Inferior Extremity: Fractures of The Calcaneum

The calcaneum transfers the weight of the body to the ground. It is fixed to its normal place by the attachment of numerous ligaments and muscles. There may be considerable disability following injury to the calcaneum. The ultimate results vary according to the severity of the injury.

MECHANISM OF INJURY

This is produced by a fall from a height and landing on the feet. The striking force of the ground from below and the force of the body weight transmitted through the tibia and talus from above sandwich the calcaneum between two opposing forces.

ASSOCIATED INJURY

1. Fracture of the lumbar spine: The upward thrust tends to produce fracture of the spine. This involves mainly the upper lumbar vertebrae.
2. Fracture of the base of skull: The base of the skull may be another common site of injury. This intracranial lesion may make the patient lose consciousness. An unconscious patient with a history of injury must be examined for injury to the heel.
3. Fracture of the opposite heel: Fracture of both the calcaneums are not uncommon and the opposite heel must also be examined.

TYPE OF INJURY

There are various ways to classify the fracture of the calcaneum. The lesions may be:

1. Extra-articular: The fracture does not involve the subtalar joint.
2. Intra-articular: It involves the subtalar joint. One must be particular to recognize the involvement of the joint surfaces.
3. Extra-articular fracture: The fracture may be of displaced or undisplaced variety. The line of fracture may pass either in a vertical or in a transverse direction. The common fractures not involving the subtalar-joint are lesions of the medial tuberosity, sustentaculum tali, beak fracture, avulsion fracture near the insertion of the tendo Achillis and fractures involving the anterosuperior or antero-inferior part of calcaneum.
4. Intra-articular fracture involving the articular surface: The intra-articular involvement of fracture may show various characteristic features. There may be minimal involvement of the subtalar joint by the fracture or there may be severe comminution and crushing of the calcaneum with gross involvement. The fracture may include the anterior part, posterior part or whole of the subtalar joint. Sometimes this may produce comminution following a serious crushing injury.

DIAGNOSIS

Clinical finding: History of a fall from a height and landing on the feet, pain, swelling, bruising and tenderness over the heel may be characteristic. Bilateral fractures of the heel are not uncommon and must be kept in mind. Spine must be carefully examined for any associated injury.

X-ray: X-rays are taken from axial and lateral views.

Axial view: This is done through plantodorsal projection. This shows fracture in relation to the subtalar joint. Fractures involving the sustentaculum, medial tuberosity and any widening of calcaneum by the violence can be recognized by this view.

Lateral view: The normal tuber-joint angle formed by joining the oblique borders of the superior surfaces of calcaneum is normally about 40 0 (Fig. 210). There is diminution of the angle in case of fracture depression of the superior borders. Sometimes the fracture line may not be visible and the diminution of the angle gives the idea about the nature of lesion. Lateral view shows any fracture involvement of the joint, beak fracture and fracture of the anterior angles.

TREATMENT

Aim of the treatment is to prevent or minimize the development of subtalar and midtarsal joint stiffness and to obtain normal functioning joints. The treatment varies according to the type and nature of injury.

1. Simple plaster immobilization: Below-knee plaster is sufficient for a case of fracture which has not involved the subtalar joint. Beak fracture, when not displaced, can be treated by plaster with the foot in flexion. Walking heel can be fixed to the heel. Immobilization is maintained for 6-8 weeks. After removal of plaster, exercise of the foot and ankle can be instituted and crepe bandage is wrapped round the foot and lower part of leg to minimize the development of oedema.
2. Treatment by active exercise: This is indicated in cases of extra-articular fractures and also in lesions of comminuted varieties. The patient is put to bed with the leg in an elevated position. Compression bandage is applied with cotton wool and crepe bandage. This enables the swelling to disappear. Foot and ankle exercises are instituted from the beginning. The patient is allowed out of bed when the pain subsides. This technique is simple and is especially satisfactory for the elderly patients. Most patients can go back to work after six months.
3. Closed reduction: Manipulation and closed reduction are usually possible in a vertical fracture with separation of the medial tuberosity. In some cases beak fracture can be reduced by closed method but internal fixation appears to be the ideal procedure. Internal fixation requires orthopedic surgical instruments which can be obtained from the orthopedic instrument manufacturers.

Technique of closed procedure: Under general anaesthesia compression is applied on both sides of the calcaneum with the operator’s hands. The compression force’ helps to reduce the displaced fracture of the medial tuberosity. During reduction of the beak fracture the foot is plantar flexed and pressure is applied with both thumbs over both sides of the terminal end of tendo Achillis. This enables the fracture segments to come into the position of alignment. Below-knee plaster is applied in both cases. The foot is immobilized in a plantar flexed position in case of beak fracture. Plaster is removed after 8 weeks.

Operative management

• Internal fixation: Fixation by bone screw or wire is ideal in cases of beak fracture. Below-knee plaster with the foot in plantar-flexed position is maintained. Siora is one of the well-known names in the market for orthopedic bone screw manufacturers and suppliers.
• Open reduction: Open reduction and bone grafting to elevate the joint surfaces have been advocated. The results are far from satisfactory and the talocalcanean joint must be fused at a later period.
• Arthrodesis: Arthrodesis may be performed later after observing the outcome of the above-mentioned simple procedures.
• Primary excision of calcaneum: In severely shattered fracture, excision of the calcaneum has been reported with satisfactory results. The operation is performed as early as possible after the injury.