eMedicine Specialties > Radiology > Musculoskeletal

Calcaneus, Fractures: Follow-up

Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist, North Manchester General Hospital, The Pennine Acute NHS Trust, Manchester UK
Coauthor(s): Rumana Rahim, MBBS, MRCS, FRCR, Specialist Registrar, Department of Radiology, North West Deanery, Manchester, UK; Klaus L Irion, MD, PhD, Consulting Staff, The Cardiothoracic Centre Liverpool NHS Trust, The Royal Liverpool University Hospital, UK; Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
Contributor Information and Disclosures

Updated: Jul 22, 2008

Intervention

Extra-articular fractures

Extra-articular fractures are managed conservatively with elevation, ice packs, and a compression bandage. Once the swelling resolves, vigorous exercises are commenced to regain subtalar and ankle movement.

If there is significant widening of the calcaneus fracture, some clinicians perform a closed manual manipulation to decrease heel width and to decrease the risk of late peroneal tendon irritation. If the Bohler angle is reduced by more than 10º, use of a transverse pin, with the subsequent incorporation of the pin in a plaster-of-Paris cast for 4 weeks, may restore calcaneal height.

Intra-articular fractures

The treatment of intra-articular fractures is controversial; 4 treatment options are available: (1) conservative management, (2) closed reduction and fixation, (3) open reduction and internal fixation, and (4) primary arthrodesis.

With conservative management, patients are treated with compression dressing; elevation and ice packs; early movement, beginning at 24 hours after treatment; non–weight-bearing mobilization after the first week; surgical shoe fitting at 14 days; and partial weight bearing in the shoe after 6 weeks, progressing to full weight bearing after 8 weeks. Reduction is not employed.

Closed reduction and fixation may be used in certain types of fractures. In this approach, a Steinman pin is used to maneuver the fragment and advance the pin to hold the fracture.

Open reduction and internal fixation are achieved by use of a lateral approach in which the subtalar joint is reduced and held with reconstruction plates. Problems with this treatment option include skin edge necrosis (8%) and deep infection (2%).

Primary arthrodesis may be achieved by means of either isolated subtalar fusion or triple fusion, because unrecognized damage to the calcaneocuboid joint or talonavicular joint may occur.

Cochrane Collaborative review of the literature

A Cochrane Collaborative review of interventions for calcaneus fractures identified 6 relevant randomized trials, 4 of which were included, 1 excluded, and 1 ongoing. The review found that all 4 trials had methodologic flaws.

Three trials, involving 134 patients, compared open reduction and internal fixation with nonoperative management of displaced intra-articular fractures. Pooled results showed no apparent difference in residual pain (24/40 vs 24/42; Peto odds ratio of 0.90; 95% CI: 0.34, 2.36). However, a lower proportion of the patients in operative group were unable to return to the type of work they were engaged in before the injury (11/45 vs 23/45; Peto odds ratio of 0.30; 95% CI: 0.13, 0.71); in addition, they were unable to wear the same shoes they wore before the injury (12/52 vs 24/54; Peto odds ratio of 0.37; 95% CI: 0.17, 0.84).

One trial, involving 23 patients, evaluated impulse compression therapy. At 1 year, there was a mean difference of 1.40 pain units on a visual analogue score (scale of 0-10; 95% CI: 0.02, 2.82) in favor of the treated group. The impulse compression group had greater degree of subtalar movement (mean difference of 14.0°; 95% CI: 3.2, 24.6) at 3 months. On average, patients in the impulse compression group returned to work 3 months earlier than those in the control group.

The reviewers concluded that randomized trials of the management of calcaneus fractures are few, small, and generally of poor quality.

Although some evidence suggests that there is a benefit with operative treatment compared with nonoperative treatment, it remains unclear whether the possible advantages of surgery are worth its risks. In light of this, it seems best to wait for the results of a large ongoing trial comparing open reduction and internal fixation with conservative treatment.

Results of 1 small trial suggested that impulse compression therapy for intra-articular calcaneus fractures may be beneficial.

More large-scale, high-quality, randomized, controlled trials are needed to confirm these results and to test other interventions in the treatment of calcaneus fractures.20,21,22,23,24,25,26

Medicolegal Pitfalls

  • In a patient who is known to have sustained a fracture of the calcaneus as the result of a fall, both of the patient's feet should be examined, because a fall from a height often produces bilateral calcaneus fractures.
  • Diagnosis of associated fractures of the vertebral column, tibia, and fibula should be actively pursued.
 
Acknowledgments

We gratefully acknowledge the contributions of Shazeya Sarwar, MBBS, MRCP, in the creation of this article.



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References
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References

  1. Barei DP, Bellabarba C, Sangeorzan BJ, Benirschke SK. Fractures of the calcaneus. Orthop Clin North Am. Jan 2002;33(1):263-85, x. [Medline].

  2. Juliano P, Nguyen HV. Fractures of the calcaneus. Orthop Clin North Am. Jan 2001;32(1):35-51, viii. [Medline].

  3. Rammelt S, Zwipp H. Calcaneus fractures: facts, controversies and recent developments. Injury. May 2004;35(5):443-61.

  4. Sanders R. Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am. Feb 2000;82(2):225-50. [Medline].

  5. Lawrence SJ, Singhal M. Open hindfoot injuries. J Am Acad Orthop Surg. Jun 2007;15(6):367-76. [Medline].

  6. Maenpaa H, Lehto MU, Belt EA. Stress fractures of the ankle and forefoot in patients with inflammatory arthritides. Foot Ankle Int. Sep 2002;23(9):833-7. [Medline].

  7. Igbigbi PS, Mutesasira AN. Calcaneal angle in Ugandans. Clin Anat. Jul 2003;16(4):328-30. [Medline].

  8. Pester S, Smith PC. Stress fractures in the lower extremities of soldiers in basic training. Orthop Rev. Mar 1992;21(3):297-303. [Medline].

  9. Essex-Lopresti P. The mechanism, reduction technique, and results in fractures of the os calcis. Br J Surg. Mar 1952;39(157):395-419. [Medline].

  10. Spitz DJ, Newberg AH. Imaging of stress fractures in the athlete. Radiol Clin North Am. Mar 2002;40(2):313-31. [Medline].

  11. Giannestras NJ, Sammarco GJ. In: Rockwood CA Jr, Green DP, eds. Fractures. Vol 2. Philadelphia, Pa: JB Lippincott;. 1975.

  12. Buckingham R, Jackson M, Atkins R. Calcaneal fractures in adolescents. CT classification and results of operative treatment. Injury. Jun 2003;34(6):454-9. [Medline].

  13. Linsenmaier U, Brunner U, Schöning A, et al. Classification of calcaneal fractures by spiral computed tomography: implications for surgical treatment. Eur Radiol. Oct 2003;13(10):2315-22. [Medline].

  14. Bradley SA, Davies AM. Computed tomographic assessment of soft tissue abnormalities following calcaneal fractures. Br J Radiol. Feb 1992;65(770):105-11. [Medline].

  15. Furey A, Stone C, Squire D, Harnett J. Os calcis fractures: analysis of interobserver variability in using Sanders classification. J Foot Ankle Surg. Jan-Feb 2003;42(1):21-3. [Medline].

  16. Clement H, Grechenig W, Peicha G, Grechenig S. [Ultrasound diagnosis in knee and foot trauma]. Orthopade. Mar 2002;31(3):332-5.

  17. Miller JH, Sanderson RA. Scintigraphy of toddler''s fracture. J Nucl Med. Dec 1988;29(12):2001-3. [Medline].

  18. Nazarian LN, Rawool NM, Martin CE, Schweitzer ME. Synovial fluid in the hindfoot and ankle: detection of amount and distribution with US. Radiology. Oct 1995;197(1):275-8. [Medline].

  19. Aronson J, Garvin K, Seibert J, et al. Efficiency of the bone scan for occult limping toddlers. J Pediatr Orthop. Jan 1992;12(1):38-44. [Medline].

  20. Schepers T, Vogels LM, Schipper IB, Patka P. Percutaneous Reduction and Fixation of Intraarticular Calcaneal Fractures. Oper Orthop Traumatol. May 2008;20(2):168-175. [Medline].

  21. Poeze M, Verbruggen JP, Brink PR. The relationship between the outcome of operatively treated calcaneal fractures and institutional fracture load. A systematic review of the literature. J Bone Joint Surg Am. May 2008;90(5):1013-21. [Medline].

  22. Gagala J, Guzik G, Modrzewski K. [Long-term results comparison of simultaneous open reduction and subtalar arthrodesis with the efficacy of closed reduction in the treatment of fresh fractures of calcaneus]. Chir Narzadow Ruchu Ortop Pol. Nov-Dec 2007;72(6):408-12; discussion 413-4. [Medline].

  23. Berry GK, Stevens DG, Kreder HJ, et al. Open Fractures of the Calcaneus: A Review of Treatment and Outcome. J Orthop Trauma. Apr 2004;18(4):202-206.

  24. Campbell JT. Intra-articular neuropathic fracture of the calcaneal body treated by open reduction and subtalar arthrodesis. Foot Ankle Int. May 2001;22(5):440-4. [Medline].

  25. Kurozumi T, Jinno Y, Sato T, et al. Open reduction for intra-articular calcaneal fractures: evaluation using computed tomography. Foot Ankle Int. Dec 2003;24(12):942-8. [Medline].

  26. Talarico LM, Vito GR, Zyryanov SY. Management of displaced intraarticular calcaneal fractures by using external ring fixation, minimally invasive open reduction, and early weightbearing. J Foot Ankle Surg. Jan-Feb 2004;43(1):43-50.

  27. Diard F, Hauger O, Moinard M, Brunot S, Marcet B. Pseudo-cysts, lipomas, infarcts and simple cysts of the calcaneus: are there different or related lesions?. JBR-BTR. Sep-Oct 2007;90(5):315-24. [Medline].

  28. Dodson NB, Dodson EE, Shromoff PJ. Imaging strategies for diagnosing calcaneal and cuboid stress fractures. Clin Podiatr Med Surg. Apr 2008;25(2):183-201, vi. [Medline].

  29. Golder WA. Anterior process of the calcaneus: a clinical-radiological contribution to anatomical vocabulary. Surg Radiol Anat. Jun 2004;26(3):163-6.

  30. Grala P, Mankowski B, Machynska-Bucko Z. Complications of dislocated calcaneal fractures. Ortop Traumatol Rehabil. Mar-Apr 2007;9(2):198-205. [Medline].

  31. Katayama K, Matsuno T. Effects of bisphosphonates on fracture incidence and bone metabolism in rheumatoid arthritis patients in general practice taking long-term corticosteroid therapy : a retrospective study. Clin Drug Investig. 2008;28(3):149-58. [Medline].

  32. Laliotis N, Pennie BH, Carty H, Klenerman L. Toddler''s fracture of the calcaneum. Injury. Mar 1993;24(3):169-70. [Medline].

  33. Molloy AP, Myerson MS, Yoon P. Symptomatic nonunion after fracture of the calcaneum. Demographics and treatment. J Bone Joint Surg Br. Sep 2007;89(9):1218-24. [Medline].

  34. Schepers T, den Hartog D, Ginai AZ, Patka P. Posterior capsular avulsion fracture of the calcaneus: an uncommon avulsion fracture. J Foot Ankle Surg. Sep-Oct 2007;46(5):409-10. [Medline].

  35. Seybold D, Schildhauer TA, Muhr G. Combined ipsilateral fractures of talus and calcaneus. Foot Ankle Int. Mar 2008;29(3):318-24. [Medline].

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Further Reading

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Keywords

calcaneus fracture, calcaneal fracture, tarsal fracture, foot fracture, heel fracture, talus fracture, calcaneum fracture, os-calcis fracture, os calcis fracture, Lover fracture, Lover's fracture

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Contributor Information and Disclosures

Author

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist, North Manchester General Hospital, The Pennine Acute NHS Trust, Manchester UK
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Institute of Ultrasound in Medicine, Royal College of Physicians, Royal College of Physicians and Surgeons of the United States, Royal College of Radiologists, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Rumana Rahim, MBBS, MRCS, FRCR, Specialist Registrar, Department of Radiology, North West Deanery, Manchester, UK
Disclosure: Nothing to disclose.

Klaus L Irion, MD, PhD, Consulting Staff, The Cardiothoracic Centre Liverpool NHS Trust, The Royal Liverpool University Hospital, UK
Klaus L Irion, MD, PhD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
Sumaira MacDonald, MBChB, PhD, MRCP, FRCR is a member of the following medical societies: British Medical Association, Royal College of Physicians, and Royal College of Radiologists
Disclosure: Nothing to disclose.

Medical Editor

Michael A Bruno, MD, Associate Professor, Departments of Radiology and Medicine, Pennsylvania State University College of Medicine; Director, Radiology Quality Management Services, Milton S Hershey Medical Center, Pennsylvania State University College of Medicine
Michael A Bruno, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, Society of Nuclear Medicine, and Society of Skeletal Radiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Thomas Lee Pope Jr, MD, FACR, Professor of Radiology and Orthopedics, Department of Radiology, Medical University of South Carolina
Thomas Lee Pope Jr, MD is a member of the following medical societies: American Roentgen Ray Society, International Skeletal Society, Radiological Society of North America, Society of Breast Imaging, and South Carolina Medical Association
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Felix S Chew, MD, MBA, EdM, Professor, Department of Radiology, Vice Chairman for Radiology Informatics, Section Head of Musculoskeletal Radiology, University of Washington
Felix S Chew, MD, MBA, EdM is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

 
 
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