Calcaneal fracture are a violation of the integrity of the calcaneus due to traumatic effects. Symptoms include pain and swelling of the heel area, expansion and flattening of the heel, inability to operate on the heel while maintaining the volume of movements of the ankle joint. Diagnosis is made by a traumatologist on the basis of complaints, examination results and radiography of the foot in 3 projections. Treatment includes the application of a plaster splint from the fingers to the knee, then physical therapy and massage.
S92.0 Calcaneal fracture
According to recent studies, calcaneal fracture account for 5.8% of the total number of fractures. They have a serious prognosis, post-traumatic flat feet and other consequences are often observed in the long term. Pathology is often combined with fractures of the lumbar and thoracic vertebrae, fractures, dislocations and fractures of the ankles. In 15% of cases, bilateral fractures of the calcaneal bones are detected. The treatment is carried out by specialists in the field of traumatology.
The cause of a calcaneal fracture is almost always a fall from a height in a standing position. The integrity of the bone is broken when the heels hit the ground. Very rarely, damage is observed as a result of a blow to the sole from below (for example, in an explosion). The severity of the fracture is determined by the height, surface features and strength characteristics of the calcaneus. In elderly patients with osteoporosis, trauma can occur with minor effects, for example, a foot slipping off a step or falling off a stool.
The calcaneus is the largest bone of the foot, bearing the bulk of the load when standing and walking. There are two main parts of the calcaneus: the body and the posterior tubercle. From above, the calcaneus is connected to the talus bone, from the front to the cuboid. The talus bone serves as a link between the calcaneus and the bones of the lower leg. When falling on the heels, the gravity of the whole body is transmitted through the bones of the lower leg to the talus bone, which wedges into the heel bone and splits it into pieces.
The type of calcaneal fracture and the direction of displacement of its fragments depend on the height of the fall and the position of the foot at the moment of impact on the ground. The impact of the traumatic force and the thrust of the triceps muscle of the lower leg lead to the displacement of the posterior parts of the bone upward, as a result of which the longitudinal arch is flattened. In the absence of reposition or the presence of residual deformation, this can cause a violation of the functions of support and walking after the fusion of fragments.
Fractures of the calcaneal bones can be compression, isolated and marginal, without displacement and with displacement of fragments. In modern traumatology and orthopedics, there are two large groups of injuries:
- Intra–articular – account for 80% of the total number of injuries to the calcaneus, include fractures, the line of which extends to the area of the subarticular joint.
- Extra–articular – are divided into fractures of the body and the tubercle of the calcaneus, the proportion of such injuries is 20%.
Fractures of the hillock, in turn, are divided into four groups:
- detachments of the median tubercle;
- fractures of the “beak” type.
The patient complains of pain in the heel area. Examination reveals a diffuse swelling of the heel area, rapidly spreading to the Achilles tendon, flattening and expansion of the heel, hematoma in the center of the sole. The contours of Achilles are smoothed out. The height of the foot decreases, and the width at the back increases. A few hours after the injury, bruises sometimes appear on the side surfaces of the foot (below the ankles)
Foot support is impossible. Movements in the ankle joint are preserved. Palpation of the heel is sharply painful. When squeezing the heel area in the transverse direction, the pain syndrome increases, becomes unbearable. With compression fractures and injuries without displacement of fragments, crepitation is not determined. In other cases, the presence of bone crunch is a variable sign.
The probability of complications increases in direct proportion to the degree of displacement of the heel fragments, depends on the quality of the reposition – with incomplete reduction of fragments and their secondary displacement, the risk of negative consequences increases. In the long-term period, patients often have post-traumatic flat feet. Intraarticular calcaneal fracture often cause the development of arthrosis of the subcutaneous joint.
The diagnosis is made by a traumatologist on the basis of anamnesis, objective examination data and the results of imaging studies. Heel injuries sometimes go unnoticed against the background of spinal and ankle injuries accompanied by vivid symptoms, so all patients with a characteristic mechanism of injury (falling to their feet from a height of more than 1.5 m) should be examined to exclude fractures of the heel bones. The survey plan includes:
- External inspection. In favor of the fracture, deformation of the heel area, the presence of diffuse edema and sharp soreness indicates. A pathognomonic sign is bone crunch.
- Calcaneal x-ray. To confirm the diagnosis and clarify the degree of displacement of fragments, radiography is performed in four projections: lateral, axial, oblique and anteroposterior. The severity of pathological changes is judged by the change in the angle of the Beler (the angle of the heel bone hillock) and the angle of the Gissan (the angle between the upper edge of the lateral part of the bone and the outer edge of the articular surface).
- Calcaneal CT. Allows you to specify the location of the primary fracture line of the heel, the number of character and displacement of fragments. It is prescribed to choose the optimal treatment tactics. It is produced in axial, coronary and sagittal projections.
Differential diagnosis of heel injury is carried out with fractures of the talus bone. The results of visualization studies play a crucial role.
Treatment is usually carried out in the conditions of the trauma department, it can be conservative or operative. The treatment program is determined by the type and severity of the heel fracture, includes an open or closed reposition (if there is a displacement), immobilization, anesthesia, a special regime, the use of additional means (crutches).
Fractures without displacement
Treatment of heel fractures without displacement and marginal fractures of the hillock is performed by conservative methods. After anesthesia of the injury site, a plaster boot with carefully modeled arches is applied to the leg. Analgesics are administered intramuscularly for anesthesia in the first days after injury. The patient is referred to physical therapy, UHF is prescribed. The plaster is removed after 8-10 weeks. The patient is recommended to wear orthopedic shoes with supinators for at least 6 months.
Compression and comminuted fractures
Treatment of complex intraarticular calcaneal fracture is associated with significant difficulties due to the difficulty of restoring the normal interposition of fragments and their retention until the moment of fusion. Taking into account the type of fracture and the nature of the displacement, the following methods can be used:
- Closed reposition. It is carried out using special manual techniques. First, the displacement along the length is eliminated, then the flattening of the heel, and finally the lateral displacement of the fragments. The limb is immobilized with a plaster cast.
- Simultaneous skeletal traction. Allows you to increase traction, increase the accuracy of manipulations. It is carried out with the help of one or two spokes, which are carried through the fragments. The spokes are fixed on staples, perform the above techniques, fix bone fragments with other spokes, apply a plaster bandage.
- Reposition by Ilizarov’s apparatus. It is indicated for stale heel injuries that cannot be eliminated by simultaneous reduction. It is produced within 1-2 weeks under regular X-ray control. In the future, treatment is carried out according to the same principles as with simultaneous stretching.
If conservative treatment is ineffective, surgical interventions are performed. Osteosynthesis of the calcaneus is performed using screws and reconstructive plates, metal structures are used with caution because of the great danger of complications. In the presence of bone defects, auto- or homocity transplantation is additionally performed. In case of complex long-standing injuries, an Ilizarov apparatus is applied for microdistraction of fragments for 2.5-3 months.
In the postoperative period, analgesics and antibacterial agents are prescribed. A mandatory part of treatment is physical therapy. Of the physiotherapeutic methods shown:
- local cryotherapy;
- ultraviolet irradiation;
- laser therapy;
- magnetic therapy.
The period of immobilization of complex calcaneal fracture is 3-4 months. After removing the plaster cast, it is recommended to wear support insoles to prevent flat feet. The total duration of the period of disability reaches 5-6 months.
With heel injuries without displacement, the prognosis is relatively favorable, with complex fractures with displacement of bone fragments, it is doubtful. In the long-term period, post-traumatic flat feet, deformities of the foot, arthrosis of the Chopar joint and the butt joint often develop. It is possible to form bony protrusions that violate the supporting function of the limb.
Preventive measures include measures to prevent falls from heights at home and at work. Prevention of complications in calcaneal fracture includes early access to medical care, strict adherence to medical recommendations regarding foot support in various phases of treatment, wearing supinators or orthopedic shoes during the rehabilitation period.