Detecting the disease
Despite the technical resources available, clinical diagnosis still plays a decisive role. It not only points the way to the necessary imaging procedures, but also enables an assessment of the damage in the soft tissue area, which is important for the further procedure and prognosis. If there is significant swelling, an acute compartment syndrome (lodge syndrome) must always be ruled out with a pressure measurement if necessary. The diagnosis is usually confirmed by X-rays in up to 3 planes. Computed tomography is an essential prerequisite for classifying the fracture and for surgical planning. Magnetic resonance imaging (MRI) is only used in rare cases.
Treatment of the calcaneus fracture
If the calcaneus fracture is not displaced and does not affect the joint surfaces, a conservative approach may be advised. In some cases, infections and comminuted fractures or concomitant diseases such as diabetes mellitus, polyneuropathy (general nerve disease), alcohol and drug addiction also force conservative functional therapy without surgery. After initial elevation, local ice cooling and administration of painkillers, active gymnastics and lymph drainage are prescribed. The aim is to reduce the severe swelling and improve mobility in the tarsal joints. It is often necessary to apply a lower leg plaster splint and a lower leg walking cast. Furthermore, relief boots (support on the tibial plateau or in the forefoot area) are used. Relief of the heel region should be maintained for 6 to 12 weeks. Full weight-bearing in the patient’s own shoe is then possible.
However, the more common procedure is surgical. All calcaneal fractures that radiate into the joint surfaces and have a displacement of more than 1 mm in width or a malposition of the hindfoot are more likely to be operated on. If the fracture is open, the damaged tissue must be removed and, if necessary, a fixation using external connecting rods (external fixator) must be applied. Bones, joint cartilage and tendons are always at risk if they are not sufficiently covered by tissue. In some cases, muscle and soft tissue from other parts of the body may even have to be transplanted to the region (flapplasty).
The precarious soft tissue coverage of the calcaneus and the observed wound healing disorders in open surgery have brought procedures with smaller incisions back into the spotlight in recent years. However, the standard operation consists of a right-angled incision made on the outside of the calcaneus.
The time of surgery is generally between the sixth and tenth day after the accident due to the usually considerable soft tissue swelling. In the meantime, the affected foot is elevated with the application of ice or the use of active venous pumps and lymphatic drainage to reduce swelling. The operation itself is performed with the patient in the lateral position. It is often necessary to apply a tourniquet in the area of the thigh. A soft tissue flap is prepared, which can then be lifted off the heel bone. This leads to an optimal view of the damaged calcaneus with the adjacent joints of the lower ankle joint. The bone fragments are first put together and the position of the calcaneus is improved and brought into the correct position. After restoring the length and shape of the calcaneus, a titanium plate is attached from the outside with screws for stabilization. The plate is available in different versions. A plate tailored to the patient is usually chosen. In some cases, it is necessary to insert bone material from the iliac crest into the resulting cavities in the calcaneus. Alternatively, bone replacement material can also be used. Only in very rare cases is a surgical procedure via an internal or external approach necessary.
Aftercare
First, the patient’s leg is slightly elevated in a well-padded splint. The inserted drains are removed 2 days after the procedure. After 2 to 5 days, physiotherapy exercises for the ankle and lower ankle joint should be started. Weight-bearing is postponed for 8 to 12 weeks, depending on the degree of fracture extension and the stability achieved surgically. Activity can be increased depending on the symptoms, but extreme exertion should be avoided until 6 months after injury. After 6 weeks, 12 weeks, 6 months and one year, a new X-ray is taken. Special hindfoot relief boots can significantly increase mobility in the initial phase.
Complications
Wound healing disorders are a common complication following surgical treatment of calcaneal fractures. Open fractures, smoking and diabetes are proven risk factors for the occurrence of wound complications. Another complication is the incorrect healing of the calcaneus. As soon as steps remain in the joint surface, premature wear and tear (osteoarthritis) in the lower ankle joint must be expected. Premature wear can occur even after correct reconstruction of the load-bearing joint surfaces of the calcaneus. The reasons for this may lie in the injury itself. Comminuted fractures have been shown to be associated with an increased incidence of this complication. Other complications include stiffness of the lower ankle joint and permanent foot pain. It is important to restore the joint surfaces of the lower ankle joint precisely in order to avoid such complications. If wear has occurred and pain persists, surgical fusion of the lower ankle joint is often necessary