MANUAL MINORS
A calcaneus (heel bone) fracture is one of the most severe foot injuries, typically caused by high-energy trauma, such as falls from height or car accidents. As the calcaneus is the primary bone that bears the body’s weight while walking, a fracture in this area can have significant consequences for foot function and mobility. Symptoms include intense pain in the back of the foot, swelling, bruising, and difficulty or inability to walk.
Diagnosis
Diagnosis is based on the trauma history and physical examination, which reveals severe heel pain, swelling, and often foot deformity. X-rays are essential to confirm the fracture and assess the extent of the damage. CT scans are used to visualise complex fractures and guide surgical treatment, especially if the subtalar joint is involved.
Differential Diagnosis
Condition | Key Differentiation |
|---|---|
Talus fracture | Pain in the upper ankle, often associated with a fall, but localised more toward the ankle. |
Ankle sprain | Pain in the ankle without evidence of fracture on X-ray. |
Calcaneal contusion | Heel pain without visible fracture on X-ray, generally from minor impact. |
Plantar fasciitis | Pain in the bottom of the heel, most intense when getting up in the morning. |
Calcaneus stress fracture | Gradual heel pain, usually without major trauma, common in athletes or runners. |
Emergency Management
In the emergency department, initial management of a calcaneus fracture includes immobilising the foot with a posterior splint to prevent further displacement of bone fragments. Ice should be applied, and the affected leg elevated to reduce swelling.
Pain control is achieved with analgesics and NSAIDs. A neurovascular assessment of the foot is essential to rule out nerve or vascular injury.
If the fracture is open or vascular compromise is present, urgent surgical intervention is required for reduction and stabilisation. For closed, uncomplicated fractures, the patient should be referred to orthopaedics for definitive treatment evaluation.
Definitive Treatment
Definitive treatment depends on the severity of the calcaneus fracture:
Non-displaced fractures:
Conservative treatment: Immobilisation with a splint or orthopaedic boot for 6 to 8 weeks, with complete weight-bearing restriction on the affected foot. Radiological follow-up is essential to ensure proper healing.
Displaced or joint-involved fractures:
Open reduction and internal fixation (ORIF): For displaced fractures or those involving the subtalar joint (joint between the talus and calcaneus), surgical treatment is necessary to realign the bone fragments and restore foot anatomy. Plates and screws are used to stabilise the bones. Surgery is crucial to reduce the risk of complications like post-traumatic arthritis.
Open fractures:
These require surgical debridement, internal stabilisation, and antibiotic prophylaxis to prevent infections. This is a surgical emergency.
Rehabilitation
Rehabilitation is essential for recovering foot function after a calcaneus fracture. Weight-bearing on the injured foot should be avoided for the first few weeks following injury or surgery. Once bone healing begins, physical therapy focuses on improving mobility, strength, and balance. Range-of-motion exercises are vital to prevent stiffness in the subtalar joint and ankle.
Complications
Calcaneus fractures carry a high risk of complications, which may include:
Post-traumatic arthritis: Especially if the fracture involves the subtalar joint.
Avascular necrosis: Due to disruption of blood supply.
Infections: Primarily in open fractures.
Non-union: In complex or poorly aligned fractures.
With proper treatment, most patients can regain mobility, but some may experience long-term functional limitations, especially in cases of severe or complicated fractures.
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