Fractures of the calcaneus can be debilitating injuries. Usually these fractures occur when tremendous forces impact the foot and damage the heel. Examples are falls from heights or motor vehicle accidents. Imagine standing on an orange and seeing it widen and squash flat. This is essentially what happens to the calcaneus.
The joint between the calcaneus and the talus is called the subtalar joint. This joint is responsible for the inward and outward movements of the foot, otherwise called inversion and eversion. When the calcaneus is fractured the movement of inversion and eversion is commonly decreased or lost completely. The upward and downward movement of the ankle (dorsiflexion and plantarflexion) is not usually affected by fractures of the calcaneus.
There are numerous problems associated with fractures of the calcaneus. One is the widening and deformity of the bone itself. Another is irregularity of the subtalar joint that leads to arthritis. Fractures to the calcaneus may also cause injuries to the heel cushion (the heel pad) and to the nerves and tendons surrounding the heel.
The ideal goal of treatment is to restore the dimensions of the heel as accurately as possible. This is always difficult because of the multiple fragments of bone that are commonly present. It is almost like trying to piece together a jigsaw puzzle.
For the majority of patients, surgery is the correct form of treatment. The goal of surgery is to restore the correct size and structure of the heel. This is done by performing what is called an open reduction and internal fixation of the fracture. The open reduction and internal fixation procedure is performed through an incision on the outside of the heel. The bone is put together and held in place with a metal plate and multiple screws. This procedure decreases the likelihood of arthritis developing and maximizes the potential for inward and outward movement of the foot.
There are times, however, when the bone is so severely smashed and fractured that, in addition to the open reduction and internal fixation, the heel joint (the subtalar joint) needs to be fused. This is done to decrease the chances of developing painful arthritis. Although the inversion and eversion movement of the foot is lost after a subtalar fusion, there is a more rapid return to activities and functions after this type of surgery.
The ideal time to perform surgery is when there is minimal swelling of the skin. We will often use a foot pump device applied to the foot for a few days to decrease the swelling. This allows us to perform the surgery as soon as possible.
Following surgery, no walking on the foot is permitted for approximately 3 months. A bandage is applied to the leg after surgery. After the stitches are removed, movement exercises and therapy are started to try to maximize the function of the foot. It typically takes approximately six months to recover from this type of injury.
Problems of the foot and ankle after calcaneus fracture
Following a fracture of the calcaneus, there are many potential problems which can occur. To some extent, this depends on the type of treatment provided. The problems which occur commonly are as follows: - Pain in the back of the heel on the outside of the ankle. This is present in the heel joint (the subtalar joint), and is usually because of arthritis in this joint.
- Stiffness in the subtalar joint. Regardless of the type of treatment, there is always some limitation of the in and out movement of the foot. This is called inversion and eversion. The problem occurs because of damage to the cartilage surface of joint, which is often associated with arthritis.
- Widening of the back of the heel and difficulty with wearing shoes. This problem occurs predominantly when surgery is not performed initially, and the heel remains wide and deformed.
- Pain on the outside of the heel and the outside of the ankle occurs due to injury to the tendons (the peroneal tendons). This is a more common problem when surgery is not performed initially, and is because of widening of the heel bone. The peroneal tendons can be torn in the process.
- Pain under the pad of the heel. This is unfortunately a permanent problem, since the specialized fatty cushion under the heel can be permanently damaged with injury. This can only be treated with correct cushioning and padding of the heel.
- Burning pain on the inside of the ankle. This can occur as a result of widening of the inside of the heel on the inside of the ankle, which causes irritation of the tibial nerve (called a tarsal tunnel syndrome)
- Pain in the ankle, which occurs in severe forms of fracture which are not treated with surgery. The heel bone is severely crushed, which leads to jamming of the front of the ankle.
Treatment of arthritis of the heel joint (the subtalar joint)
Arthritis of the heel joint will lead to pain in the outside of the ankle, and stiffness of the back of the foot. Walking on uneven ground surfaces is difficult since the inversion and eversion movement of the subtalar joint is missing. The treatments can consist of anti-inflammatory medication, injection of the subtalar joint with cortisone, special arch supports and heel cushions, and surgery. We have reported in the literature that when surgery is necessary to correct the problem, that the longer it takes to perform this surgery after a fracture of the calcaneus, the longer it will take to return the individual back to a more normal lifestyle, in particular heavy work. There are many different types of surgery which can be performed, and this is determined by the severity of the deformity, and the presence of arthritis.
