Heel bone fracture

A heel bone fracture often results from jumping or falling from a great height. Men are affected five to eight times as often as women, and walking is restricted immediately after the accident because of pain. A heel bone fracture can in part be treated conservatively.


Causes

A heel bone fracture most often occurs due to excessive force acting on the area of the heel bone. The most common cause of heel fracture is falling from a great height (about 80%), followed by traffic accidents (about 10%), sport accidents (about 8%) and fatigue fractures (2%). In 20% of cases the fracture is bilateral. Osteoporosis is also a possible cause, which means a heel bone fracture is an after-effect. Half of all heel bone fractures are due to accidents at work or between work and home. Men are affected five to eight times as often as women, mainly between 35 and 60 years of age.

Symptoms

Acute swelling in the rear of and above the ankle is seen in case of a heel bone fracture. Usually the entire foot is swollen and significant discolouration from bruising is generally apparent. The mobility of the foot is restricted because of severe pain.

In some cases the skin and soft tissue in the area of the heel bone tear due to the accident. This compound fracture is at increased risk of infection. Since this is an emergency, immediate medical treatment is required in the form of an operation.

Diagnosis

After the doctor has obtained an initial impression based on a detailed medical history and a description of the accident, imaging methods are used in addition for diagnosis. X-rays are taken in three planes and magnetic resonance imaging (MRI) is performed. Computer tomography (CT) is necessary to classify the heel bone fracture and plan a possible operation.

Therapy

If the heel bone fracture has not shifted and no joint surfaces are affected, conservative treatment is usually recommended. Relieving orthoses help promote faster healing.

An acute heel bone fracture is treated based on the PRICE rule (protection, rest, ice, compression, elevation). Pain relief is administered in combination with active physiotherapy in the form of lymph drainage. This is intended to reduce the pronounced swelling and improve mobility in the tarsal joints. Depending on the course of treatment, strain on the heel should be relieved for at least 6 to 12 weeks.

However, the heel bone fracture is more complex in many cases. All heel bone fractures that radiate into the joint surfaces and exhibit an offset of more than 1 mm in width are operated. An operation is also performed if the hindfoot is incorrectly positioned. Here the affected area is generally operated by means of a right-angled incision on the outside of the heel bone. Since the soft tissue usually swells significantly, this is done between 6 and 10 days after the accident. In the meantime, swelling of the affected foot is reduced by means of elevation, cooling and lymph drainage.

In case of a compound fracture, damaged tissue is removed in an operation and the joint is secured, usually by means of external connecting rods. The bone fragments are first assembled during the operation; then the heel bone alignment is improved and it is brought back to the correct position. Once the length and shape of the heel bone have been restored, a plate with screws is installed for stabilisation.

After the operation, the leg is initially positioned in a padded splint until physiotherapy begins after 2 to 5 days. Depending on the extent of the fracture and the stability achieved by the operation, weight bearing is generally avoided for at least 8 to 12 weeks. Extreme strain on the heel should be avoided for the next 6 months as well but the level of activity can be increased gradually. Another X-ray is usually taken after about 6 weeks, 12 weeks, 6 months and a year. Special heel relief orthoses can significantly increase mobility in the early phase.


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