Dr. Ebraheim’s educational animated video describes the calcaneal extra-articular fractures.
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Calcaneal Fractures Extra-Articular Fractures
An anterior process fracture is frequently missed and misdiagnosed as an ankle sprain (sprain-fractures). They are the result from forced plantar flexion and inversion. They are usually treated conservatively; surgery is done for displaced large fragments. A tuberosity body fracture results from an axial load injury. A CT scan may be needed to rule out intra-articular extension. A tuberosity avulsion fracture is an important extra-articular fracture. The injury is usually due to sudden dorsiflexion of the gastrocnemius and soleus muscles, which pull the Achilles tendon upwards causing an avulsion fracture of the calcaneus. It may cause skin compromise at the back of the heel. Other predisposing factors of avulsion fracture include diabetes and osteoporosis. A type I avulsion fracture is a “sleeve” type tuberosity fracture. A type II fracture is a “beak” type avulsion fracture. A type III avulsion fracture is an infrabursal avulsion fracture, and it is rare. Most calcaneal fractures are closed injuries that are treated nonoperatively or with surgery when the fracture is intra-articular, and the fracture is displaced. The timing of surgery is usually after improvement of the soft tissue condition. Avulsion fractures are different. They require urgent care for reduction and fixation of the fracture. This will eliminate the risk of skin complications and restore the function of the Achilles tendon. A sustentacular fracture results from heel loading accompanied by forced inversion of the foot. Surgery is rarely needed. The flexor hallucis longus tendon is lodged underneath the sustentaculum. A stress fracture of the calcaneus is typically felt deep in the bone and produces a vague complaint of heel pain. Stress fractures of the calcaneus are typically seen in athletes who are overtraining, using improper foot wear, or those with mechanical abnormalities. The pain from a stress fracture appears suddenly and remains constant. Pain and swelling on both sides of the heel may be seen and felt. The pain associated with a calcaneal stress fracture can usually be reproduced by squeezing the heel from both sides. Pain from a calcaneal stress fracture can be confused with the pain from plantar fasciitis. The pain from plantar fasciitis is most severe in the morning and when the patient first stands on their feet. Imaging tests may be helpful to confirm diagnosis of a stress fracture. The fracture may be difficult to see on x-rays until the fracture begins to heal. X-rays at 4-6 weeks will show the fracture line on the posterior aspect of the calcaneus as a radiodense vertical line. The fracture is best shown on lateral x-ray of the foot. MRI is usually helpful in the diagnosis if the clinical picture is not clear. Calcaneal stress fracture are usually treated conservatively. Patients should avoid activities such as running and jumping. They should use proper foot wear to cushion the heal (orthotics). Patients should be non-weight bearing for 6 weeks utilizing a boot or a cast.