Bilateral flatfoot before Surgery and  Bilateral flatfoot after Surgery
Ankle Arthroscopy and Subtalar Arthroscopy
Ankle Arthritis in Rhuematoid patient and Ankle Replacement in Rhuematoid Arthritis
Diabetic foot before Surgery and Diabetic foot after Surgery
Claw toe deformity in Rhuematoid patient and Claw toe deformity in Rhuematoid patient after surgery
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Calcaneum or Heel Bone


Fracture Heel Bone (Calcaneum)

Heel bone fractures or Calcaneal fracture are one of the commonest fractures of foot. These fractures represent approximately 60% of all the tarsal bone fractures. They are caused by direct impact injuries like a fall from height or road traffic accident when one lands on his or her feet. Heel fractures are associated with fractures of the spine in 10 % of the cases.

       
  normal heel bones   heel bones after a fracture
       

Heel bone fractures are very disabling injuries. They are mainly of two types. About 75% are intra-articular and the rest are extra-articular. Most of the intra-articular calcaneal fractures are associated with damage to cartilage of the joint below ankle joint called subtalar joint. Subtalar joint is responsible for inwards and outward movement of your heel called inversion and eversion. As the fracture damages the subtalar joint surface, it leads to restriction of inversion eversion movements of the heel. These movements help you to walk on uneven surfaces and hence it becomes uncomfortable to walk on an uneven footpath.

Imagine standing on a ripe mango and see it getting crushed. Same way when one falls on a heel it squashes and broadens out. As the impact damages the cartilage of subtalar joint, it can develop arthritis. Squashing and impact also damages the nerve endings and fat pad in the heel cushion leaving hypersensitivity and pain in the heel.

       
xray of normal heel   xray of fractured heel  

On the right is a picture of a foot that had a bad calcaneus fracture and was treated without surgery. Compare the shape of the flattened out heel on the left with the normal heel on the left.

Aim of heel fracture treatment is to restore normal height and alignment of the heel bone and subtalar joint as best as possible. This is important to restore normal mechanics of foot and walking. Sometimes when the there are multiple pieces of fractured bone it is difficult to achieve this goal. However, most of the patients benefit from surgery.

Surgery of calcaneal fracture requires opening up of the fracture, reduction of fracture fragments and internal fixation of the fracture. The open reduction and internal fixation procedure is performed through an incision on the outside of the heel. The bone is put together and held in place with a metal plate and multiple screws. This procedure decreases the likelihood of arthritis developing and maximizes the potential for inward and outward movement of the foot.

Intra-articular Fracture

  heel xray showing reduction of heel bone height and broadening  
       
  restoration of heel height after surgery   restoration of heel width after surgery

The x-ray above shows the left foot prior to surgery. The x-ray below shows the foot after the operation. Note that the height and shape of the heel bone have been perfectly restored.

       

There are times, however, when the bone is so severely smashed and fractured that, in addition to the open reduction and internal fixation, the heel joint (the subtalar joint) needs to be fused. This is done to decrease the chances of developing painful arthritis. Although the inversion and eversion movement of the foot is lost after a subtalar fusion, there is a more rapid return to activities and functions after this type of surgery.

Surgery for Calcaneal fracture

When can I have surgery for my heel bone fracture?

Ideal time to have surgery on heel is once the swelling has subsided. Depending upon the swelling surgery can be safely done up to about 3 weeks after the injury.

Heal fracture healing time

You will be in a plaster for 2 weeks after surgery. Stitches are removed at 2 weeks and physiotherapy and exercises are started. This helps you to regain function and strength in the foot quicker and help you to walk earlier. 

Extra-articular fracture

  extra articular fracture of calcaneum   extra articular fracture after failure of percutaneous fixation
   
  same case after revision fixation
 

This fracture of the heel bone above was fixed with screws that have been inserted through small skin punctures instead of large skin incisions. They failed to hold the reduction and pulled out. This was subsequently treated with open reduction internal fixation.

Arthritis of the heel joint (the subtalar joint) after fracture

Arthritis of the heel joint develops commonly after intra-articular calcaneal fractures. This is because of damage to the joint surface at the time of injury. If it occurs patient will complain of pain at the heel and pain in the outside of the ankle, and stiffness of the back of the foot. Walking on uneven ground surfaces is difficult since the inversion and eversion movement of the subtalar joint is missing. The treatments can consist of pain-killer tablets, injection of the subtalar joint with cortisone, special arch supports and orthotics and surgery.

Type of surgery in such cases depends upon the severity of arthritis and the reason for pain. If joint is severely damaged and has developed arthritis of subtalar joint than fusion is the best option.

       
  xray showing subtalar arthritis after calcaneal fracture   xray after subtalar fusion

This fracture of the heel bone above was fixed with screws that have been inserted through small skin punctures instead of large skin incisions. They failed to hold the reduction and pulled out. This was subsequently treated with open reduction internal fixation.

When should I see Dr Bhargava after a heel fracture? 

Fracture of heel bone is a disabling injury. This can lead to many continuing problems. There may be one or few combined. They include :-

1
Pain and stiffness in the back of the heel and on the outside of the ankle.This problem occurs because of damage to the cartilage surface of the subtalar joint and subsequent arthritis in the subtalar joint.
   
       
2.
Broadening of the back of the heel and difficulty with wearing shoes. This problem occurs predominantly when surgery is not performed initially, and the heel remains wide and deformed.
   
       
3.
Pain on the outside of the heel and the outside of the ankle occurs due to injury to the tendons (the peroneal tendonitis). This is a more common problem when surgery is not performed initially, and is because of widening of the heel bone. The peroneal tendons can be torn in the process.
   
       
4. Pain under the pad of the heel. This is unfortunately a permanent problem, since the specialized fatty cushion under the heel can be permanently damaged with injury. This can only be treated with correct cushioning and padding of the heel.    
       
5. Burning pain on the inside of the ankle. This can occur as a result of widening of the inside of the heel on the inside of the ankle, which causes irritation of the tibial nerve (called a tarsal tunnel syndrome)    
       
6.
Pain in the ankle, which occurs in severe forms of fracture which are not treated with surgery. The heel bone is severely crushed, which leads to jamming of the front of the ankle.    
 

Sports injury of heel Bone-Stress fracture of heel bone

Due to overuse a stress fracture can occur in the bone. It is common for soldiers, who have to do a lot of marching, and in road runners. Calcaneal stress fractures can also occur from a sudden force to the heel, such as landing on the heel from a height such as while playing Basket Ball.

       
 
stress fracture of calcaneum