Calcaneus (Heel Bone) Fractures

Fractures of the heel bone, or calcaneus, can be disabling injuries.

They most often occur during high-energy collisions — such as a fall from height or a motor vehicle crash. Because of this, calcaneus fractures are often severe and may result in long-term problems.

The calcaneus is the most frequently fractured tarsal bone. Tarsal bone fractures account for about 2% of all adult fractures. Of these, 60% are calcaneus fractures.

The heel bone is often injured in a high-energy collision where other parts of the skeleton are also injured. In up to 10% of cases, the patient can also sustain a fracture of the spine, hip, or the other calcaneus.

Injuries to the calcaneus often damage the subtalar joint and cause the joint to become stiff. This makes it difficult to walk on uneven ground or slanted surfaces.

Types of Fractures

The severity of a fracture usually depends on the amount of force that caused the break. There are many types of calcaneus fractures, including:

Stable fracture. This type of fracture is nondisplaced. The broken ends of the bones meet up correctly and are aligned. In a stable fracture, the bones usually stay in place during healing.

Displaced fracture. When a bone breaks and is displaced, the broken ends are separated and do not line up. This type of fracture often requires surgery to put the pieces back together.

Open fracture. Broken bones that break through the skin are called open, or compound. These types of injuries often involve much more damage to the surrounding muscles, tendons, and ligaments. Open fractures have a higher risk for complications and take a longer time to heal.

Closed fracture. With this injury, the broken bones do not break the skin. Although the skin is not broken, internal soft tissues can still be badly damaged.

Comminuted fracture. This type of break is very unstable. The bone shatters into three or more pieces.

Cause

The calcaneus can be injured in a fall, twisting injury, or motor vehicle collision. A simple twisting injury may result in the calcaneus being cracked. The force of a head-on car collision may result in the bone being shattered (comminuted fracture).

Different causes can result in similar fracture patterns. For example, when landing on your feet from a fall, your body’s weight is directed downward. It drives the talus bone down into the calcaneus. In a motor vehicle crash, the calcaneus is driven up against the talus. In both cases, the resulting fracture patterns are similar. The greater the impact, the more the calcaneus is damaged.

Symptoms

The most common symptoms of a calcaneus fracture are:

  • Pain
  • Bruising
  • Swelling
  • Heel deformity
  • Inability to put weight on the heel or walk

In some minor calcaneus fractures, the pain is not enough to stop you from walking, but you may limp. This is because when you walk, the Achilles tendon acts through the calcaneus to support your body weight. If the calcaneus is deformed following an injury, the muscle and tendon cannot generate enough power to support your weight. Your foot and ankle will feel unstable, and you will walk differently.

Diagnosis

It is important that your doctor knows the circumstances of your injury. For example, if you fell from a tree, how far did you fall?

It is just as important for your doctor to know if you have any other injuries or medical problems, such as diabetes.

Your doctor also needs to know if you take any medications.

Other tests that may help your doctor confirm your diagnosis include:

X-rays. This test is the most common and widely available diagnostic imaging technique. X-rays create images of dense structures, like bone, so they are particularly useful in showing fractures.

Computed tomography (CT) scan. After reviewing your x-rays, your doctor may recommend a CT scan of your foot. This imaging tool combines x-rays with computer technology to produce a more detailed, cross-sectional image of your body. It can provide your doctor with valuable information about the severity of the fracture. Studying CT scans helps your doctor plan your treatment. He or she will often show you the images to help you understand the nature and severity of your injury.

Treatment

In planning your treatment, your doctor will consider several things, including:

  • The cause of your injury
  • Your overall health
  • The severity of your injury
  • The extent of soft tissue damage

Because most calcaneus fractures cause the bone to widen, the goal of treatment is to restore the normal anatomy of the heel. In general, patients whose normal heel anatomy is restored have better overall outcomes. Recreating normal anatomy, however, most often involves surgery. Surgery is associated with a higher risk of complications.

Your doctor will discuss the treatment options with you.

Nonsurgical Treatment

If the pieces of broken bone have not been displaced by the force of the injury, you may not need surgery. Casting or some other form of immobilization may be an option. This will keep the broken ends in proper position while they heal.

You will not be able to put any weight on your foot until the bone is completely healed. This may take 6 to 8 weeks, and perhaps longer.

Surgical Treatment

If the bones have shifted out of place (displaced), you may need surgery.

If the skin around your fracture has not been broken, your doctor may recommend waiting until swelling has gone down before having surgery. Keeping your leg immobilized and elevated for several days will decrease swelling. It also gives skin that has been stretched a chance to recover.

This waiting period before the operation often improves your overall recovery from surgery and decreases your risk of infection.

Open fractures, however, expose the fracture site to the environment. They urgently need to be cleansed and require immediate surgery.

Early surgery is also often recommended for an avulsion fracture. Although uncommon, a piece of the calcaneus can be pulled off when the Achilles tendon tears away from the bone (avulsion). For this type of fracture, early surgery can decrease the risk of injury to the skin around the Achilles tendon.

The following procedures are used for various types of calcaneus fractures.

Open Reduction and Internal Fixation

During this operation, the bone fragments are first repositioned (reduced) into their normal alignment. They are held together with special screws or metal plates and screws.

Percutaneous Screw Fixation

Sometimes, if the bone pieces are large, they can be moved back into place by either pushing or pulling on them without making a large incision. Special screws can be placed through small incisions to hold your bone pieces together.

Your Doctors

Tips for Healthy Feet

  • Don’t ignore foot pain, it isn’t normal. If pain persists, see a physician.
  • Inspect your feet regularly. Note changes in color and temperature, thickness or discoloration of nails, and cracks or cuts in the skin. Peeling or scaling on the soles could indicate athlete’s foot. Any growth on the foot is not considered normal.
  • Wash your feet regularly, especially between the toes. Be sure to dry them completely.
  • Trim toenails straight across, but not too short. Be careful not to cut nails in corners or on the sides; it can lead to ingrown toenails. People with diabetes, poor circulation, or heart problems are more prone to infection and should not treat their own feet.
  • Make sure that your shoes fit properly. Replace worn-out shoes as soon as possible, and try on new shoes later in the day when feet tend to be at their largest.
  • Select and wear the right shoe for your activity, in other words, running shoes for running.
  • Don’t wear the same pair of shoes every day, but rather alternate them.
  • Avoid walking barefoot. Your feet are more prone to injury and infection when walking barefoot. When at the beach or wearing sandals, remember to use sunscreen on your feet as well as the rest of your body.
  • Use home remedies cautiously. Self-treatment often turns a minor injury into a major foot problem. If you have diabetes, it is essential that you see a podiatric physician at least once a year for a thorough check-up.