Mechanism of injury and types of fractures
When landing on the heels, the talus wedges into the heel and splits it, pushing the articular surface down. As a result, the heel becomes wider, lower and turns outward, and the arch of the foot flattens. Such fractures are called intra-articular, and they determine the long-term prognosis. Extra-articular fractures involve the tubercle or processes of the calcaneus and are more easily tolerated. A separate option is an avulsion fracture of the tubercle, when the Achilles tendon tears off a fragment of bone; it requires urgent treatment because the stretched skin over the fragment can become dead.
- Intra-articular compression fractures are the most common
- Extra-articular fractures of the tuberosity and processes
- Avulsion fracture of the calcaneal tuberosity
- Bilateral fractures due to a fall from a height
- Stress fractures due to prolonged stress
- Pathological fractures in osteoporosis and diabetes
Symptoms
Immediately after the injury, severe pain occurs in the heel and it is impossible to support the leg. The foot quickly swells, bruising appears on the lateral surfaces of the heel and on the sole, which is considered a characteristic sign. The heel externally widens and flattens, the axis of the foot may change. Movement in the ankle joint is preserved, but turning the foot in and out is sharply painful. If the swelling is significant, the skin becomes tense and blisters may appear; in this condition, surgery is postponed until the swelling subsides.
- Severe heel pain and inability to gain weight
- Rapid swelling of the foot and ankle area
- Bruising on the sole and sides of the heel
- Widening and flattening of the heel
- Sharp pain when turning the foot
- Blisters on the skin with severe swelling
Diagnostics
X-rays of the calcaneus are performed in the lateral and axial projections, assessing the Böhler angle - an indicator that decreases when the articular surface is pressed. However, X-rays do not allow a full assessment of an intra-articular fracture, so the main method is computed tomography: it shows the number of fragments, the degree of displacement and the condition of the subtalar joint, and on its basis a decision is made about surgery. If you fall from a height, be sure to take pictures of the lumbar and thoracic spine and examine the second foot, even if it does not hurt.
- X-ray of the calcaneus in lateral and axial projections
- Calculation of Böhler angle
- CT scan of the foot and ankle
- X-ray of the spine after a fall from a height
- Examination of the second foot
- Assessment of skin and soft tissue condition
Treatment
Fractures without displacement are treated conservatively: elevated position of the leg, cold, anesthesia, fixation with a plaster splint or orthosis and complete exclusion of support for 6–8 weeks with ambulation on crutches. Movement in the toes and ankles begins early to avoid stiffness. In case of significant displacement and destruction of the articular surface, osteosynthesis is performed with a plate and screws; surgery is often postponed for 1–2 weeks until the swelling subsides, otherwise there is a high risk of suppuration and skin necrosis. For smokers and people with diabetes, the risk of complications is significantly higher, so minimally invasive techniques are sometimes chosen.
- Elevation, cold and pain relief in the first days
- Cast or orthosis without support for 6–8 weeks
- Walking on crutches with complete weight-bearing
- Osteosynthesis with a plate and screws during displacement
- Delaying surgery until swelling subsides
- Quitting smoking during treatment
Recovery and aftermath
The return of support occurs gradually, usually from 8–12 weeks, with the permission of the doctor and under the control of images. Rehabilitation includes restoring movements in the ankle and subtalar joints, strengthening the lower leg muscles, working on gait, selecting shoes and insoles that support the arch. Even with successful treatment, some people report pain when walking on uneven surfaces, limited rotation of the foot, and fatigue. When arthrosis of the subtalar joint develops with persistent pain, surgery to immobilize the joint is discussed. Returning to heavy physical work may take six months or longer.
- Gradual return of the load from 8–12 weeks
- Development of the ankle and subtalar joints
- Strengthening the muscles of the lower leg and foot
- Custom insoles and cushioned shoes
- Monitoring fusion using images
- Discussion of arthrodesis for persistent pain and arthrosis