Please help, I've broken my heel bone!

[mneagle]

Enough of the bickering.

 

Jens, go to an ortho foot doctor and let us know what happens.

 

Here's a relatively modern (2003) summary concerning calcaneus fractures from an orthopoedic textbook. It should leave you with the right questions to ask the surgeon. When I was working in the ER it seemed like they were doing more surgery, but it sounds like there is still some debate about closed vs. open treatment. It would be important to let the surgeon know that you intend on returning to rock climbing and other athletic activities. This may be important in determining how to proceed. (See below under treatment and decision making for details on this.)

 

 

Canale: Campbell's Operative Orthopaedics, 10th ed.

 

Copyright © 2003 Mosby, Inc.

Chapter 86 – Fractures and Dislocations of Foot

 

G. Andrew Murphy

 

Fractures of Calcaneus

The appropriate care of calcaneal fractures continues to be an unresolved dilemma. The history of the treatment of these fractures is characterized by periods of enthusiasm for surgical intervention followed closely by periods of advocacy of closed treatment methods. Since the early 1990s enthusiasm for certain surgical procedures for carefully selected fractures in appropriate surgical candidates has increased. As technology in imaging has improved, we have learned more of the anatomical features of these fractures, and now several objective studies in the literature with sufficient follow-up recommend surgical treatment for some fractures.

 

MECHANISM

Calcaneal fractures can be extraarticular (not involving the subtalar joint) or intraarticular (involving the subtalar joint). Extraarticular fractures involving the body, anterior process, or tuberosity should be treated with cast or brace immobilization and non-weight-bearing for the first 6 weeks. An exception to this is the displaced tuberosity avulsion fracture, which serves as the attachment of the tendo calcaneus ( Fig. 86-1). Open reduction and internal fixation of this fragment with a large partially threaded cancellous screw is advised to restore the power of the tendo calcaneus and prevent a wide heel with the ensuing difficulties of shoe-fitting. Another extraarticular fracture that may need early intervention is the avulsion of the anterior process of the calcaneus by the bifurcate ligament. Minimally displaced fractures of the anterior process are easily missed and should be suspected in a patient who does not recover appropriately from a lateral ankle sprain. If the fragment is small or diagnosis is delayed, this fragment can be simply excised.

 

Intraarticular fractures account for approximately 75% of calcaneal fractures and have historically been associated with poor functional outcome. These fractures are uniformly caused by an axial load mechanism such as a fall or a motor vehicle accident and may be associated with other axial load injuries such as lumbar, pelvic, and tibial plateau fractures. Cadaver studies, anatomical dissections, and the use of computed tomography (CT) have allowed a detailed description of the mechanism of injury and the resulting fracture patterns ( Fig. 86-2 ). The contact point of the calcaneus is situated lateral to the weight-bearing axis of the lower extremity. As an axial load force is applied to the posterior facet of the calcaneus through the talus, shear forces are directed through the posterior facet toward the medial wall of the calcaneus ( Fig. 86-3). The ensuing fracture (primary fracture line) is almost always present and extends from the proximal, medial aspect of the calcaneal tuberosity, through the anterolateral wall, usually in the vicinity of the crucial angle of Gissane. The most variable aspect of this fracture line is its position through the posterior facet of the calcaneus; it can be located in the medial third near the sustentaculum tali, the central third, or the lateral third near the lateral wall. As the axial force continues, two things happen: the medial spike attached to the sustentaculum is pushed farther toward the medial heel skin, and various secondary fracture lines occur in the region of the posterior facet. Often an anterior fracture extends toward the anterior process and may exit into the calcaneocuboid joint. The additional fractures of the posterior facet can be divided into two types, as described by Essex-Lopresti ( Fig. 86-4). If the fracture line producing the posterior facet fragment exits behind the posterior facet and anterior to the attachment of the tendo calcaneus, the injury is called a joint depression type ( Fig. 86-4, B ). If it exits distal to the tendo calcaneus insertion, it is called a tongue type ( Fig. 86-4, C ).

 

As the talus pushes the posterior facet and the underlying thalamic fragment into the body of the calcaneus, it also pushes out the lateral wall, closing down the space for the peroneal tendons and occasionally abutting the fibula. As the force is removed, recoil of the talus occurs, leaving a depressed, thalamic fragment, and the medial spike is retracted into the soft tissues. For this reason, medially open fractures of the calcaneus require deep dissection to thoroughly expose and irrigate the medial spike. Simply excising the skin wound in this injury results in inadequate debridement.

 

ROENTGENOGRAPHIC EVALUATION

Roentgenographic evaluation of the fracture should include five views. A lateral roentgenogram is used to assess height loss (loss of Böhler angle) ( Fig. 86-5) and rotation of the posterior facet. The axial (or Harris) view is made to assess varus position of the tuberosity and width of the heel. Anteroposterior and oblique views of the foot are made to assess the anterior process and calcaneocuboid involvement. A single Brodén view, obtained by internally rotating the leg 40 degrees with the ankle in neutral, then angling the beam 10 to 15 degrees cephalad, is made to evaluate congruency of the posterior facet ( Fig. 86-6). For surgeons experienced in the care of these fractures, three roentgenograms may be sufficient, but most often CT scans are obtained to evaluate the injury completely. The scans should be ordered in two planes: the semicoronal plane, oriented perpendicular to the normal position of the posterior facet of the calcaneus, and the axial plane, oriented parallel to the sole of the foot ( Fig. 86-7 ).

 

CLASSIFICATION

With increasing use of CT scanning for these fractures, more complex classification systems have been developed that have been shown to have prognostic value in the treatment of these injuries. While the Essex-Lopresti system has been used for many years and is useful in describing the location of the secondary fracture line, it does not describe the overall energy absorbed by the posterior facet, demonstrated by comminution or displaced fragments ( see Fig. 86-4). Classification systems by Crosby and Fitzgibbons, and Sanders have become more widely accepted in evaluation of these fractures ( Fig. 86-8 ). Both classifications are based on CT scans and describe comminution and displacement of the posterior facet. The advantage of the Sanders classification is its precision regarding the location and number of fracture lines through the posterior facet. However, both systems lack descriptions of other important aspects of these fractures, namely, heel height and width, varus-valgus alignment, and calcaneocuboid involvement. Although CT scans have become valuable in the evaluation and classification of these fractures, it should be emphasized that correlation with plain roentgenograms is mandatory. Ebraheim et al. demonstrated that a CT scan may underestimate sagittal plane rotation of the depressed fragment. For this reason, plain lateral roentgenograms must be used to scrutinize the displacement seen on a CT scan.

 

TREATMENT

Closed treatment of intraarticular calcaneal fractures includes closed manipulation and casting, compression dressing and early mobilization, traction-fixation, manipulation as recommended by Böhler, and pin fixation as recommended by Essex-Lopresti. Closed treatment methods have been successful in some studies. Omoto et al. reported success in 11 of 12 patients treated with his manipulation technique. Aitken reported 75% return to employment using methods similar to those described by Böhler. Kundel, Brutscher, and Bickel compared the results of 30 patients treated operatively with 33 patients treated nonoperatively. Age, associated trauma, calcaneocuboid joint involvement, Böhler angle (postinjury), workers' compensation status, percentage of joint depression, and tongue type were compared. The authors specifically excluded patients with comminuted fractures. They found that the only statistically significant advantage of operative over nonoperative treatment was the ability of patients to return to their previous occupation. They also noted that those who had near anatomical reductions with normal restoration of Böhler angle did better than those who did not have anatomical reductions, and they concluded that open reduction and internal fixation of intraarticular calcaneal fractures can be expected to benefit only those patients with near-anatomical reconstruction. Crosby and Fitzgibbons compared 23 type II intraarticular calcaneal fractures treated with open reduction and internal fixation with 10 type II fractures treated with closed methods. The fractures treated with open reduction and internal fixation had superior results to those treated by closed means. Thordarson and Krieger also had similar results in a small prospective, randomized series with follow-up of only 17 months for operatively treated fractures and 14 months for nonoperatively treated fractures. Results were statistically better after open reduction and internal fixation through the extensile lateral approach than after nonoperative treatment. Essex-Lopresti recommended treatment on the basis of displacement and type of fracture as follows: (1) conservative treatment for nondisplaced or minimally displaced fractures with early range of motion, (2) axial fixation with a metallic pin for tongue-type fractures, and (3) open reduction and internal fixation for joint depression fractures. Although the debate over open or closed treatment of calcaneal fractures may continue for some time, most authors would agree that the inability to surgically obtain and maintain an anatomical reduction of the posterior facet is probably associated with a worse outcome than closed nonoperative treatment.

 

Open reduction can be obtained through a medial approach (McReynolds, Burdeaux), combined medial and lateral approach (Stephenson, Romash), or a lateral approach alone (Benirschke and Sangeorzan, and Sanders et al.). Also, success after open reduction followed by immediate arthrodesis has been reported by several authors.

 

Decision Making in Calcaneal Fractures

Goals common to all types of treatment of calcaneal fractures are as follows: (1) restoration of congruency of the posterior facet of the subtalar joint, (2) restoration of the height of the calcaneus (Böhler angle), (3) reduction of the width of the calcaneus, (4) decompression of the subfibular space available for the peroneal tendons, (5) realignment of the tuberosity into a valgus position, and (6) reduction of the calcaneocuboid joint if fractured.

 

Factors to be considered in formulating a treatment plan are as follows:

 

Age of the patient. Most of these injuries occur in patients younger than the physiological age of 50 to 55 years. Older patients should, in general, have closed treatment.

 

Health status. An insensate limb caused by either trauma (sciatic or tibial nerve disruption) or disease (diabetes or other neuropathy) is a strong relative contraindication to open treatment. Patients with limited ambulation as a result of other medical conditions likewise should be treated closed.

 

Fracture pattern. Sanders Type I or nondisplaced fractures should be treated closed. Types II and III fractures can be treated with open reduction. Type IV can be treated either closed or, in experienced hands, with open reduction and immediate arthrodesis.

 

Soft tissue injury. As described earlier, fractures that are open medially require more aggressive debridement than simple opening of the wound to wash out the soft tissue. The medial spike should be exposed and debrided. It is better to wait 2 to 3 weeks until the wound is stable before internal fixation is attempted. Open treatment should not be performed through tight, swollen soft tissues and certainly not in the region of fracture blebs. The report by Levin and Nunley is an excellent guide to evaluation and management of more complex soft tissue problems.

 

Surgeon's experience. Sanders et al. have confirmed that the learning curve for this fracture is somewhat steep, and with substantial literature supporting closed methods of treatment, a thorough knowledge of the anatomy and clearly defined goals are necessary for a successful outcome.

[sk]

we can all speculate but what really mattes is that Jens does what he is comfortable doing, seeks the medical help he desires and heals. just because some of us my have had difficult instances when we broke something does not mean everyone will. sometimes a broken bones is just a broken bone.

 

lets not forget how terribly mikey broke his feet. I think he has just as much personal experience and anecdotal experience as any of us.

[layton]

I shattered all of my metatarsals on both feet, and required surgery immediately (ok 2 weeks later after the swelling went down).

 

Jens hasn't provided enough info on what type of fracture and where the fracture was for any good reccomendations. The x-ray doc should have given him a follow up which...he should follow.

[Jens]

I'm back from my 3 hour surgery on my calcaneal fracture (broken heel).

They tell me that the surgery was succesful. Since it is my right leg I can't drive for a few months

----------------

I'm eager for visitors and I might even divuldge secret new route opportunities from my "little black book" to those who come over and can tolerate my chestbeating.

-----------------

For any kind soul so inclined, I'd reall enjoy a lift to any of the upcoming pub clubs and or cc.com events. I'm in Ballard and my house is easy to find.

thanks for all responses to helping me know what to ask the doctors

take care

Jens

PS. As soon as my energy returns, I'm also looking to carpool with anyone to the Seattle Vertical World so I can play on the hangboards and lift weights. If anyone is coming from the north, I am about 1 mile from the gym and just a dash off 15th.

[sk]

i am glad to hear the surgery went well

 

to a speedy recovery

[rhyang]

I'm back from my 3 hour surgery on my calcaneal fracture (broken heel).

They tell me that the surgery was succesful. Since it is my right leg I can't drive for a few months

 

Congrats ! re: driving - when I broke my left talus, I could not operate the clutch in my standard-transmission car. However, I had a hand-operated lever installed under the dash by a company that does this kind of thing (obviously I had to get used to shifting before/after turns, but that's another story ...) I don't know who could do that in the PNW however, nor if that would work at all for the right side (or if it would fit on your car)

[catbirdseat]

Jens, I'd be happy to give you a lift to a Pub Club, if we ever have another one. Isn't it about time? Dave!