Calcaneal Fracture

Fractures in Children

The calcaneus is the major weightbearing bone at the end of the lower extremity.  Injury to this bone in children and teenagers is relatively rare. Fractures that extend into the joint are even more uncommon. Stress fractures to the bone in which the bone has been overworked or injuries that occur outside of the joint are more common.

Most fractures to the calcaneus in children and teenagers occur after falling from a height.  The mechanism of most of these injuries is direct impact of the heel against the ground. If the child has fallen from a height such as from a roof or ladder, other areas of the lower extremity and spine must be evaluated. Wrist injuries can be seen with these fractures as well.

A child or teenager with this injury will have an immediate swelling but it is diffuse around the end of the ankle and bottom of the foot and heel region. There will be extreme tenderness to touch the heel and the individuals have difficulty putting any weight on the lower extremity.

Injuries to the compartments of the foot are relatively uncommon but if present would be irritated with numbness and tingling in the arch of the foot and extreme pain with any motion of the toes.

X-rays are necessary to evaluate the injury.  If the injury is outside of the joint region then no further studies may be necessary. If the joint surface has been affected then CT scans are needed to evaluate the full extent of the injury.

Treatment: Nondisplaced and minimally displaced fractures to the heel can be treated comfortably in a nonweightbearing cast while the individual uses crutches.  The fractures will heal rapidly and immobilization is usually necessary for no more than six weeks.

If there is any malalignment then it can be gently manipulated back in to the proper position. If the malalignment is more major then the individual should be given a general anesthetic and allow the doctor to place the foot back in to its normal position while the position is held with a percutaneous pin.

If there has been an injury to the joint surface and the surface is grossly malaligned, the fracture should be openly reduced and internally fixated with a small plate and screws to allow the joint to heal as well as possible.

Complications to calcaneal fractures are relatively uncommon when they occur outside of the joint region. When they occur in the joint they can be accompanied by long-term stiffness and swelling to the joint.  Occasional deformity may be present, putting more stress on the outside or inside of the ankle and foot.  It can also be associated with arthritis at some point in the future. Arthritis is more common when the fracture is in multiple pieces, despite the appearance of an excellent anatomic reduction.

Stress fractures are more simple injuries that occur when an athlete is increasing activity level very quickly over a short period of time.  There will not appear to be any minor or major trauma to the area. Just diffuse pain with weightbearing on the heel. X-rays may be necessary at first but follow­ up films usually show the stress fracture to the bone.   Immobilization in a boot is all that is necessary to prevent uneventful healing and a full return to activity.