-onset swelling. The ulna bone may also be broken.

<span class="mw-page-title-main">Clavicle fracture</span> Medical condition

A clavicle fracture, also known as a broken collarbone, is a bone fracture of the clavicle. Symptoms typically include pain at the site of the break and a decreased ability to move the affected arm. Complications can include a collection of air in the pleural space surrounding the lung (pneumothorax), injury to the nerves or blood vessels in the area, and an unpleasant appearance.

<span class="mw-page-title-main">Talus bone</span> One of the foot bones that forms the tarsus

The talus, talus bone, astragalus, or ankle bone is one of the group of foot bones known as the tarsus. The tarsus forms the lower part of the ankle joint. It transmits the entire weight of the body from the lower legs to the foot.

<span class="mw-page-title-main">Ankle fracture</span> Medical condition

An ankle fracture is a break of one or more of the bones that make up the ankle joint. Symptoms may include pain, swelling, bruising, and an inability to walk on the injured leg. Complications may include an associated high ankle sprain, compartment syndrome, stiffness, malunion, and post-traumatic arthritis.

<span class="mw-page-title-main">Subtalar joint</span>

In human anatomy, the subtalar joint, also known as the talocalcaneal joint, is a joint of the foot. It occurs at the meeting point of the talus and the calcaneus.

<span class="mw-page-title-main">Calcaneal spur</span> Medical condition of the heel

A calcaneal spur is a bony outgrowth from the calcaneal tuberosity. Calcaneal spurs are typically detected by x-ray examination. It is a form of exostosis.

<span class="mw-page-title-main">Calcaneocuboid joint</span> Joint between the calcaneus bone and the cuboid bone in the foot.

The calcaneocuboid joint is the joint between the calcaneus and the cuboid bone.

<span class="mw-page-title-main">Trimalleolar fracture</span> Medical condition

A trimalleolar fracture is a fracture of the ankle that involves the lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia, which can be termed the posterior malleolus. The trauma is sometimes accompanied by ligament damage and dislocation.

<span class="mw-page-title-main">Astragalectomy</span>

Astragalectomy, sometimes called a talectomy, is a surgical operation for removal of the talus bone (astragalus) for stabilization of the ankle.

<span class="mw-page-title-main">Mandibular fracture</span> Medical condition

Mandibular fracture, also known as fracture of the jaw, is a break through the mandibular bone. In about 60% of cases the break occurs in two places. It may result in a decreased ability to fully open the mouth. Often the teeth will not feel properly aligned or there may be bleeding of the gums. Mandibular fractures occur most commonly among males in their 30s.

<span class="mw-page-title-main">Olecranon fracture</span> Medical condition

Olecranon fracture is a fracture of the bony portion of the elbow. The injury is fairly common and often occurs following a fall or direct trauma to the elbow. The olecranon is the proximal extremity of the ulna which is articulated with the humerus bone and constitutes a part of the elbow articulation. Its location makes it vulnerable to direct trauma.

<span class="mw-page-title-main">Sinus tarsi</span> Section of the hindfoot

The sinus tarsi, also known as the talocalcaneal sulcus, is a cylindrical canal in the hindfoot. It has a complex anatomy, with five ligamentous structures and a pad of adipose tissue (fat). The tarsal canal opens up into the sinus tarsi, however, the tarsal canal is a distinct structure.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 "Calcaneus (Heel Bone) Fractures-OrthoInfo - AAOS". orthoinfo.aaos.org. January 2016. Archived from the original on 18 June 2017. Retrieved 12 October 2017.
  2. 1 2 3 4 5 6 Palmersheim K, Hines B, Olsen BL (April 2012). "Calcaneal fractures: update on current treatments". Clinics in Podiatric Medicine and Surgery. 29 (2): 205–20, vii. doi:10.1016/j.cpm.2012.01.007. PMID   22424485.
  3. ↑ Calcaneus Fractures at eMedicine
  4. ↑ Richman JD, Barre PS (June 1986). "The plantar ecchymosis sign in fractures of the calcaneus". Clinical Orthopaedics and Related Research. 207 (207): 122–125. doi:10.1097/00003086-198606000-00022. PMID   3720074.
  5. ↑ Berry GK, Stevens DG, Kreder HJ, McKee M, Schemitsch E, Stephen DJ (April 2004). "Open fractures of the calcaneus: a review of treatment and outcome". Journal of Orthopaedic Trauma. 18 (4): 202–206. doi:10.1097/00005131-200404000-00002. PMID   15087962. S2CID   26196764.
  6. 1 2 Heier KA, Infante AF, Walling AK, Sanders RW (December 2003). "Open fractures of the calcaneus: soft-tissue injury determines outcome". The Journal of Bone and Joint Surgery. American Volume. 85 (12): 2276–2282. doi:10.2106/00004623-200312000-00002. PMID   14668494.[ permanent dead link ]
  7. 1 2 Soeur R, Remy R (November 1975). "Fractures of the calcaneus with displacement of the thalamic portion". The Journal of Bone and Joint Surgery. British Volume. 57 (4): 413–421. doi:10.1302/0301-620X.57B4.413. PMID   1194308.[ permanent dead link ]
  8. ↑ Stoller DW, Tirman PF, Bredella M (2004). "Ankle and foot, osseous fractures, calcaneal fractures". Diagnostic imaging: orthopaedics . Salt Lake City: Amirsys. pp.  70–4. ISBN   9780721629209.
  9. ↑ Salzler MJ, Bluman EM, Noonan S, Chiodo CP, de Asla RJ (April 2012). "Injuries observed in minimalist runners". Foot & Ankle International. 33 (4): 262–266. doi:10.3113/FAI.2012.0262. PMID   22735197. S2CID   13506657.
  10. ↑ Cheng S, Suominen H, Sakari-Rantala R, Laukkanen P, Avikainen V, Heikkinen E (July 1997). "Calcaneal bone mineral density predicts fracture occurrence: a five-year follow-up study in elderly people". Journal of Bone and Mineral Research. 12 (7): 1075–1082. doi: 10.1359/jbmr.1997.12.7.1075 . PMID   9200007.
  11. ↑ Kathol MH, el-Khoury GY, Moore TE, Marsh JL (September 1991). "Calcaneal insufficiency avulsion fractures in patients with diabetes mellitus". Radiology. 180 (3): 725–729. doi:10.1148/radiology.180.3.1871285. PMID   1871285.
  12. ↑ "Diabetes Mellitus". The Lecturio Medical Concept Library. Retrieved 26 August 2021.
  13. 1 2 Badillo K, Pacheco JA, Padua SO, Gomez AA, Colon E, Vidal JA (2011). "Multidetector CT evaluation of calcaneal fractures". Radiographics. 31 (1): 81–92. doi:10.1148/rg.311105036. PMID   21257934.
  14. 1 2 Kadakia AR, Seybold JD (2016). "Disorders of the foot and ankle, Section 18: Trauma: Calcaneous Fractures". In Miller MD, Thompson SR (eds.). Miller's Review of Orthopaedics (Seventh ed.). Philadelphia, PA: Elsevier Health Sciences. p. 562. ISBN   978-0-323-39042-2.
  15. ↑ Radswiki; et al. "Calcaneal fracture". Radiopaedia. Archived from the original on October 14, 2017. Retrieved July 20, 2017.
  16. ↑ Bohler J (July 1973). "Lorenz Böhler: in memoriam". The Journal of Trauma. 13 (7): 658–659. PMID   4577042.
  17. 1 2 Calcaneus Fractures~treatment at eMedicine
  18. ↑ Rodemund C, Krenn R, Kihm C, Leister I, Ortmaier R, Litzlbauer W, et al. (November 2020). "Minimally invasive surgery for intra-articular calcaneus fractures: a 9-year, single-center, retrospective study of a standardized technique using a 2-point distractor". BMC Musculoskeletal Disorders. 21 (1): 753. doi: 10.1186/s12891-020-03762-9 . PMC   7666766 . PMID   33189140.
  19. 1 2 Lewis, Sharon R.; Pritchard, Michael W.; Solomon, Joshua L.; Griffin, Xavier L.; Bruce, Julie (2023-11-07). "Surgical versus non-surgical interventions for displaced intra-articular calcaneal fractures". The Cochrane Database of Systematic Reviews. 11 (11): CD008628. doi:10.1002/14651858.CD008628.pub3. ISSN   1469-493X. PMC   10628987 . PMID   37933733.
  20. ↑ Godges J, Klingman R. "Calcaneal Fracture and Rehabilitation" (PDF). Kaiser Permanente. Archived (PDF) from the original on 2016-03-06.
  21. ↑ Hatzokos I, Karataglis D, Papadopoulos P, Dimitriou C, Christodoulou A, Pournaras J (January 2006). "Treatment of intra-articular comminuted os calcis fractures". Orthopedics. 29 (1): 25–29. doi:10.3928/01477447-20060101-15. PMID   16429931. S2CID   39928758.
  22. ↑ Lee P, Hunter TB, Taljanovic M (2004). "Musculoskeletal colloquialisms: how did we come up with these names?". Radiographics. 24 (4): 1009–1027. doi:10.1148/rg.244045015. PMID   15256625. S2CID   45306174.

Bibliography

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