Calcaneal fracture

introduction

At a Calcaneal fracture (Calcaneus fracture) is a Fracture injury to the calcaneus, so one Part of the ankle.
Most of the time, such breaks arise through traffic accidents or one Fall from a great height. The resulting fracture usually prepares patients Big pain. Depending on the type of injury, a broken heel bone can either conservative (i.e. without surgery) or, more often, treated surgically become. Long-term consequences of this type of injury are not uncommon, at least with complicated fractures.

definition

A broken calcaneus is understood to mean that Fracture of the calcaneus anywhere.
A distinction is made between Impression fractures (in which the tibia is pressed onto the heel bone and therefore leads to a break relatively centrally) and Marginal fractures.
In addition, one can distinguish between one isolated fracture of the calcaneus (So ​​if no other damage has occurred, which always means that the joint is not involved, one speaks of one extra-articular fracture) and a broken heel bone, in which the joint (intra-articular fracture) or other structures such as the Achilles tendon (then also as Duckbill fracture designated) are also affected.

causes

The classic mechanism of injury that underlies a fractured calcaneus is a Fall from a great height. When landing, a great force is exerted on the heel bone, which it cannot withstand and ultimately breaks through. There is a so-called Impression break. Often times this fracture arises immediately both sides.
As a result, people who act accordingly are often affected high-risk sports perform, such as parachutists or climbers. Sometimes, on the other hand, a false landing following a “normal” jump is enough to cause a broken heel bone.
Depending on the course, you can also some traffic accidents associated with a fractured temporal bone. Through a Ankle twisting A calcaneal fracture can also occur, but in such a case a marginal fracture of the heel bone usually occurs.

More rarely, a petrous bone fracture occurs on the floor of an existing one Fatigue of this bone, like for example in the context of a osteoporosis can occur. Then there is no need for as much external force as usual, because the previously damaged bone breaks faster.

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My name is dr. Nicolas Gumpert. I am a specialist in orthopedics and the founder of .
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Athletes (joggers, soccer players, etc.) are particularly often affected by diseases of the foot. In some cases, the cause of the foot discomfort cannot be identified at first.
Therefore, the treatment of the foot (e.g. Achilles tendonitis, heel spurs, etc.) requires a lot of experience.
I focus on a wide variety of foot diseases.
The aim of every treatment is treatment without surgery with a complete recovery of performance.

Which therapy achieves the best results in the long term can only be determined after looking at all of the information (Examination, X-ray, ultrasound, MRI, etc.) be assessed.

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Symptoms

The main symptom of a broken calcaneus is that painwhich starts immediately after the triggering event in the affected heel. This pain is often so severe that it causes a Occurrence with stress, therefore a standing and a walking, impossible power.
The mobility of a part of the ankle joint, namely in the joint between the heel bone and the ankle bone, is partially or completely eliminated, at least if the fracture is accompanied by joint involvement.
Often times the damaged heel falls through one swelling or one Broadening in the area of ​​the fracture or one bruise (Hematoma) on. In addition, there may be deformation of the Foot, for example one Flat foot, come.

More signs

A Calcaneal fracture is a very serious fracture which usually only occurs as a result of strong external trauma such as a fall from a great height. The first signs of a broken heel bone are severe pain in the area of ​​the back of the foot, especially when stepping on it. On the other hand, it happens very quickly major swellings in the area of ​​the calcaneus (Calcaneus) as well as to Bleeding (Hematomas). These hematomas can extend over the entire area of ​​the heel bone and into the lower leg. The swelling can also get bigger and include the lower leg.

If there is also severe muscle swelling, the lower leg muscles may squeeze nerves, which in turn leads to it Numbness comes in the area of ​​the foot or the lower leg. Such muscle swellings (medically referred to as compartment syndrome) must be taken extremely seriously and must be treated surgically immediately with the help of a relief incision, otherwise permanent nerve and vascular damage can occur, which in the worst case can lead to amputations.
In some cases, a fracture of the heel bone results in what is known as an open fracture, in which parts of the heel bone are pushed outward through the skin, making the bone visible. Most often, however, are the first signs of a broken heel bone swelling, Incapacity, Pain and Hematomas.

diagnosis

In order to make the diagnosis of a broken calcaneus, the patient is first of all asked exactly about his complaints and how it came about, for example, whether an accident has occurred that can be directly linked to the symptoms.
Subsequently the doctor examines the heel, looks for any swelling and bruises that may be present and checks whether and if so how far they are Mobility of the ankle is restricted.
Subsequently, if a heel bone is suspected, a X-ray in two planes take place (i.e. once from the front and once from the side). However, the X-ray image alone is often not sufficient to make an accurate diagnosis. Therefore most of the time there is a Computed Tomography (CT) or Nuclear spin or magnetic resonance tomography (MRI) necessary.
With the help of this procedure, the fracture including any accompanying injuries can be assessed more precisely, it can be classified and the further procedure can be planned based on these results.

You can find more information on our website MRI of the foot.

Differential diagnoses / alternative diagnoses to the calcaneus fracture

We have summarized all the causes and diagnoses that can lead to heel bone pain in our own topic heel bone pain.

therapy

The Calcaneal fracture therapy depends on the severity and the shape of the injury. In principle, both conservative (non-surgical) and surgical treatment are possible for this clinical picture.

First of all, the treatment begins on the spot and, as with most traumatic injuries, is based on the so-called "PECH scheme“, Which every person concerned can do himself before consulting a doctor. This stands for:

• P like Break: immobilizing the foot and stopping any stressful activities
• E like ice: a cooling of the affected area
• C like Compression: Apply pressure to the painful area, if necessary with a pressure bandage
• H like Elevate (Put your feet or legs up)

The majority of calcaneal fractures must surgically supplied become.
A conservative treatment is only preferred if the Break uncomplicated (i.e. if there is neither a debris fracture nor a joint involvement with a step formation of the joint surface).
Another reason for purely conservative therapy is if Contraindications to surgery exist, for example if a Soft tissue infection exists or if the patient is in a poor general condition which would be associated with an excessive surgical risk.
For a person affected this means that he has a Lower leg cast which he usually gets put on ten to twelve weeks must wear and that the leg for one stored up for a long time and chilled must become.
Additionally should Medication which can reduce the pain and reduce the swelling.

If the Rupture postponed (dislocated) is and no contraindications If you are against a surgical procedure, surgery is usually carried out. Usually come with breaks large fracture fragments Wires or plates are used, with the help of which the individual pieces can be fixed after all elements have been returned to their original position (repositioning).
The aim is always to make the ankle look the way it did before the injury. that this procedure is called (Plate) osteosynthesis designated.
Any small bone fragments that may have arisen, however, are removed. Should the Achilles tendon torn off (and possibly also have a small piece of bone torn out), this condition is usually resolved with the help of a Screw fixation provided.
At a Involvement of the joint Parts of the bone between the heel and talus may have to be refilled (Cancellous plastic) to ensure a certain stability.

Heel fracture surgery

With a broken calcaneus there is two possibilities treat this. For one thing, there is conservative method of treatment in the case of the leg especially elevated will and at the cooling and Lymphatic drainage act sufficiently decongestant to let the break grow together by itself. More often, however, a fractured calcaneus becomes one Therapy through surgery devices. During the operation of the calcaneus fracture, the surgeon must first know the starting position of the fracture. Small breaks can with Wires or more often with plates In contrast, open calcaneal fractures are treated with a so-called External fixator should be treated as this ensures maximum stability.

Before the Operation of the calcaneus fracture the swelling in the foot must have decreased significantly. So before an operation can take place, the patient must put your foot up for about a week, cool with ice and also a Lymphatic drainage receive. Only after adequate decongestion the fracture of the heel bone can then take place.
During the operation a about 4-5 cm large cut made on the outside of the heel bone. The patient therefore lies on their side during the operation so that the surgeon has a better view of the calcaneus. To prevent excessive bleeding, a so-called tourniquet in the thigh area created.
To a good view To get the heel bone fracture and the lower ankle joint must be in the operating room first Layers of fat and muscles exposed become. Only then does the surgeon get a good view of the calcaneus fracture. Should smaller fragments of bone are present, they are removed. Then the calcaneus is reconstructed and put back together so that it receives its physiological shape and the fragments are as close together as possible so that they can then heal better.

Most of the time a Titanium plate placedwhich is then fastened with screws. In patients at high risk for Wound healing disorders (Smoker, chronic venous insufficiency, diabetic...) sometimes only small incisions are used, through which wires are inserted, which in turn are supposed to sufficiently stabilize the calcaneus. However, surgery of the calcaneus fracture using a titanium plate and screws is safer and more frequently used. Then the wound is closed again and the patient is afterwards for inpatient for about a week recorded.

Duration of healing

A calcaneal fracture is a serious fracture that should not be taken lightly as there are patients in whom the fracture does not heal properly despite adequate treatment. Especially after-effects like premature joint wear (Arthrosis) can lead to the fact that the duration of the heel bone fracture does not only refer to the actual phase of bone growth, but that the heel bone fracture leads to a permanent change in living conditions. Depending on how strong the heel bone (Calcaneus) is broken, becomes a conservative therapy or one operative therapy prefers.

The time it takes to heal a fractured calcaneus therefore also depends on the type of therapy chosen.
In patients with a “straight” fracture or in patients who suffer from previous illnesses like the Diabetes (Diabetes mellitus) could lead to wound healing disorders, conservative therapy is preferred. This involves putting the foot up, cooling it and administering painkillers. Lymph drainage is also done to reduce the swelling in the foot. At this conservative therapy is the duration the healing of the calcaneus fracture about 6-12 weeks. In younger patients, in whom the heel bone has erupted for the first time, 6 weeks are usually sufficient, in older patients who may also have comorbidities such as diabetes, the healing time can then be longer than 12 weeks.
It is also important to know that even after 12 weeks the healing may not be complete and that the healing process may then also stop and the patient then has to live with the long-term consequences. Normally, however, after 12 weeks of healing, the patient should be able to fully load the foot again.

Usually, however, the surgical approach is preferred. Before the operation, the foot must first be made to swell by lifting it up and cooling it. This takes about one to two weeks. Even with that surgical procedure, the healing time after the operation is about 6-12 weeks. However, physiotherapeutic measures can already be started after the first week. However, since the complete healing of the heel fracture can take up to 6 months, it is important that the patient after 6 months With extreme athletic stresssuch as jogging or playing football, as otherwise the risk of late complications is too high.

course

Following an operation, the patient may remove the affected leg just minimal load.
This means that the leg initially weighs no more than 10 to 15 kg approximately only partially exposed for six weeks may be.
There are also shoes especially for such injuries, so-called "Heel relief shoes"That are recommended to patients. To aid the healing process, you should also decongestant drugs should be taken if pain persists is the Use of pain medication displayed. In addition, the leg should occasionally be raised because this is the Wound healing promotes.

The long-term course and prognosis of a calcaneus fracture are heavily dependent on the severity of the injury.
Uncomplicated fractures heal completely in up to 90% of cases and without consequences.
At complicated fractions Unfortunately, there is one more often long-term course.
The fracture can lead to a Joint wear (arthrosis) come between the heel and the talus. Such osteoarthritis can be quite painful and must be helped by insoles or orthopedic shoes.
Further possible long-term consequences are Misalignments of the foot.

All of these complications can occur both after conservative and surgical therapy.

Calcaneal fracture, orthosis

At a Calcaneal fracture Therapy can take place through surgery or conservatively through rest. In both cases a so-called Orthosis or, in this case, heel relief orthotics increase the patient's quality of life and help the patient not to be too immobile despite the fracture.

An orthosis is one orthopedic shoe which one for the patient individually is made and in this case the heel bone is completely relieved after the break. In contrast to a cast, the patient can use this heel relief orthosis run smoothly and is thus can be mobilized again faster what especially as Anti-thrombosis prophylaxis is very useful. An orthosis is used after a broken heel, regardless of whether the patient has been operated on before or whether the broken heel has been treated conservatively.

An orthosis can also be used in the case of a bilateral fracture of the heel bone as the patient is able to move around continuously and does not need a wheelchair to keep both heels still. In addition, a heel relief orthosis can also be used to stiffen the lower ankle joint, which is sometimes necessary if the heel bone fracture does not heal completely as desired.

Heel fracture, long-term consequences

The Long-term consequences of a fracture of the heel bone are not to be underestimated and unfortunately occur quite often with such a complicated fraction compared to other fractions.

If a patient decides in favor of surgical therapy, he must deal with the usual Long-term consequences expect an operation. On the one hand, after the operation of the fracture of the heel bone, a blood clot can form in the veins in the leg, which is only lying still in bed, because the veins can no longer pump the blood up from the feet because the leg's muscles are working. That blood clot, which one too thrombus is called because it consists of red blood platelets, the thrombocytes, can now get into the lungs and cause a pulmonary embolism here, which in the worst case is fatal. Since the leg must always be immobilized after a heel fracture, the patient also receives anti-thrombosis injections and thrombosis stockings to avoid the long-term consequences of a pulmonary embolism after a heel fracture.

Another dreaded long-term consequence of a broken calcaneus is Wound healing disorders. These are particularly common Smokers or Diabetics in front. It is possible that the wounds do not heal properly after the operation and, in the worst case, become severely infected. In this case, only a high-dose antibiotic therapy, which is administered via the vein, and in the worst case, a new operation in which the wounds are cleaned in the sterile operating room can help.

An additional late consequence in one Calcaneal fracture is not one adequate coalescence the fragments of the calcaneus, which can then lead to the patient having permanent problems walking and / or developing a misalignment of the foot. Such a malfunction is a fairly common long-term consequence of a calcaneus fracture compared to other fractures and should therefore always be considered. Due to the incorrect healing it can lead to premature joint wear (arthrosis) come in the lower ankle. Another long-term consequence of a broken heel bone is that the patient, due to premature osteoarthritis in the lower ankle joint after the operation, can only move the affected leg with pain within a few months or years, or requires another operation to counteract the osteoarthritis. A stiffening and a very painful lower ankle joint are further possible long-term consequences of a broken calcaneus.

prophylaxis

Ultimately, there is not much you can do to prevent a heel fracture other than avoiding sports that put you at increased risk for the injury.
In addition, underlying diseases such as osteoporosis, which predispose to fractures in general and therefore also to heel fractures, should be treated appropriately.