Heel Bone (Calcaneal ) Fracture

Everything You Wanted to Know About Heel Bone Fractures

The medical term for the heel bone is  “calceaus”. For that reason, when when you fall and break your heel bone, any doctor in the San Francisco Bay Area (or anywhere else for that matter) will tell you that you have a “calcaneal fracture.” This article by San Francisco Foot Surgeon Dr.Christopher Segler will explain calcaneal fracture treatment.

 Calcaneal fracture xray in surgery with plates and screws in heel bone.

 

Calcaneal fractures are five times more common in men than women. We podiatrists presume that this is because men more often tempt fate with hazardous activities such as rock climbing, standing on ladders, and otherwise tempting gravity. Because the most common cause of a heel bone fracture is a “fall from a height,” about 20% of all people who sustain a calcaneal fracture will also have fractures of the spine. That’s right  1 out of five people with a broken heel also have a broken back.

As a foot surgeon with a podiatry practice, I have treated patients with calcaneal fractures that happened from falls while climbing in the Pinnacles, falling of trails in Yosemite, falling of ladders while attempting to save a few dollars by trimming one’s own trees and even one young man who caught just a little too much air on his snowboard.  In the San Francisco Bay Area it seems there are many activities that just put people at risk of foot and ankle injuries from falls.

Why Are Calcaneal Fractures So Bad?

The heel bone is the largest of the 26 bones in you foot. It has several areas covered with cartilage that make up the subtalar joint and calcaneocuboid joint. These joints are critical to the motions of the foot called “pronation” and “supination.” Without pronation or supination, you cannot walk on uneven surfaces, absorb impact from walking or adapt to uneven walking surfaces. When the heel bone breaks these joints get damaged.

The heel bone is also very fragile. Essentially it is like a hard boiled egg. The outer shell is strong, unless it cracks. When you fall and break the heel bone, the sides often explode outward. The subtalar joint surfaces get smashed down into the inside of the heel bone. 

If you break your ankle, it is usually pretty easy for your foot surgeon to fix it in surgery. It is much like putting a broken piece of wood back together with screws. But the bone in the heel is not like solid wood, it is more like styrofoam with a thin outer shell. Unlike a broken leg, it is very difficult to put it back together perfectly.

Do I Need Surgery to Fix a Heel Bone Fracture?

For you podiatrist to determine whether or not you will need surgery to fix your broken heel, several things must be considered. First, is the fracture one that disrupted the joint surfaces. Second, did the heel bone explode apart. Third, are you a good surgical candidate (as in healthy enough that surgery with general anesthesia won’t be too risky).

How Podiatrists Classify the Severity of Calcaneal Fractures

The question most people have with any injury is “how bad is it?” With heel bone fractures, the most frequently used classification scheme is called the “Saunders CT Classification System.” The good news about this system is that it can give your surgeon a great deal of information about joint involvement of the break in the heel bone. The bad news is that a CT scan is required. But if you need surgery, you would definitely want your podiatrist to have all of this information heading into the operating room.

How Soon After I Beak My Heel Will I Have Surgery?

In most cases, your podiatrist will need to way about 7-10 days before operating on your broken heel. The reason for this is that the heel bone has a very solid blood supply and when it breaks, it bleed inside the foot causing tremendous swelling and bruising. If your podiatrist operates too soon, you may end up with the surgical incision popping open (a term called “dehiscence.” 

The longer your foot surgeon waits for the swelling to go down, the less chances you will have any problems with the skin and soft tissue healing after surgery. But the heel bone actually heals faster than any other bone of the foot. So at about 2 weeks the bone already can start to solidify. The edges of the bone cortex (outer shell) become blunt and no longer fit together nicely like a jigsaw puzzle. Any longer than about 2 weeks and your podiatrist will have to pry the joint surfaces back out of the hardening bone. It just becomes a surgical judgement call when it is best to operate on your heel fracture. 

What is the Goal of Calcaneal Fracture Surgery?

There are basically two goals your podiatrist is going to attempt to achieve in the operating room. The first goal is to get the heel bone back to a narrow, more normal width and shape. Because the sides of the heel bone often explode outward, you may be simply left with a heel that is too wide to fit in shoes if it isn’t put back in position. 

The second goal is to get the joint surfaces back into the best alignment possible. This is very difficult to achieve. But is the only hope of giving you the ability to walk normally after the fracture heals. And if you end up with arthritis, it is important that the joints are at least in normal enough position that fusing the joint later will still be possible. 

What Happens in the Operating Room During Heel Bone Surgery?

The anesthesiologist will put you to sleep and monitor your vital signs, breathing, etc. Your foot surgeon will inject local anesthetic into your foot and ankle so your foot will be numb during the surgery and when you wake up. The surgical team will clean your foot and leg and place sterile  drapes over you to prevent any bacteria from infecting your surgical site. A tourniquet will be placed around your thigh or ankle to prevent bleeding during the surgery. 

In most cases your podiatrist will make a hockey-stick shaped incision along the outside of your heel to work on the broken bone. Your foot surgeon will then use a combination of direct inspection and xrays in the operating room to get the bone fragments back into better position. Once in position, some combination or plates and screws will be used to secure the broken pieces of bone that will allow the heel bone to heal.

What Happens after Heel Bone Surgery?

When you wake up in the recovery room you will have a fiberglass splint on your foot and leg. The dressing will keep the swelling down and protect the surgical repair. You will be given crutches and instructed on how to use them. You cannot walk on the foot until your podiatrist sees heeling on your post-operative xrays. This usually takes somewhere around six weeks. Physically therapy will help you recover from any stiffness and weakness in the foot and ankle. 

Will My Foot Be Normal If I Have Heel Bone Surgery?

The short answer is no. Heel bone fractures are devastating injuries. Every patient is different. Some do better than others, but I most patients who have a broken heel and need surgery will have some level of discomfort at some point in the future. But in spite of this, many return to all of the activities they enjoy.

 

Dr. Christopher Segler is a San Francisco Podiatrist and Foot Surgeon. He published the largest study ever conducted on lower extremity injuries among climbers. The study was funded by a grant from the American Alpine Club. Because he is a rock climber, ice-climber and foot surgeon, he seems to attract athletic minded patients who hope to get back outdoors as quickly as possible. 

 

  

 

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