| disease | Calcaneous Fracture |
Adults are more commonly affected, often sustaining injuries from falls from heights or crush injuries. These injuries are frequently accompanied by spinal fractures, pelvic fractures, and injuries to the head, chest, and abdomen. It is crucial not to overlook these during initial diagnosis. The calcaneus, being a cancellous bone, has a relatively rich blood supply, making non-union rare. However, if the fracture line enters the articular surface or if reduction is poor, post-traumatic arthritis and pain during weight-bearing on the calcaneus are common.
bubble_chart Etiology
Calcaneal fracture is the most common among tarsal fractures, accounting for approximately 60% of all tarsal fractures. It is mostly caused by falling from a height, landing on the foot, and the heel suffering a vertical impact.
(1) Longitudinal fracture of the calcaneal tuberosity is mostly caused by the medial prominence of the tuberosity being subjected to shear force when the heel lands in an everted position after falling from a height. It rarely displaces and generally does not require treatment.
(2) Horizontal (beak-shaped) fracture of the calcaneal tuberosity is a type of avulsion fracture caused by the Achilles tendon. If the avulsed bone fragment is small, it does not affect the function of the Achilles tendon. If the fracture fragment exceeds one-third of the tuberosity, and there is rotation and severe tilting, or severe upward traction, surgical reduction and screw fixation may be performed.
(3) Fracture of the sustentaculum tali is caused by the impact from the inferomedial side of the talus when the foot is in an inverted position, which is extremely rare. Generally, there is little displacement. If there is displacement, it can be pushed back into place with the thumb and fixed with a short leg cast for 4-6 weeks.
(4) Fracture of the anterior part of the calcaneus is relatively rare. The injury mechanism is strong adduction of the forefoot combined with metatarsal flexion. An oblique X-ray should be taken to rule out avulsion fracture of the anterior superior process of the calcaneus, and a short leg cast can be applied for 4-6 weeks.(5) Fracture near the talocalcaneal joint is a fracture of the calcaneal body. The injury mechanism is also caused by falling from a height and landing on the heel, or the heel being subjected to an upward recoil force. The fracture line is oblique. On the anteroposterior X-ray view, the fracture line runs from posteromedial to anterolateral but does not pass through the talocalcaneal joint surface. Since the calcaneus is cancellous bone, the body of the calcaneus widens bilaterally on the axial view. On the lateral view, the posterior half of the calcaneal body along with the calcaneal tuberosity is displaced posterolaterally, causing the plantar surface of the calcaneus to bulge into a rocker-bottom shape.
The heel can become extremely swollen, the posterior ankle groove may become shallow, and the entire hindfoot may exhibit swelling and tenderness, which can easily be misdiagnosed as a sprain. In addition to taking a lateral X-ray, an axial view of the calcaneus should be taken to determine the type and severity of the fracture. Furthermore, since the calcaneus is a spongy bone, clear fracture lines may not be visible after compression, making it difficult to distinguish. Often, the severity of the fracture must be analyzed based on changes in the bone's shape and measurements of the tuberosity-joint angle.
The aforementioned fracture can be reduced under lumbar anesthesia by using the thenar eminence of both hands to compress both sides of the calcaneus, correcting the widening of the calcaneal body to both sides. Simultaneously, with the metatarsus in flexion, forcefully pull down on the calcaneal tuberosity to restore the tuberosity joint angle. After reduction, the lower leg can be immobilized with a Gypsum cast for 4 to 6 weeks.
For calcaneal compression comminuted fractures involving the subtalar joint, there are differing opinions on treatment, which can be summarized into four methods.
(1) Conservative treatment, also known as non-reduction exercise therapy. The injured foot is bandaged with an elastic bandage, and the affected limb is elevated. Early functional movement of the affected limb and weight-bearing with crutches are encouraged. Many believe that this method results in faster functional recovery and better outcomes compared to immobilization therapy. Most patients can resume normal activities within six months, and about 3/4 of patients can return to normal work. This method is particularly suitable for calcaneal compression fractures that do not involve the subtalar joint.
(2) Bone traction treatment. Under continuous traction of the calcaneal tuberosity, treatment is carried out according to the principle of early activity, which can reduce disability.
(3) Open reduction. Suitable for young people with lateral collapse fractures of the talus. The talar tuberosity angle and the width of the calcaneal body can be corrected first, followed by surgical correction of the joint surface. A lateral incision of the calcaneus is made to lift the collapsed joint surface to its normal position, and the cavity is filled with cancellous bone to maintain the reduction. Postoperatively, a tubular Gypsum cast is used for fixation for 8 weeks. Some believe that using seasonal epidemic internal fixation without Gypsum external fixation yields more satisfactory results.
The above methods are general principles, but calcaneal fractures involving the subtalar joint are highly irregular and cannot be correctly classified. Treatment methods are difficult to standardize, the rehabilitation period is long, and it is difficult to accurately evaluate the effectiveness of advanced stage treatments. Moreover, it is impossible to determine a specific effective treatment method for each type of fracture.
Traumatic Arthritis
Heel sprain
