FRACTURE OF THE CALCANEUS
What is it?
Fractures of the heel bone or calcaneus can be really debilitating injuries. When the heel bone is injured, it is typically caused by tremendous forces which impact on the foot, for example associated with falls from a height, or in a motor vehicle accident.
Imagine standing on an orange, and this is in effect what happens to the calcaneus, which essentially gets squashed flat, and then widens.
The joint between the calcaneus and the talus is called the subtalar joint. This joint is responsible for the inward and outward movements of the foot, otherwise called inversion and eversion. When the calcaneus is fractured, the movement of inversion and eversion is commonly decreased or lost completely.
The upward and downward movement of the ankle (dorsiflexion and plantarflexion) is not usually affected by fractures of the calcaneus.
These include widening and deformity of the bone itself, irregularity of the subtalar joint which leads to arthritis, and injuries to the heel cushion (the heel pad), as well as the nerves and tendons surrounding the heel.
Treatment of the calcaneus fracture
The ideal goal of treatment is to restore the dimensions of the heel as accurately as possible. This is always difficult because of the multiple fragments of bone that are commonly present. It is almost like trying to piece together a jigsaw puzzle.
However, surgery can be performed and for the majority of patients, surgery is the correct form of treatment. The goal of surgery is to restore the anatomic dimensions and structure of the heel, and this is performed by what is called an open reduction and internal fixation (ORIF) of the fracture with a plate and screws.
This improves the shape of the heel, decreases the likelihood of arthritis developing, and maximizes the potential for inward and outward movement of the foot.
There are times however when the bone is so severely smashed and fractures, that although surgery is indicated, in addition to the open reduction and internal fixation, the heel joint (the subtalar joint) is fused. This is performed to decrease the inevitable likelihood painful arthritis developing subsequently. Although the inversion and eversion movement of the foot is lost after a subtalar fusion, there is a more rapid return to activities and functions after this type of surgery.
There is another type of minimally invasive surgery which we perform to fix a calcaneus fracture which uses mini punctures or incisions on the foot. Instead of making a large incision on the heel which has a high complication rate, these punctures are made and screws are inserted into the bone. The reduction of the bone pieces and the fracture is always as good as when a large incision is made, but the risks of a problem with the healing are a lot less with the mini incision approach.
HOWEVER THIS IS NOT ALWAYS POSSIBLE IF IT IS A VERY SEVERE FRACTURE.
Surgery: general facts
- Surgery cannot be performed when there is marked swelling in the ankle.
- The ideal time to perform surgery is when there is minimal swelling of the skin, and frequently, surgery will have to be delayed for more than a week in order to perform surgery more safely.
- Sometimes we are able to perform surgery more quickly if we admit the patient to hospital and apply an ice pump called an intermittent compression foot pump.
- We will sometimes on rare occasions also wrap the foot in a special bandage called an Unna boot, and give the patient a fluid pill called a diuretic to decrease swelling.
- Surgery is performed under a general anesthetic and takes approximately 2-3 hours to perform.
- The surgical procedure is called an open reduction and internal fixation.
- The surgery is performed through an incision on the outside of the heel which exposes the side of the heel and the fracture. At times tiny punctures are made instead of a large incision or a mixture of the 2 incisions.
- The bone is put together and held in place with a metal plate and multiple screws.
- A large bandage is applied to the leg with plaster incorporated into the dressing to prevent movement of the ankle and decrease pain.
Post- operative recovery: General facts
- There will be a hard plaster bandage applied to the leg for 6-8 weeks after surgery.
- In order to stay off your foot, you will need to use crutches, a walker, a wheelchair or a scooter type device called a roll-about.
- Your first follow up visit will be at approximately 2 weeks to check the incision healing.
- I generally use absorbable stitches which did not need to be removed however if for whatever reason I used non-absorbable stitches these will be removed at approximately 2 weeks once the skin is healed.
- We will usually apply a below-knee cast for you to wear at this time for a period of approximately 6-8 weeks at which point he will be converted to Moon boot which will be used for a further 6 weeks.
- If the surgery is on your right ankle, you should be able to drive an automatic vehicle at 6 weeks. If the surgery is on the left ankle, you may drive between 8-10 weeks.
- Exercises of the foot and ankle are to be encouraged at about 6 weeks after surgery.
- You will not be putting weight on the leg for 6-8 weeks, but are allowed to be as mobile as you can, with crutches or a walker device.
- If you have access to a swimming pool, I encourage you to use this as soon as the incisions are completely dry and healed in addition to having the cast removed, which will be at about 8 weeks. Swimming will significantly improve your recovery and allow you to begin bearing some weight on the leg in the pool.
- You would remove the boot for twenty minutes three times a day to exercise.
- You may begin to walk without the boot at about 10 weeks at home.
- When walking, this is only in the boot, and never without support. You should plan to use a physical therapist for about 1-2 months.
- Physical therapy is important to regain the strength and movement.
- There will be moderate swelling of the ankle and leg for about 6-9 months.
- Stiffness of the subtalar joint is common after this surgery.
- You will continue to improve your strength and movement for about one year.
- You can expect to have some soreness, aching and stiffness for about 6 months.
- You may require removal of hardware at a later stage however this is not a must.
Exercise, work and activity after your calcaneus fracture
- For many individuals, a return to a very active lifestyle is difficult following this injury.
- For some, this may mean the ability to walk without pain and for others, a more regular exercise routine as well as working without restrictions may be more important.
- Some individuals are not able to return to a job which requires walking and climbing on uneven surfaces.
Specific post-operative recovery
- Foot is wrapped in a below knee splint with bandages.
- Elevate the leg on some pillows when awake however when sleeping elevate the base of the bed with 2 bricks or thick books so that the limb does not fall of the pillow at night and you wake up swollen.
- Apply ice packs.
- Take pain and DVT prophylaxis medication as prescribed.
- Expect numbness in foot 4-12 hours, followed by pain for usually one more day.
- Do not allow foot to hang down and under no circumstances bare weight.
- If you are travelling, move the toes as much as possible to stimulate the calf muscle however travel during this time is not advisable.
- First follow-up in the office.
- Wound inspection for any possible complications or irritable areas.
- Application of below-knee cast for 6-8 weeks.
- Strict non-weightbearing in cast with post-operative shoe and crutches initially to pain and swelling.
- Can allow foot to hang down at 3 weeks provided no pain and swelling occurs.
- Cast is removed by my dressing Sister and wound inspected.
- If incision is dry and completely healed, swimming is permitted for rehabilitation purposes taking care to not jump in the pool or apply any unnecessary force.
- Gentle exercise on bicycle or swimming in a pool with a flipper permitted preferably guided by physiotherapist.
- At this stage removable Moon boot is fitted and foot is prevented from taking excessive load and must be used for 6 weeks for any form of walking however patient does not need to sleep with this boot.
- 30lbs/13.63kgs body weight on the leg is allowed 5 minutes twice a day when washing/bathing.
- Control x-ray is taken.
- If swelling is problematic you may require the use of a compression sock.
- Start physical therapy under supervision with my protocols and this will focus on scar desensitisation and joint motion mostly.
- More vigorous exercise with Biokineticist for the next 8-12 weeks in order to achieve strength within 10% of the unaffected side hence clearing you for return to sport.
- Control x-ray is taken.
- Can discontinue boot at this stage and use a shoe with a supportive sole and a slight heel lift (heel cup) inside the sole of the shoe .
- May require gait analysis and custom orthotics to be made on an individual basis.
- Followup in my consultation rooms.
- Control x-ray is taken.
- Photographs and video taken of range of motion and strength.
- Final followup in my consultation rooms.
- Photographs are taken of range of motion and strength.
- Control x-ray is taken.
- Patient outcome score taken.
- Swelling and residual weakness can often be expected up until this point.
- Patient is usually discharged at this stage.