What is a Calcaneal Fracture?

A fracture is a medical condition in which a bone is cracked or broken. A calcaneal fracture is a break in the calcaneus or heel bone. It is a painful and disabling injury that most commonly occurs as a result of a high-energy event such as a motor vehicle accident or a fall from a height.

Calcaneal fractures can be quite severe. Treatment normally includes surgery to reconstruct the normal heel anatomy and restore mobility so that patients can resume their normal activities. However, even after appropriate treatment, some fractures may cause long-term complications, including swelling, pain, loss of movement, and arthritis.

Anatomy of the Calcaneus

The calcaneus or heel bone is the largest bone in the ankle forming the heel and is situated at the lower back part of the foot. The calcaneus forms the subtalar joint with the talus, which helps in the inward and outward movement of the foot. A fracture of the calcaneus reduces or prevents movement of the subtalar joint. Calcaneus fractures may lead to deformity of the calcaneus bone, irregularity of the subtalar joint, arthritis, and affect the surrounding tendons and nerves of the heel.

Types of Calcaneal Fractures

Based on the involvement of the subtalar joint, calcaneal fractures are divided into intra-articular or extra-articular fractures.

• Intra-articular fractures involve the joint and any of the three subtalar articulating facets (the location where two bones meet). Intra-articular fractures are the most severe form of calcaneal fractures and include injury to the cartilage (the connective tissue covers and protects the ends of bones in a joint).
• Extra-articular fractures may involve the calcaneal body and associated structures, but not the joint. Examples of these fractures include stress fractures caused by mild injury or overuse and traumatic injuries such as avulsion fractures (where a chunk of calcaneal bone is pulled off by a ligament) or crush injuries resulting in several fracture fragments.

Causes of Calcaneal Fractures

Calcaneus fractures are mostly caused due to trauma or high impact conditions such as a fall from a ladder where the heel gets crushed from body weight or a motor vehicle collision where the heel gets crushed against the floorboard. An ankle sprain or stress fracture may also cause the heel bone to become fractured.

Signs and Symptoms of Calcaneal Fractures

Some of the typical signs and symptoms of a calcaneal fracture include:

• Sudden heel pain
• Swelling around the heel area
• Bruised heel and ankle
• Edema
• Hematoma or skin discoloration towards the sole of the foot
• Difficulty in bearing weight on the injured heel
• Absent or limited inward and outward movement of the foot
• Difficulty walking
• Deformity of the foot

Diagnosis of a Calcaneal Fracture

Your doctor will review your symptoms and medical history and conduct a thorough physical examination of your foot and ankle to check for range of motion, blood supply, and other signs of fracture. Your doctor may order a computer tomography (CT) scan in which images are taken from various planes to diagnose the degree of calcaneal injury. Foot X-rays may also be ordered which show the break in the heel bone or reduction in Bohler’s angle (angles less than 20°, or more than 5° that is smaller than the uninjured side, indicate a fracture).

Treatment for Calcaneal Fracture

The treatment approach for a calcaneus fracture depends on the type and severity of injury.

Non-Surgical Treatment

Non-surgical therapies for calcaneus fracture include:

• Rest, ice, compression, and elevation (R.I.C.E.) therapy: You should allow the injured foot to rest to promote healing. Treat the injured area with ice to reduce swelling, pain, and inflammation. Use compression stockings or a bandage. While you rest in bed, elevate the foot above the level of the heart to reduce swelling.
• Immobilization: Your foot will be partially or completely immobilized if the fracture has not displaced. Casting the injured foot prevents movement of the fractured bone. Walking with the help of crutches is advised to avoid bearing body weight.

Surgical Treatment

Surgery is recommended for intra-articular or displaced calcaneal fractures. The surgical procedure is called an open reduction and internal fixation (ORIF) and is performed under the effect of general anesthesia. Your surgeon will make an incision on the outside of the heel to expose the heel fracture. The fractured heel bones are placed together and fixed in place with a metal plate and multiple screws. This procedure minimizes the chance of developing arthritis and allows inward and outward movement of your foot. Your surgeon will plaster the foot to prevent movement of the ankle for a specified period of time to promote healing.

Once the plaster is removed, your doctor may advise physical therapy and exercise to maintain range of motion for the joints of the foot and ankle. The foot muscles will gain flexibility with strengthening exercises such as toe-walking, weight exercises, jump training, and exercise using the stairs.