The area of most concern with childer with injuries to the heel bone is the growth plate in the calcaneus called the apophysis (below left). Injuries to this in children is very painful, causes limping especially after activity, and in severe cases can alter the growth of the bone. X-ray imaging (below right) can show changes in the growth plate in sever cases but should be compared to an x-ray of the un-injured foot to compare.
MRI imaging is best to demonstrate the injury.
HEEL BONE (CALCANEAL) FRACTURES
By: Robert H. Sheinberg, D.P.M., D.A.B.P.S., F.A.C.F.A.S.
What is the calcaneus?
Answer: It is the heel bone that has a hard outer shell and soft inside. The top of the bone has cartilage that assists the bones in the foot in moving.
How do injuries occur?
Answer: Injuries usually occur from falls from a height or jumping off of a high object (i.e. table, roof or ladder).
What happens to the bone when it gets injured?
Answer: It usually shatters into multiple pieces (comminution). The bone shortens in height and increases in width.
What injuries are associated with these fractures?
Answer: Injuries may occur concurrently to the wrist and lower back.
What should be done immediately after the injury?
Answer: The immediate application of ice and compression will keep down some of the swelling. Strict nonweightbearing with crutches is extremely important. Immediate care is necessary from your physician.
Will the foot be placed in a cast or will surgery be necessary?
Answer: Nondisplaced fractures may be casted. The patient is put on crutches for six weeks. Displaced fractures will usually require surgery.
How is it corrected?
Answer: The bone fragments are usually displaced or out of their normal alignment. These fragments need to be put back into their original position and held with pins, screws and plates.
Does surgery require hospitalization?
Answer: The procedure is usually performed in an outpatient setting. If there are other conditions associated with the fracture or medical conditions co-exist, hospitalization may be needed.
What possible postoperative care may be needed to insure good recovery?
Answer: Patients will remain nonweightbearing for six to twelve weeks.
When could a person return to work or sports following these injuries?
Answer: Sedentary jobs can resume after one to three weeks. Work requiring extensive weightbearing may take six to twelve months. If the bone injury is severe, a change in a person’s job may be needed. Sports modifications will also be necessary.
Will there be work restrictions?
Answer: Sedentary jobs will provide little problem for patients with calcaneal fractures. Work restrictions will be necessary for the person who has to weightbear. Walking long distances or standing for a period of time will adversely affect the foot. These restrictions may be in place for up to one year. In some cases these restrictions may be permanent.
Will there be activity restrictions?
Answer: Activities that require walking long distances or running will be limited. Return to some sports may take a year or more. In some cases, where the fracture is severe, activities that do require any type of lengthy weightbearing will no longer be allowed. Sports that require side to side motion (i.e. tennis) may be affected.
Will there be an impairment rating given to an employee injured at work?
Answer: These injuries are associated with an impairment rating. The injury does lead to arthritis in an important joint in the foot. Additionally, stiffness is always seen in this joint (subtalar), and the ankle joint may also be affected.
What are some long term problems that may develop?
Answer: The most common problem that will develop is osteoarthritis in the joint that connects the foot to the ankle. This joint is responsible for assisting people to move from side to side. In addition, this joint helps the body absorb shock when the foot hits the ground. Other problems that may develop include tendon and nerve dysfunction. Difficulty with wearing shoes may also be present, as the heel bone may be widened. There is often discomfort on the bottom of the heel, as the fat pad under the heel gets injured.
What is the long term prognosis?
Answer: The injury to the cartilage is often overlooked with these types of fractures. Once the cartilage has been broken, osteoarthritis will develop. The more pieces that are broken. the worse the prognosis. Occasionally a two or three part fracture is seen. This is where the bone has been fractured in only two or three pieces. It is easier to put this bone together and the prognosis is better. Full return to sports and activities performed prior to the injury will be somewhat limited.
Will further surgery be necessary in the future?
Answer: If the bone has widened during the initial injury causing tendon and nerve problems, a piece of bone may be taken off the outer wall of the heel to reduce the bulkiness. If the joint develops osteoarthritis that is mild, arthroscopic surgery may be performed to clean out the joint. If the arthritis is severe, a fusion of the joint to prevent any type of motion will be needed. This will eliminate the pain and allow normal mobility. Occasionally, the hardware that is placed in the fracture site will become an irritant and this may also be removed. If the ankle has been affected by this fracture an arthroscopic procedure to remove any abnormal tissue may be warranted.
How will a fusion affect my foot and will the fusion cause problems in other areas?
Answer: A fusion to the injured bone and joint will virtually eliminate pain in that region. Fusion to the subtalar joint will cause the ankle joint to work harder in allowing the foot to ambulate as normal as possible. The ankle may become affected later, as osteoarthritis may develop from overuse. Once a fusion is performed in the foot the person will be able to resume work with little or no restrictions. Pain will be eliminated. It is by far the best procedure that we could perform in this joint, as our ability to do other procedures and provide relief is limited. If the ankle does become painful, arthroscopic surgery may help to eliminate the pain.