Calcaneal Fractures are a consequence of a fall from height in most cases, although it can occur in other circumstances such as a road traffic accident.
The mechanism of injury is what is termed an axial-loading force (vertical type force). Such injuries are not as uncommon as one would expect due to the increased level of participation in extreme sports such as parkour, rock-climbing etc.
As such it is no longer as uncommon to witness this in the younger demographic such as the adolescent.
As the mechanism of injury suggests, it is a violent force that causes this sort of injury.
Thus, one has to be on the look-out for concomitant injuries such as injuries to the spine, hip, or long bones of the lower limbs, and of the calcaneus of the other foot. If it is indeed a fall from a height, it is prudent to rule out any head injuries as well.
Is Surgical Treatment Mandatory?
Broadly speaking the calcaneal fracture may be dichotomised into 2 types -the Extra-Articular and Intra-Articular.
The Extra-articular fracture does not carry as many implications with it as the Intra-articular one. In this instance, surgery is recommended if there is exceptional pressure over the soft tissue due to displacement of fracture (especially if the patient is diabetic), or if there is a dramatic decrease in the strength of the pull of the Achilles tendon.
The Intra-articular Fracture, as the word suggests, involves damage to the joint. Hence the amount of displacement may already point one towards the need for surgical fixation. The calcaneus is an integral part of the joints of the foot and ankle and there are radiological guidelines which suggest if certain angles are changed that surgical treatment is necessary.
Why is there controversy regarding whether to fix the calcaneal fracture?
There are several types of Calcaneal fractures. The ones implicated in the axial-loading scenario, tend to be those of the intra-articular types. This means the joint is damaged.
Depending on the severity, some feel it may be an exercise in futility in trying to restore the very comminuted (shattered) joint, as it may require fusion in the future.
This is coupled with the fact that the traditional approach to the fixation of the calcaneus fracture involves making a large incision over the outside of the foot. This incision and the stripping of soft tissues required in order to visualise the fracture carries a high risk of damage to the skin and soft tissue overlying the injury.
If that should happen, the soft tissue may die and become infected and there’s a chance the patient needs more drastic forms of intervention and may end up losing the foot.
Hence some feel trying to piece back together the shattered pieces in the face of a dicey soft tissue situation, is no more beneficial than waiting out the fracture and allowing it to heal in its deformed state. When the soft tissue is more settled, the option of fusion can be pursued.
There is no hard and fast rule, however, we prefer to pursue fixation where possible as the fusion of joints can have further ramifications down the road. Dr Tay Guan Tzu has had good results with the use of a different surgical approach and technique which is less damaging to the soft tissues, while still allowing one the good visualisation of the fracture.
This approach has been used by Dr Tay in Paediatric patients as well and has yielded good results as well.
Figure 3. X-Rays of another patient.