Introduction
Calcaneus fracture is a very rare fracture of the calcaneus bone of the heel. However, the effects can be quite crucial and cause weakening of the foot. Calcaneus is the largest of the seven-foot bones called the tarsal bones, whose function is to withstand body weight. Calcaneus bone is present at the junction where the tibia, fibula, and talus bone articulate. Calcaneus fracture is also called a lover’s fracture in the olden days, as it occurs when a person jumps off a lover's balcony. Calcaneus fracture can be a disabling injury in patients with disproportionate foot, trauma, or increased workload.
What Causes Calcaneus Fracture?
Calcaneus fractures are caused by high-energy trauma, falls, road traffic accidents, blunt wounds or injuries that cause penetrating wounds, unexpected twisting movements, and jumping in, with road traffic accidents being the most common cause overall. Fractures caused by stress are also an acceptable cause of occurrence when the ankle is used frequently, such as in runners and athletes.
How Commonly Is Calcaneus Fracture Seen?
The fracture of the tarsal bone is around two percent of all fractures. Fracture of the calcaneal bone contributes fifty to sixty percent of the overall tarsal fractures in which the chances of it being an open fracture is less likely to occur. Calcaneus fracture has a very traditional male predominance, but the incidence of fractures in females has recently kept increasing. The incidence of calcaneus fracture is commonly seen in young adults between the ages of twenty to thirty-nine and is rarely seen in children. The incidence rate is higher in people with associated systemic conditions like diabetes (increased blood sugar level) and osteoporosis (a clinical condition characterized by softening bones).
How Does Calcaneus Fracture Occur?
Calcaneus fracture occurs when high-intensity stress acts directly perpendicularly to the ankle bone. The direct force of injury causes a fracture on the calcaneus bone or when the bone quality is poor or compromised in cases like osteoporosis (softening of the bone). As a result of the injury, the bone appears flattened, widened, and shortened comparatively.
How Is Calcaneus Fracture Clinically Seen?
After a traumatic injury, patients usually complain of unlocalized diffuse pain, swelling, and reddish-black discoloration at the injury site. There is considerable difficulty in moving or bearing weight. Plantar ecchymosis (a purplish clot at the center of the midfoot) associated with the Achilles tendon (rupture of the fibrous membrane connecting the calf muscles and the ankle) is a very evident sign of calcaneus fracture. The skin at the site of the injury is checked for any possible tenting sign (where the skin stays upward like a tent when pulled) due to dehydration and loss of skin elasticity.
What Are the Types of Calcaneus Fractures?
Calcaneus fractures are broadly divided into two types:
Extra Articular Fractures: These injuries occur due to the loosening of the tuberosity (the most prominent and elevated part) of the calcaneal bone from the Achilles tendon and anterior ligaments of the foot. Extra-articular fractures account for twenty-five percent of calcaneal fractures. The extra-articular fractures can be classified mainly into two types:
Essex- Lopresti Classification: The calcaneus fracture is classified into two types, namely:
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Joint Depression Type: A type of fracture having a single vertical line through the gissane's angle separating the calcaneus bone into anterior and posterior portions.
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Tongue Type: This is also a vertical line fracture seen in a depressed manner, along with a posterior horizontal line creating a larger posterior fragment of the bone.
Sanders Classification: This classification is given based on the findings in computed tomography (CT). These are classified as follows:
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Type 1 - The fracture is nondisplaced or shows minimal displacement.
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Type 2 - Has a lot of bony fragments in the posterior region and is subdivided into A, B, and C types depending on the fracture line.
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Type 3 - Three bony fragments are seen, each interlinked along with a depressed middle segment, and are subdivided as AB, AC, and BC.
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Type 4 - The fracture is seen as four individual pieces.
Intra Articular Fractures: It is the most common calcaneus fracture type, with an incidence rate of 75 percent. Here the talus bone acts as a hammer or wedge at the calcaneus bone's Gissane angle, causing it to fracture.
How Is Calcaneus Fracture Evaluated?
Calcaneus fracture is best evaluated using imaging techniques, and the imaging methods used are:
- Radiographs (X-Ray): Radiographs are two-dimensional images used to find fractures and dislocations. They help to identify the vertical and horizontal fracture lines running along the calcaneus bone and its displacement.
- Computed Tomography (CT): Computed tomography is a three-dimensional image used for evaluating bony structures. In calcaneus fractures, CT is mainly used as a diagnostic criterion for the classification of the fracture. As it is a three-dimensional imaging technique, it shows the relation of the bone along with associated structures like ligaments and tendons (Achilles tendon)
How Is Calcaneus Fracture Managed?
The management of calcaneus fractures is as follows:
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Immediate Management: A Calcaneus fracture is not fatal, but it can be traumatic and needs emergency care. Emergency management is done by cleaning the wound to prevent wound contamination, and pain management is achieved by putting the patient on painkillers. Vital signs are monitored, and stability is ensured.
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Non-Surgical Management: The patient is admitted and advised to rest. Ice compression and elevation are necessary. The injured leg is immobilized using external splints or braces. Patients are contraindicated to bear weight on the injured leg or perform vigorous or stress-bearing activities.
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Surgical Management: Surgical treatment is done to restore the structure and function of the calcaneus bone along with the blood supply. The surgical procedures are delayed until a wrinkling sign is seen (where the skin wrinkles when pinched). The soft tissue swelling post-surgery is seen to subside within three weeks. Surgical intervention is advised in cases showing dislocation. Fracture of the anterior process is more than 25 percent fracture of the calcaneus body.
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Post-Operative Management: The patient is advised for a padded splint to provide cushioning for a period of two to five days and rest for two to three weeks. Weight-bearing is contradicted for eight to twelve weeks, after which physiotherapy and strengthening are advised.
The healing of the calcaneus fracture is relatively good, with a very high prognosis. A better prognosis is seen in women and young adults, and patients with less footwork or workload. The complications related to calcaneus fracture are fracture of the spine due to compression, compartment syndrome of the foot (it is a condition seen by severe pain due to accumulation of interstitial fluid and pressure), and post-operative complications like inflammation of the bone (osteomyelitis), wound contamination, delayed wound healing, malunion of the bones, etc.
Conclusion
The calcaneus fracture is a rare fracture of the foot; when it occurs, it compromises a body’s stability and is very important to restore the foot's function. Calcaneus fractures are treated with surgical and non-surgical management, and the patient is advised to rest for several weeks with periodic monitoring. Calcaneus fracture shows an excellent prognosis, and the foot movements are restored effectively.
