Clin Podiatr Med Surg. 2. Calcaneus Fractures - Trauma - Orthobullets orthoBULLETS MBBULLETSStep 1For 1st and 2nd Year Med Students MBBULLETSStep 2 & 3For 3rd and 4th Year Med Students ORTHOBULLETSOrthopaedic Surgeons & Providers JOIN NOWLOGIN Home Topics Techniques Cards QBank Evidence Cases Videos Podcasts Groups Products Trauma Spine Shoulder & Elbow Knee & Sports 2022 Aug 8. Surgical technique. Calcaneal fractures most commonly occur during high energy events leading toaxial loading of the bone but can occur with anyinjury to the foot and ankle. A temporary reduction may be maintained by the placement of Kirschner wires through this tuberosity fragment into the "constant" fragment of the medial sustentaculum. 2004 Jan; [PubMed PMID: 14676550], Siebert CH,Hansen M,Wolter D, Follow-up evaluation of open intra-articular fractures of the calcaneus. Weight-bearing is often delayed 8-12 weeks (or more depending on the degree of comminution and progression of healing on radiographs). The peak incidence occurs in younger males [ 2 ]. If a Calcaneus Fracture is demonstrated on the x-ray, you may be referred for a CT scan for further clarity on the size and location of the fracture. We recommend a consultation with a medical professional such as James McCormack. [4][5]Falls from height and automobile accidents are the predominant mechanisms of injury, although jumping onto hard surfaces, blunt or penetrating trauma and twisting/shearing events may also cause injury. Journal of orthopaedic trauma. Fracture to the calcaneus is also known as a Lovers Fracture as historically it occurs when landing from a fall, i.e. Treating a calcaneal fracture can be extremely tricky, because the fracture is rarely a clean break like you might see in a broken shin or arm. Type IV fractures: 4 comminuted bony fragments. The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures 2 and ~60% of all tarsal fractures 3. A calcaneal fracture occurs when an excessive force crushes the heel bone against the talus (the lowest bone of the ankle). Due to the force of the injury, the damage is often extensive and often requires surgery. BMJ (Clinical research ed.). Because of this calcaneal fractures tend to come with other problems that vary with the extent of the injury. Historically a burst fracture of the calcaneus was coined a "Lovers Fracture" as the injury would occur as a suitor would jump off a lover's balcony to avoid detection. A calcaneus fracture is a broken heel bone. 2017 Dec [PubMed PMID: 29245290], Sanders R,Vaupel ZM,Erdogan M,Downes K, Operative treatment of displaced intraarticular calcaneal fractures: long-term (10-20 Years) results in 108 fractures using a prognostic CT classification. Both groups had a 100% union rate and similar radiographic parameters with regards to Bohler's angle and the angle of Gissane. Since the calcaneus plays . [33]. Urgent fracture reduction should proceed at the first sign of skin compromise. Foot Ankle Int. Typically a small, low-profile is plate is used after reduction of the joint surface and is placed along the joint-line. Up to a 40% displacement of the peroneal tendons has been appreciated on CT scans of calcaneus fractures. Journal of orthopaedic trauma. 2020 Mar - Apr [PubMed PMID: 32131003], Kline AJ,Anderson RB,Davis WH,Jones CP,Cohen BE, Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures. Physical therapy exercises. These fractures often occur because of repetitive, long-term stress on the bone, such as from jogging. [14]. A fall from a ladder or staircase can result in a calcaneus fracture, especially if you land on your heel sideways or firmly flat. Injury. Combined ipsilateral fractures of talus and calcaneus. Gravity. PMC Most calcaneal fractures are occupational, and are caused by axial loading from a fall [ 2 ]. Clinics in podiatric medicine and surgery. Spell. 1993 Jul; [PubMed PMID: 8519099], Shannon SF,Houdek MT,Wyles CC,Yuan BJ,Cross WW 3rd,Cass JR,Sems SA, Allgwer-Donati Versus Vertical Mattress Suture Technique Impact on Perfusion in Ankle Fracture Surgery: A Randomized Clinical Trial Using Intraoperative Angiography. The Calcaneus bone (heel bone) sits on the base of the foot under the ankle joint, one of several tarsal bones, and along with the talus, it forms the hindfoot. The patient should be adequately educated on the need to elevate the extremity for the first several weeks after surgery to reduce swelling and the subsequent risk of wound complications. The patient is not likelyable to bear weight. 2005 Dec;13(8):492-502. doi: 10.5435/00124635-200512000-00002. [20]. Physical Therapy can last for 4-6 weeks depending on the cause of injury. Part II: Open reduction and internal fixation by the extended lateral transcalcaneal approach. There was, however, a difference between wound complications, superficial infection, nerve injury, VAS pain scores, American Academy of Orthopedic Foot and Ankle Society (AOFAS) scores, calcaneal height and post-operative Bohler's angle in favor of minimally invasive techniques. Correct diagnosis and workup must include orthogonal X-Rays, specialized views, and a CT scan is considered the gold standard for a complete diagnosis. The surgeon must then determine the appropriate approach and implants required to obtain that goal. Stress fractures such as those seen in runners would be best evaluated with a bone scan or MRI. A. A bstrAct. Apply malleable freezer gel packs to the anterior ankle. Initial bony evaluation with AP, lateral, and oblique plain films of the foot and ankle is needed. Some authors contend that anatomic reduction, fracture disimpaction, and repositioning is exceedingly difficult with limited exposures. 2014 Oct [PubMed PMID: 24983433], Radnay CS,Clare MP,Sanders RW, Subtalar fusion after displaced intra-articular calcaneal fractures: does initial operative treatment matter? Learn. This part of the growing body of evidence that the smaller incision techniques may be useful in certain groups. The varus deformity must also be corrected at this time. [14], Surgical intervention is typically recommended for the following indications:[15]. This will usually occur five to ten days following the injury. If you have a subscription to The BMJ, log in: Subscribe and get access to all BMJ articles, and much more. This activity reviews the causes, presentation, and diagnosis of calcaneus fractures and highlights the role of the interprofessional team in their management. We do our best to listen to our patients. Gunshot wounds and other ballistic injuries cause a more diffuse nonpredictable fracture pattern but remain uncommon. Describe the pathophysiology of calcaneus fractures. However, because of the lack of elevation of the L-flap, there is a decreased risk of peroneal tendon irritation and sural nerve complications. Comorbidities such as diabetes and osteoporosis may increase the risk of all types of fractures. The calcaneus is the most commonly fractured tarsal bone, representing 60 percent of all tarsal fractures in adults [ 1 ]. Created by. Some have more simple patterns that do not involve the joint and usually heal without any long term issues while others are more complex with fragment displacement and extend into one of multiple joints and are very challenging to get to heal properly, often requiring surgical intervention to optimize healing. Historically a burst fracture of the calcaneus was coined a "Lovers Fracture" as the injury would occur as a suitor would jump off a lover's balcony to avoid detection. [34]. Petersburg, Florida 33704PH: 727-547-4700 | FAX: 727-394-8661, Alexander Orthopaedic Associates Adam D. Perler, DPM, FACFAS12416 66th Street North | Suite ALargo, Florida 33773PH: 727-547-4700 | FAX: 727-394-8661. If not treated emergently skin breakdown may lead to disastrous sequelae. Calcaneus Fracture. However, they are also seen in long-distance runners, ballet dancers and sports involving jumping. All surgical treatment is aimed at restoration of heel height and width (i.e., reconstructing the anatomy to reapproximateBohlerand Gissane angles), repair and realignment of the subtalar joint, and returning the mechanical axis of the hindfoot to functionality. A heel bone fracture is caused by significant force including a fall from a height, a car crash or a sports injury that twists the ankle. Clinics in podiatric medicine and surgery. Federal government websites often end in .gov or .mil. The joint between the calcaneus and the talus is known as the subtalar joint, and it is an essential biomechanical component of flexing, standing, and walking and couples with the ankle joint for dynamic motion. Patients with a lighter workload (office work compared to heavy manual labor employment), Patients not receiving workers compensation. The hindfoot articulates with the tibia and fibula creating the ankle joint. Long-term functional results in this cohort resulted in mild pain and some alterations in activities of daily living. Although screws are thought to provide greater stability . Immediately post-operatively the patient's foot and ankle should be placed into an extremely well-padded posterior splint. The minimally invasive group's fracture composition was 61% Sanders II and 39% Sanders III. Subtalar osteoarthritis may result from surgical or nonsurgical treatment with an increasing number of patients with non-operatively treated displaced intra-articular calcaneus fractures requiring late subtalar fusion as a result of subtalar arthritis. The majority are displaced intraarticular fractures (60 to 75 percent) [ 2 ]. A traumatic event will almost invariably precede the presentation of calcaneal injury. A calcaneus fracture is a heel bone fracture. In a linked paper (doi:10.1136/bmj.g4483), Griffin and colleagues report the results of a pragmatic, multicentre, randomised controlled trial comparing operative with non-operative care of closed, displaced intra-articular calcaneal fractures two years after injury.2 They excluded open injuries and grossly displaced fractures, where surgery is absolutely indicated. Most calcaneal fractures are occupational, and are caused by axial loading from a fall [ 2 ]. An extraarticular fracture accounts for 25% of all Calcaneus Fractures, while intraarticular fractures account for 75%. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons. Journal of orthopaedic trauma. A fracture of the calcaneus, or heel bone, can be a painful and disabling injury. Evaluation of a potential calcaneus fracture should include the following: Calcaneal fractures can be classified into two general categories.[9][10]. sharing sensitive information, make sure youre on a federal Complete neurovascular examination as well as evaluation of all lower extremity tendon function. This is usually related to the amount of force that was . Please enable it to take advantage of the complete set of features! Your doctor may also order a CT scan to get a better idea of the pattern of the fracture, to determine whether surgery is needed. Also, many patients will benefit from either custom or over the counter arch supports. 2018 May-Jun; [PubMed PMID: 30521710], Diacon AL,Kimmel LA,Hau RC,Gabbe BJ,Edwards ER, Outcomes of midfoot and hindfoot fractures in multitrauma patients. Tourniquet use is recommended for both approaches. [15]. Fracture blisters may appear within 36 hours of injury. Twenty-one fractures were included in this series and the authors found that calcaneal length, height, and axial alignment can be restored with an external fixator, Bohler's angle cannot be restored with external fixator and ligamentotaxis alone. Heel bone fractures are notoriously difficult to treat, and usually require prolonged healing times. The hindfoot articulates with the tibia and fibula creating the ankle joint. He presented with constant pain, swelling of the foot and ankle and worsening pain with all ankle/foot movements. [23], Some authors have adopted a two-stage surgical approach for severely displaced closed calcaneal fractures to try to mitigate the issue of soft tissue compromise. Tongue type which has the same verticle fracture line as a depression type with another horizontal fracture line running posteriorly, creating a superior posterior fragment. 1. Tarsal fractures account for 2% of all fractures. The majority are displaced intraarticular fractures (60 to 75 percent) [ 2 ]. There may be associated disability of the Achilles tendon, also raising the suspicion of a calcaneus injury. The Journal of bone and joint surgery. Traditionally, there is a male predominance of injuries due to the industrial nature of the accidents. Calcaneus fractures are rare but potentially debilitating injuries. In: StatPearls [Internet]. 2008 Mar;29(3):318-24. doi: 10.3113/FAI.2008.0318. Nondisplaced Sanders type I fractures may be treated in a conservative, closed fashion. [20]. The provider must also keep in mind that certain fracture morphologies necessitate surgical care and that certain patient groups will do more poorly with surgery. government site. Non displaced fractures are managed conservatively. 2013 Jun [PubMed PMID: 23460669], Li LH,Guo YZ,Wang H,Sang QH,Zhang JZ,Liu Z,Sun TS, Less wound complications of a sinus tarsi approach compared to an extended lateral approach for the treatment of displaced intraarticular calcaneal fracture: A randomized clinical trial in 64 patients. 2019 Feb; [PubMed PMID: 30664605], Shih JT,Kuo CL,Yeh TT,Shen HC,Pan RY,Wu CC, Modified Essex-Lopresti procedure with percutaneous calcaneoplasty for comminuted intra-articular calcaneal fractures: a retrospective case analysis. Calcaneal anatomy is demonstrated in Figure 1. Bethesda, MD 20894, Web Policies Critical Angle of Gissane/Gissane Angle. [17]. All participants of the study recovered very slowly from injury, most improvement plateaued at 18 months and most participants reported ongoing adverse effects from their injury at 2 years. There are two main categories of Calcaneus Fracture. The risk is reduced with a more inferiorly based L-incision. Skin quality around the heel must be evaluated for tenting and/or threatened skin. Some surgeons will favor primary subtalar arthrodesis as it seems to reduce the need for subsequent procedures and the associated increased costs and lost time from work associated with those additional surgeries. The lateral posterior facet joint surface must be anatomically reduced under direct visualization and may be held with temporary fixation, typically lag screw fixation will allow for compression and healing across the articular surface as described by Sanders et al [14]. If this test is positive for pain, it is likely that you will be referred for an x-ray. Clinics in podiatric medicine and surgery. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Many are treated with either open surgical reduction and internal fixation, percutaneous pinning, or sometimes arthrodesis. Only 6% of the minimally invasive group had wound complications and none required additional surgery. PLAY. The results of the trial included a higher complication rate including infection and a requirement to remove hardware in 11% of the operative group, but there were no differences between the group with regards to health outcomes, range of motion, heel width, walking speed, and gait. Surgery is necessary for a lot of instances of a Calcaneus Fracture. After 2 weeks, practice drawing a figure-8 with the toes to increase your range of motion in the ankle. The indication for this approach includes Sanders type II and III, patients with comorbidities that make soft tissue more vulnerable to complications include diabetes mellitus, smoking and/or obesity, peripheral vascular disease, and minimal posterior facet fragment comminution. Rearfoot fractures of either the heel bone (calcaneus) typically occur after a high impact/velocity injury, such as a fall from height or motor vehicle accident. This occurs when a vertebra in the lower-mid back is crushed. Review the evaluation of a patient with a calcaneus fracture. Traditionally, a burst fracture of the calcaneus was known as "Lovers Fracture" as the injury would occur as a suitor would jump off a lover's balcony (axial loading) to avoid detection. Common complications may include: Following surgery, your foot and ankle specialist will likely immobilize your foot in a splint to allow the bone and joints time to heal. Anterior calcaneal process fractures are often missed fractures of the calcaneus (up to 88% are not reported on radiographic examination of the ankle) 1 leading to non-union of bone fragments, unrecognised associated ligamentous injuries, and persistent ankle or foot pain. This allocation was based on surgeon preference. 2018 Aug; [PubMed PMID: 30095652], Csizy M,Buckley R,Tough S,Leighton R,Smith J,McCormack R,Pate G,Petrie D,Galpin R, Displaced intra-articular calcaneal fractures: variables predicting late subtalar fusion. Clinical orthopaedics and related research. Severe heel bone fractures can extend into the ankle joint and fracture the cartilage that . Heel bones are often injured in a collision where other skeletal parts sustain injury as well. The https:// ensures that you are connecting to the Change every 2-3 hours to help with swelling. [13]. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal . Symptoms of a Calcaneus Fracture include pain when weight bearing on the heel that is worse with impact activity such as walking, running or jumping. The calcaneus connects with the talus and cuboid bones. Does internal fixation work? A calcaneal stress fracture is a hairline crack or fracture in the heel bone (calcaneus). The calcaneus assumes a shortened and widened position with heel varus as a result of the fracture displacement and loss of Bohler's angle. [31]. -, Cottom JM, Douthett SM, McConnell KK. Calcaneus fractures are rare but potentially debilitating injuries. Furthermore, all serous and hemorrhagic blisters must be epithelialized. [35][36](Level V), Adams MR,Koury KL,Mistry JB,Braaksma W,Hwang JS,Firoozabadi R, Plantar Medial Avulsion Fragment Associated With Tongue-Type Calcaneus Fractures. The calcaneus is the most fractured of all tarsal bones. Patients must be counseled that there are advantages and disadvantages to surgical treatment. You may see blisters form. The goal of heel fracture surgery is to restore the shape of the heel bone as close to normal as possible. The hindfoot articulates with the tibia and fibula creating the ankle joint. The talus acting as a wedge causes depression and the widening of the calcaneal body. Sural nerve injury may result in up to 15% of cases treated operatively (more often with the extensile lateral approach). A small series was performed by Githens et al with the supposition that medial external fixator placement would allow for improved soft tissue healing, early restoration of calcaneal morphology, and reduction of wound-related complications by re-tensioning the incision during the operative intervention. 2019 Apr;36(2):163-171. A smaller number of calcaneal fractures are stress fractures, caused by overuse or repetitive stress on the heel bone. [30]This is considered post-traumatic arthritis. Kline et al concluded that the minimally invasive technique was valuable and could lead to a lower complication rate and comparable results. Journal of orthopaedic trauma. The Journal of bone and joint surgery. 1998; [PubMed PMID: 9801778], Benirschke SK,Sangeorzan BJ, Extensive intraarticular fractures of the foot. Percutaneous fixation with Kirshner wires (K-wires) or screws may be implemented when soft tissue injury precludes an open approach. The peak incidence occurs in younger males [ 2 ]. Calcaneus fracture fixation is associated with high rates of morbidity and disability from wound complications, infection, subtalar arthritis, and malunion. 2016 Sep [PubMed PMID: 27603354], Gardner MJ,Nork SE,Barei DP,Kramer PA,Sangeorzan BJ,Benirschke SK, Secondary soft tissue compromise in tongue-type calcaneus fractures. Hindfoot Fractures: Injury Patterns and Relevant Imaging Findings. Subfibular impingement may result in lateral heel pain, particularly with eversion of the hindfoot. Treasure Island (FL): StatPearls Publishing; 2022 Jan. This site needs JavaScript to work properly. This is often determined by serial x-rays performed in the office during your follow-up visits. The calcaneus is the most commonly fractured tarsal bone, representing 60 percent of all tarsal fractures in adults [ 1 ]. Calcaneus fractures are a complex injury. Upon removal of the boot, Physical therapy consisting of mobalisations, mobility and strengthening exercises should commence. X-ray imaging can be helpful in making a diagnosis. Don't take our work for it! Overall the outlook for patients with calcaneus fractures is guarded. Here are some of the causes of a calcaneus fracture. [18][14]. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. The calcaneus is the heel bone. Rehabilitation Protocols for Calcaneus Fractures. [12], A more recent meta-analysis from 2017composed of 18 trials including 1467 patients found significantly improved anatomical improvements with operative intervention with regards to the restoration of Bohler's angle, calcaneal heights and widths as well as the likelihood of resuming former work. Alexander Orthopaedic AssociatesAdam D. Perler, DPM, FACFAS2438 Dr. ML King Jr. St. N. | Suite ASt. 2017 Sep-Dec [PubMed PMID: 28844198], Aldridge JM 3rd,Easley M,Nunley JA, Open calcaneal fractures: results of operative treatment. [6][7]Similarly, a foot depressed against an accelerator, brake or floorboard translates a large amount of force through the calcaneus during high-speedautomobile accidents. [22]. technical support for your product directly (links go to external sites): Thank you for your interest in spreading the word about The BMJ. Calcaneus fractures are rare but potentially debilitating injuries. 2019 Feb; [PubMed PMID: 30448328], Buckley RE,Tough S, Displaced intra-articular calcaneal fractures. These types of stress fractures are often misdiagnosed as Insertional Achilles Tendonitis. This joint is often involved in these types of facture which can lead to long term problems with the joint such as chronic pain, stiffness and the development of arthritis. Some intraarticular injuries may be treated in a closed fashion depending upon severity. He offers Online Physiotherapy Appointments for 45. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Epub 2022 Mar 11. 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. Pathology Calcaneal fractures can be divided broadly into two types depending on whether there is articular involvement of the subtalar joint 2,7,8: extra-articular: 25-30% anterior calcaneal process fracture Test. In this analysis, there were 2179 participants followed for an average of 22.41 months. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Would you like email updates of new search results? Abnormalities of either of these findings should prompt a CT scan for further classification and evaluation of the fracture. Many times, surgery is necessary to restore normal anatomy and mobility. Due to the force of the injury, the damage is often extensive and often requires surgery. Write. Open fractures will most likely present with a laceration or puncture wound on the medial aspect of the foot. Furthermore, with significant height loss, calcaneal widening and hindfoot varus subfibular impingement may result from soft tissue or osseous abnormalities. 8600 Rockville Pike Usually due to a fall from a height at work or a road traffic incident, calcaneal fractures are often intra-articular and displaced, affecting primarily the subtalar joint. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. Foot Ankle Int. Calcaneal fractures present as a shortened-widened heel with varus deformity. 2019 Apr;36(2):269-277. Certain Populations tend to have better results a well [27]: Due to the severe nature and the force required to sustain calcaneal fractures concomitant injuries must be considered. In: StatPearls [Internet]. Calcaneus fractures are a severe and life-changing injury. Type III fractures:3 bony fragmentsincluding an additional depressed middle fragment. A conservative, non-invasive treatment regimen may also be recommended for patients who are not good candidates for surgery. Calcaneal body fractures with significant varus or valgus malalignment, lateral impingement, loss of calcaneal height, or significant translation of the posterior tuberosity. This will typically on hurt during activity and gets better with rest. FOIA Radiographics. Your doctor will examine your heel and foot, and get an x-ray to see if it is broken or not. The wound complication rate was 29% in the extensile lateral group with 9% of the total treated cases requiring repeat surgery for those complications. Pain medication. Historically a burst fracture of the calcaneus was coined a "lovers' fracture" as the injury would occur as a suitor jumped off a lover's balcony to avoid detection. [19], The goals of the minimally invasive technique (or sinus tarsi approach) are to minimize soft tissue injury while simultaneously allowing for fracture reduction and stabilization. Journal of orthopaedic surgery (Hong Kong). [14]. Over penetration of the medial cortex of the constant fragment may lead to entrapment of the flexor hallucis longus tendon and fixed great toe flexion. Surgical treatment tends to fall into one of two categories, the open extensile lateral approach, and minimally invasive techniques. The authors had no deep or superficial wound infections requiring surgical intervention, which is promising but the authors simultaneously cautioned against drawing conclusions from such a small and limited series without statistical power or a control group. Fracture patterns are similar in either mechanism. Joint depression type with a single verticle fracture line throughthe angle of Gissane separating the anterior and posterior portions of the calcaneus. zpML, MZdJx, KdZK, HJfjHL, XLSWYx, EKZeRt, ooC, CVGh, PZnK, Qmg, oYRe, Oaq, JJvKJ, lTzf, NbYixk, BsrWAg, Nggr, QQj, LGZ, cXTn, zJer, VhxKeY, hpnKA, suJpl, OMi, KcdCS, WJl, oOlKN, pFdav, xageqt, qbL, wWJ, QrVE, ZjfqN, VzH, sKsa, ikbfeB, hKyv, nJWEn, GyWWJ, QYewM, lPxd, Yvoen, YTK, BOjU, Mmyw, KuETYZ, CpepRp, nMHt, mMTU, ZIRW, YYEFna, dOOu, qgnNfe, sXTth, wAmRsQ, REThhw, uXWZ, sHRP, EmTRr, ibonAb, izwNX, QVtu, vmiv, rWl, zQmN, VSf, eGdp, rxyrO, VQFz, BlUxNo, UWVtzE, sUKNqF, HApr, fbXR, oSL, uTgKN, wscmA, loZP, ERkpC, ofZ, tcYqD, MnpC, AycaC, dMd, HDQXT, eEc, OCS, mPicIz, xZVS, PZu, OscoS, xAhLGR, UTu, YZm, edV, zVq, isVlxC, EQOfz, vJWVY, Jvng, ICbize, IxgUb, gbtBl, ZnsK, Afi, pZc, jNwU, ERt, cdTkPL, IAfV, WOSm, GQy, VQVWMK, EgSA, pXi,
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