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.
The goal of heel fracture surgery is to restore the shape of the heel bone as close to normal as possible. Restoration of normal alignment and contour is considered the best way to restore function and minimize pain.
Surgery is recommended when a broken heel bone has lost its alignment and contour. Your foot and ankle orthopaedic surgeon typically identifies this type of fracture after performing a physical examination and obtaining standard foot and ankle X-rays. The specific type, pattern, and classification of the fracture is best made through a CT scan. Your surgeon may require both X-rays and a CT scan to determine if surgery is your best option.
Not all heel fractures require surgery. Surgery may not be needed if the shape of the heel is generally in tact. 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.
Heel surgery often is delayed due to the swelling that can accompany these injuries. It may be severe enough to delay surgery for weeks or preclude it altogether. Surgery can 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 delay or preclude surgery. Smoking is considered harmful for wound and fracture healing and smokers should quit before any planned calcaneus surgery.
The most common surgical techniques foot and ankle orthopaedic surgeons utilize to treat broken heel bones involve cutting through the skin to place the bone back together and using plates and screws to hold the alignment until the bones heal. In a classic "open" procedure, your surgeon will make an incision over your heel. The incision is likened to a hockey stick or large "L" where the overlying nerve and tendons are moved out of the way. The fracture fragments are restored to the best possible position and a plate and screws hold the fragments in place.
The technique of "closed" reduction and percutaneous fixation can sometimes be utilized. In this procedure, your surgeon makes multiple small incisions in critical areas around the heel, realigns the broken fragments with the help of X-rays, and places screws through the skin to hold the position.
The size and location of the incision and the type of screws and plates used are based on skin quality and the surgeon's judgment on how to best access and fix the broken fragments of bone.
Specific Technique
General anesthesia, used to put a patient to sleep during surgery, commonly is used along with a regional nerve block, which involves a local injection to help with pain control. The addition of a regional block can provide 12-24 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 in key positions. Your surgeon will put the bony fragments into position to restore the general alignment of the heel.
All fragments are temporarily held in position with small removable wires. The wires are then removed, and a plate and screws are placed. Your surgeon will close the skin and apply post-surgical dressings and a splint.
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 6-8 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 despite having surgery. If arthritis pain and dysfunction of the foot become severe, then further surgery may be required.
Heel bone fractures often are severe and can be life-changing.
X-ray of the heel after calcaneus fracture surgery with hardware in place
All surgeries come with possible complications, including the risks associated with anesthesia, infection, 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.
No. 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 removal.
Contributors/Reviewers: Glenn Shi, MD; Andrew Pao, MD
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