Calcaneus Fracture Surgery

What is a calcaneus fracture?

The calcaneus is the heel bone. Fractures, or breaks, of the calcaneus commonly occur after a fall from a height or car accident. Treatment of these fractures may require surgery.
 

What are the goals of calcaneus fracture surgery?

The goal of surgery for a calcaneus fracture is to restore the shape of the calcaneus as close to normal as possible.

View of hardware placement

 Restoration of normal alignment and contour is considered the best way to restore function and minimize pain. 
 

What signs indicate surgery may be needed?

Surgery is recommended when a broken calcaneus has lost its alignment and contour. Identification of the fracture is typically made after a physical examination by obtaining standard foot and ankle X-rays. The specific type, pattern and classification of the fracture is best made by obtaining a CT scan. Your surgeon will review both X-rays and the CT scan to determine if your break would be best managed by surgery.
 

When should I avoid surgery?

There are several reasons why surgery may not be recommended for a calcaneus fracture. Patients with diabetes may be at increased risk for infection or wound healing problems. Patients with poor blood flow may also have difficulty healing properly. Elderly individuals may have difficulty with surgical rehabilitation.
 
Surgery is often delayed due to the swelling that typically accompanies these injuries. The swelling may be severe enough to delay surgery for weeks or preclude it altogether. Surgery can more safely proceed when the skin at the surgical site at the lateral heel wrinkles, indicating the dangerous swelling has gone away. 
 
Medications such as immuno-suppressants or steroids may slow healing and may also preclude surgery. Smoking is generally considered harmful for wound and fracture healing. Quitting smoking prior to any planned surgery may diminish those risks. 
 

General Details of Procedure

The most common surgical techniques utilized to treat a broken calcaneus involve cutting through the skin to place the bone back together and using plates and screws to hold the alignment. A classic “open” procedure involves an incision over the lateral aspect of the heel. The incision is likened to a hockey stick or large “L” where the overlying nerve (sural) and tendons (peroneal) are moved out of the way. The fracture fragments are restored to the best possible position. Internal fixation refers to the placement of a plate and screws to hold the fracture in place. 

Post-surgery X-ray of hardware in place
 
 
The technique of “closed” reduction and percutaneus fixation can sometimes be utilized. Multiple small incisions are placed in critical areas around the heel. The broken fragments can be realigned without looking directly at the fracture.This is done with the help of X-rays in the operating room. Screws are then placed through the skin to hold the position.
 

Specific Technique

General anesthesia, used to put a patient to sleep during surgery, is commonly used in conjunction with a regional nerve block, which involves a local injection to help with pain control. The addition of a regional block can provide 12 to 24 hours of pain control after surgery. Surgery can be a same-day procedure or planned with a hospital stay.
 
A tourniquet is used to minimize bleeding and to ensure proper visualization of critical structures that are protected during the surgery. For the standard open approach, a hockey stick or “L” incision is made on the outside of the heel. The sural nerve and the peroneal tendons are moved out of the way and the skin is held back by placing wires is key positions. The bony fragments are then visualized. The general alignment of the heel is restored. The fragments are then placed into position.
 
All fragments are temporarily held in position with small removable wires. The wires are then removed and a plate and screws are placed. The skin is then closed. Post-surgical dressings and a splint are applied. 
 

What happens after surgery?

Expect a lengthy recovery after calcaneus fracture surgery. You will be given a splint or cast. You should not put weight on your foot for at least six to eight weeks until there is sufficient healing of the fracture. The foot remains very stiff and some permanent loss of motion should be expected. Most patients have at least some residual pain despite complete healing.
Everyone who sustains a malaligned break of the calcaneus, particularly involving the joint, should expect to develop some arthritis. If arthritis pain and dysfunction of the foot are severe, then further surgery may be required. These fractures are severe and can be life-changing.
 

Potential Complications

There are complications that relate to surgery in general. These include the risks associated with anesthesia, infection,

Post-surgery X-ray of hardware
  damage to nerves and blood vessels, and bleeding or blood clots.
 
Complications from treatments for displaced calcaneus fractures can be severe. The most common early complications are in skin healing and nerve stretch. Most wound healing complications can be treated with wound care. Occasionally further surgical treatment may be required. The development of a deep wound infection often requires surgery and antibiotics. Nearly all nerve stretch complications will resolve over time.
 

Frequently Asked Questions

Do the plates and screws need to be removed?
No, plates and screws do not need to be removed. If they are causing pain or irritation, your surgeon may consider removing them, but he or she will make sure there is enough fracture healing before proceeding.
 
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