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Review of Heel Fractures That Heal Wrong or Don't Heal

Falls from a height or car accidents that cause fractures of the heel change a person's life forever. The impact often causes more than one fracture of the calcaneus (heel bone). The injury can also affect the bone above (the talus) and the supportive soft tissue structures. Recovery is very slow and many times the bone just doesn't heal.

With malunion the calcaneus fractures separate, the bone widens, and deformity results. The fracture heals but the bone is not knitted back together properly. The impact of the talus above the calcaneus down into the calcaneus causes a loss of hindfoot height. Change in the angle between the talus and the calcaneus occurs. As a result of all these changes, the affected person can no longer walk normally.

If the calcaneal fracture line extends into the other bones of the ankle, there can be problems with impingement (pinching). Either a piece of bone breaks off and gets jammed in the joint or a nearby ligament gets pinched between the two bones. The joint cannot move normally. Pain, loss of motion, and change in movement pattern can occur.

Not only that but there are often additional injuries with dislocation of tendons and damage to the nerves. These problems can add to the difficulty of walking. There is usually a loss of natural shock-absorption in the heel and foot leading to increase wear and load on one side of the joint(s). Damage to articular cartilage of the joint surface may never recover. In the end, when the bones and joints no longer line up properly, many patients develop posttraumatic arthritis.

What can be done to help patients with calcaneal malunion? The surgeon must perform a thorough physical history and exam (PH&E) in order to identify all areas that are affected. Information on the location of the pain, what increases or decreases the pain, and any previous treatment is reviewed. Motion, strength, and sensation are assessed.

X-rays taken in the standing (weight-bearing) position from different angles (side, back, above) show the fractures lines, of course. But the images also give the surgeon an idea of the new shape of the bones, changes in alignment and angles, and deformity or changes in weight-bearing load. CT scans can also be very useful as they provide a three-dimensional (3-D) view of the bones and joints. From the CT scans, surgeons gain a better appreciation of any deformities and joint damage.

These pieces of the puzzle are important when planning treatment because there isn't one simple problem that must be addressed. There are often multiple factors to consider. Besides changes in anatomy, biomechanics, and gait (walking pattern), the patient's lifestyle, goals, expectations, and needs at work, home, and play must all be reviewed. Other health or medical problems may enter the mix as well.

Management may begin with conservative (nonoperative) care. The goals are to decrease pain and improve comfort and function. Nonsurgical treatment can include special shoes, orthotics (shoe inserts), bracing, medications for pain relief, and/or injections with a numbing agent combined with a steroid (anti-inflammatory).

Physical therapy is an important part of conservative care. The therapist focuses on improving joint motion, strength, and movement patterns needed for daily activities, work, and recreational activities or hobbies.

For those patients who have severe deformities that cannot be treated conservatively (or for those who do not respond to nonoperative care), there are a variety of surgical techniques that can help. Once again, the surgeon chooses the best surgical approach based on the problems present at the time of the evaluation. Muscle tightness can be corrected with surgical release (lengthening) of the tendon. Instability can be treated with a fusion of two or more bones called arthrodesis.

The surgeon does everything possible to correct deformities, improve alignment, and decompress (take pressure off) tendons or nerves. Bone may be removed from some areas or built up in other areas to correct alignment or restore calcaneal height. Hardware such as pins or screws may be needed to hold the bones together until fusion is complete. Intra-operative X-rays (taken during surgery) are used to make sure everything is lined up correctly.

Some patients are not good candidates for surgery. For example, the presence of a painful post-traumatic condition called complex regional pain syndrome (CRPS) does not respond to surgery. Surgery is an added trauma and may even make things worse. Likewise, heel pad pain does not go away with surgery.

The authors warns patients calcaneal fractures that don't heal properly are difficult to treat successfully. Patients can expect changes in their lives as a result of these types of injuries. Treatment can help moderate disability but irreversible damage to the bones and/or joints is common. Patients will probably have to change some of their activities when pain, altered gait, and nerve problems can't be relieved or corrected.

Reference: Rahul Banerjee, MD, et al. Management of Calcaneal Malunion. In Journal of the American Academy of Orthopaedic Surgeons. January 2011. Vol. 19. No. 1. Pp. 27-36.

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