Calcaneus Fracture: Classification, Diagnosis and Treatment
Calcaneus fracture or heel fracture is a very common fracture of the of the foot.
Please see the page on anatomy of the foot to get a getter understanding of this fracture. (skip if you have already done so)
This fracture can be divided into two types
- extra-articular or those fractures that do not involve the subtalar and calcaneo-cuboid joints
- intra-articular or those fractures that involve the subtalar and calcaneo-cuboid joints
Extra-articular fractures constitute about 1/4 th of all fractures of calcaneum and they are of the following types according to the part of the calcaneum fractured
- sustentaculum tali
- anterior process
- medial process
- body of the calcaneus
Extra-articular fractures of sustentaculum tali, anterior process, medial process, are caused by injuries that twist the foot.
Undisplaced fractures of the sustentaculum tali and anterior process are treated by immobilization of the foot in a plaster cast for 6 to 8 weeks. Displaced fractures are treated by surgery.
Fractures of the medial process are treated by plaster cast immobilization for 4 to 6 weeks.
Fractures of the tuberosity is caused by a sudden forceful contraction of the calf muscles. This causes the tuberosity to break off from the calcaneus. These fractures are more common in elderly people because of osteoporosis. Undisplaced tuberosity fractures are treated by plaster cast immobilization for 6 to 8 weeks.
Displaced fractures require surgery. If surgery is not done then the calf muscles will become weak and ineffective. After surgery a plaster cast is applied for 6 to 8 weeks.
Extra-articular fractures of the body of calcaneus are caused by a fall from height. These fractures can be
- undisplaced (hairline) or minimally displaced
- displaced fractures in which the bone fragment has moved proximally (upwards)
- comminuted (multiple bone pieces) fractures that result in widening of the bone
End result of this fracture is universally good what ever treatment method is used.
This x ray shows a undisplaced extra-articular fracture of the body of calcaneus. Red arrows point to the fracture lines.
Improvement in the alignment of this fracture is done when
- there is widening of the heel as this will irritate the peroneal muscle tendons and make wearing shoes difficult
- heel has shifted up wards as this will make the calf muscles loose and weaken them
Widening of the heel is corrected by side to side compression of the heel with the palms and upward migration of the heel is corrected by traction. After this a plaster cast is applied till fracture union which is usually 6 weeks.
Intra-articular fractures are caused by vertical loading force on the calcaneus, such as fall from height. The talus bone acting as a wedge and hammer fractures the calcaneus bone. These fractures constitute the remaining 3/4 th of calcaneal fractures. They are of two types according to Essex-Lopresti
- tongue type
- joint depression type
Classification of intra-articular fractures according to Sanders using CT scanning
- Type 1 are undisplaced
- Type 2 are two part or split fractures
- Type 3 are 3 part or split depression
- Type 4 are comminuted or having multiple fragments
Symptoms of intra-articular fractures include
- severe pain and rapid swelling in the heel after injury
- inability to walk or patient walks on his toes
- dark reddish discolouration of the sole and skin of the heel due to seepage of blood
- associated fractures of the back or the other bones of the lower limb may be present
Less severe symptoms are seen in extra-articular fractures.
Diagnosis is by x rays of the foot in different positions. X rays of the opposite uninjured foot are also taken to compare the change in the Bohler angle (see graphic). CT scans may also be required for classification and better evaluation of the fracture.
Initial treatment of all calcaneus fractures (extra and intra-articular) includes
- bed rest
- elevation of the foot
- use of ice to reduce swelling
- anti-inflammatory medication to decrease pain and swelling
Treatment of intra-articular calcaneus fracture according to classification.
- In Type 1 and undisplaced type 2 and 3 fractures exercises are started as soon as the swelling decreases and pain allows. The patient is not allowed to walk on his heel for at least 6 weeks.
- Displaced type 2 and 3 fractures are treated by surgery in which the fracture fragments are re-aligned and held with plate and screws.
- In Type 4 fractures an attempt is made to improve the alignment of the fracture by manipulation they are then treated similar to type 1 fractures. In these fractures perfect anatomy can not be restored because of multiple fragments, hence the goal of treatment is to get the patient mobile as quickly as possible.
Complications of calcaneus fracture can be either immediate or late.
Immediate complications include
- injury to the skin, nerves and blood vessels by displaced fracture fragments
- Compartment Syndrome in the foot
Late complications include
- arthritis of the subtalar and calcaneo-cuboid joints
- irritation and pressure over peroneal muscle tendons
- bone spur formation causing heel pain
Frequently Asked Questions
When can I suspect that I have a calcaneus fracture?
If after injury you have pain in your heel and your heel can not support your body weight then you probably have a fracture. I don't mean to say that you should try to stand on your heel. You can press your heel gently with your hands and if you have significant pain then the fracture probably has occurred.
What are the chances of developing arthritis after calcaneus fracture?
Intra-articular fractures with displacement have the highest chances of developing arthritis because the joint can become incongruous. Damage to cartilage at the time of injury can also lead to arthritis in undisplaced fractures and fractures that have been aligned by manipulation or surgery.
What is the treatment for arthritis?
Arthritis of the subtalar joint or calcaneo-cuboid is treated by fusion of the joint surgically. Fusion should only be done when pain is significant and affects daily activities.
What are the symptoms of peroneal tendon irritation?
Peroneal tendon irritation caused pain and swelling on the outer side of the heel. This occurs due to excessive widening of the bone. Treatment is by removing the excessive bone by surgery.
I hope the information provided was helpful. If you have any query about calcaneus fracture you can ask me at the contact me page.
This page was last updated on 23th June 2009.
Other causes of foot pain...
Tarsal Tunnel Syndrome
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