Calcaneus Fracture

A calcaneus fracture is a broken heel bone. There are two types of calcaneus fractures: one involves the subtalar joint and one does not involve the joint.

The subtalar joint is formed by the calcaneus and the bone above it, which is called the talus. This joint allows side-to-side motion of the foot, which is important for walking on uneven surfaces. Calcaneal fractures that involve the subtalar joint are usually the most severe.

Symptoms

Symptoms of a heel fracture include pain, swelling and bruising of the heel. Patients usually are unable to walk. In fractures with severe swelling, blisters may develop around the heel.

Causes

High-energy injuries usually cause calcaneus fractures that involve the subtalar joint. Falls from a height and car accidents are the most common causes. Low-energy injuries such as twisting the ankle can cause smaller chips or bone fragments to break off from the edges of the calcaneus. These are called avulsion fractures. These do not usually involve the joint surfaces.

Diagnosis

X-rays along with physical examination are used to diagnose fractures of the calcaneus. A CT scan may be needed to look more closely at the pieces of the fracture or to see aspects that are not seen on the X-rays.

Treatments

Some heel fractures can be treated without surgery. The foot can be placed in a split or a removable fracture boot so that patients can work on ankle and foot motion. The amount of time that the patient has to keep weight off of the foot depends on the severity of the fracture.

Surgery may be recommended if the fracture involves the joint and pieces are displaced. A plate and/or screws may be used to hold the pieces of the fracture in place. With a severe fracture, a fusion of the subtalar joint also may be recommended.

Recovery

Recovery can take a long time. The period of non-weightbearing usually lasts for 8-12 weeks. Physical therapy can help with motion and improve the function of the foot.

Calcaneus fractures are significant injuries. Pain, stiffness, and swelling may last for months or indefinitely depending on the severity. Most people are able to return to work and recreational activity once their recovery is complete.

Risks and complications

Healing of the surgical incision can be a problem after surgical treatment of heel bone fractures. These usually resolve with local wound care, however, deep infections can occur and may need more surgical treatment. Other complications can include permanent stiffness of the subtalar joint after a calcaneus fracture, limiting side-to-side motion of the foot. Fractures that involve the subtalar joint can develop arthritis over time. Painful arthritis is treated with injections, bracing and sometimes a surgery to fuse the subtalar joint.

Calcaneus fractures may cause heel widening, making it difficult to fit into a shoe. This may be able to be treated surgically.

Additionally, the tendons that pass along the outer border of the calcaneus can become damaged or irritated. This can be treated with bracing or surgery.

FAQs

When can I return to exercise and activity?

Fractures of the heel bone can be devastating injuries. Returning to exercise and recreational activity can be difficult. Most people can resume low-impact exercise (swimming, biking, or elliptical machine use) a few months after their injury. Returning to high-impact exercise (running, jumping, and hopping) takes longer. Sometimes the injury is so severe that returning to high-impact activity is not possible.

Calcaneal Osteotomy

The calcaneus, or heel bone, plays an important role in walking. A calcaneal osteotomy is a controlled break of the heel bone, performed by a foot and ankle orthopedic surgeon, to correct deformity of the foot and ankle.

The heel bone can be realigned to achieve a different orientation, which can correct many different deformities and foot/ankle problems. For example, abnormally high or low arches can be addressed with a calcaneal osteotomy. The ultimate goals of all osteotomies are to relieve pain, improve alignment and walking, and reduce the likelihood of arthritis.

Diagnosis

If your pain is worsening or you have a deformity of the foot and ankle that is not responding to other treatments, a calcaneal osteotomy may be part of your surgical reconstruction plan. Discuss your options with your foot and ankle orthopedic surgeon. If you are at high risk for medical complications, the risks of surgery may outweigh the potential benefits.

Treatment

A calcaneal osteotomy commonly is combined with other procedures to reconstruct the foot. This type of surgery usually is an outpatient procedure, meaning you can go home the same day as surgery, but will vary depending on each patient and surgeon.

Specific

Techniques In a calcaneal osteotomy, an incision is made on the outer or lateral side of the foot. After the bone is cut, it is moved to the desired location and fixed in place. Most often, surgical implants such as screws hold the bones together and support healing.

The four most common types are the Evans, Dwyer, Medial Shift, and Lateral Shift.

Evans osteotomy: If you look down at your foot, you can see an inside edge and outside edge of the foot. For the foot to be straight, the inside edge of the foot and outside edge of the foot must be similar lengths. An Evans osteotomy is a controlled break that makes the outside part of the foot longer to help make the foot straight. Often a bone graft is used. The procedure may be performed on patients with flatfoot deformity.

Dwyer osteotomy: This is a break that removes an outside-based wedge of bone from the calcaneus in order to realign the foot. It is sometimes performed on patients with abnormally high arches.

Medializing osteotomy: In this procedure, the heel bone is cut and moved towards the inside part of the foot to help restore a fallen arch. Arthritis, loss of tendon function, and injury are some causes of a fallen arch.

Lateralizing osteotomy: This is another osteotomy for abnormally high arches. In this procedure, the heel bone is cut and shifted to the outside to reduce the arch and improve alignment.

Recovery

You will be placed in a splint or boot. Depending on your surgeon’s preference, the splint may be changed to a cast in 1-2 weeks. You will have to keep weight off your foot for 4-6 weeks. At that point, progressive weight bearing usually can start. Getting back to regular activities typically takes 3-6 months and swelling will improve slowly. If you have another foot or ankle procedure done at the same time, your recovery may be longer.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

The potential complications associated with calcaneal osteotomies are nerve and tendon injury, failure of the bone fragments to heal together, loss of correction of the deformity, painful hardware and infection. Your orthopedic surgeon will discuss the risks and benefits of surgery with you in detail.

FAQs

What are the chances that my bone will not heal?

This is uncommon and can happen approximately five percent of the time. Smoking, infection, and poor circulation all are potential risk factors. Should you choose to have surgery, your doctor will discuss these risks with you.

Bunionette

A bunionette (also known as a tailor’s bunion) is a painful bony prominence, or bump, on the outside of the little (pinky) toe. Over time, the bunionette may worsen as the little toe moves inward and the fifth metatarsal (the bone connected to it) moves outward. Rubbing between the bump and tight shoes may also cause a callus to grow over the area. All bunionettes can cause pain and pressure on the outside of the foot, though often they do not cause symptoms.

Treatments

The initial treatment of a bunionette is non-surgical. This can include wearing shoes that are roomier with a wide toe box to avoid rubbing on the bony prominence. Padding the little toe using a toe sleeve may reduce discomfort as well.

If your bunionette is painful even after wearing wide, comfortable shoes, if you cannot wear comfortable shoes because of the size of your bunionette, or if you continue to have problems after non-surgical treatment, your foot and ankle orthopedic surgeon may recommend surgery. The goals of this surgery are to remove the bony prominence and correct alignment to decrease pain. Surgery should be avoided if you have poor circulation or uncontrolled diabetes, if you are a chronic steroid user, or if you smoke cigarettes. These are risk factors for delayed healing of incision and bone.

Bunionette surgery is usually an outpatient surgery, meaning you can go home the same day as the surgery. It involves removing the bony prominence of the bunionette. In a larger bunionette that is causing an alignment problem, breaking the fifth metatarsal bone and restoring normal alignment may be necessary. Your foot and ankle orthopedic surgeon will explain what kind of surgery is needed for you and why.

Specific Techniques

The type of surgery to correct the bunionette depends on the shape of the fifth metatarsal bone, type of bunionette, and patient’s wishes.

• If you have a painful prominence without a bony growth, the surgery usually involves removing the painful soft tissue of the little toe.
• If you have a Type 1 bunionette, it means you have an enlarged bump at the outer end of the fifth metatarsal head (where the toe meets the foot). During surgery, this bony growth is removed.
• Sometimes the bony protuberance is so big that the bone of the fifth metatarsal needs an osteotomy, which is breaking the bone to realign it. The bone is cut and moved towards the fourth metatarsal to correct the alignment.
• If you have a curved shape to your little toe (Type 2 bunionette) or angle (Type 3 bunionette) between the fourth and fifth metatarsal, your surgeon will often do an osteotomy. This osteotomy is done to straighten out the fifth metatarsal.
• If a bunionette deformity is treated with an osteotomy, the bone may be held straight with a steel wire, screw, or plate and screws, depending on the surgeon’s preference.

Recovery

After the surgery, patients may need to stay off their operated foot with no weight or heel weight bearing on it for a period of weeks. Patients will need to wear a post-surgical shoe or a short CAM boot on their foot to keep it protected after surgery. You may also need to use crutches or a walker depending on your activity level and pain. In severe deformities, some surgeons will place a short leg splint to better protect the surgical correction. The specific amount of time that your foot needs to be protected after surgery depends on the type of surgery and the surgeon’s protocol. The operated foot will need to be elevated above the level of the heart as much as possible for at least the first few days. This will help to decrease swelling.

Your stitches are usually taken out 2-3 weeks after surgery. You will be asked to not soak your foot or get the surgical area wet until your stitches are out.

Your foot and ankle orthopedic surgeon may ask you to do knee and ankle exercises at home after surgery. This can help maintain your joint motion and flexibility. If your doctor thinks that you need physical therapy after the soft tissue and bone is healed, he or she will discuss that with you.

Swelling is the last thing to improve for most patients after bunionette surgery. It can take 6-12 months for your foot’s swelling to completely improve after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Potential complications after bunionette surgery are rare. Possible problems include bleeding from the wound, injured nerves around the little toe, poor wound healing or bone healing if an osteotomy is done, and the possibility of recurrence of the bunionette.

FAQs

If my bunionette deformity is treated without surgery, can I ever wear high heels and pointed shoes?

Wear pointed-toe shoes as little as possible. This does not mean that you cannot ever wear these shoes, but you should limit the time wearing them in order to decrease pain and the chance that the bunionette will get worse.

If I’m treated with surgery, will the deformity come back?

Most bunionettes do not come back after being treated with the right type of surgery. The surgery should correct the underlying cause of the problem. However, wearing shoes that are too narrow can still cause irritation and inflammation at the operated little toe.

Bunion

Bunion is the name for a prominent bump along the inside of your big toe. If you notice a swollen, painful big toe, you may have a bunion. More than one-third of women in America have bunions. Bunions often are hereditary, but they also develop from wearing tight shoes.

If you have a painful, swollen lump on the outside of your foot near the base of your little toe, it may be a bunionette (“tailor’s bunion”). Similar to a bunion, bunionettes can be caused by wearing shoes that are too tight.

Symptoms

With a bunion, the base of your big toe (metatarsophalangeal joint) gets larger and sticks out. The skin may be red and tender, and wearing any type of shoe may be painful. This joint flexes with every step you take, so the bigger your bunion gets, the more it may hurt to walk. Bursitis (painful swelling with inflammation) may set in. Your big toe may tilt toward your second toe or move all the way under it.

In addition, the skin on the bottom of your foot may become thicker and painful. Pressure from your big toe may force your second toe out of alignment, sometimes overlapping your third toe or the big toe. An advanced bunion may make your foot look deformed. If your bunion gets too severe, it may be difficult to walk. Your pain may become chronic and you may develop arthritis.

Prevention

Most bunions are treatable without surgery. Prevention is always best. To minimize your chances of developing a bunion, never force your foot into tight shoes that don’t fit or that crowd your toes. Choose shoes that conform to the shape of your feet and ones with wide insteps, broad toe boxes, and soft soles. Avoid shoes that are short, tight, or sharply pointed, and those with heels higher than 2 1/4 inches.

If you already have a bunion, wear shoes that are roomy enough to avoid putting pressure on the big toe. This should relieve most of your pain. You may want to have your shoes stretched out professionally. You also may use protective pads to cushion the painful area, or a spacer to maintain the gap between the big toe and the second toe.

Treatments

If your bunion has progressed to the point where you have difficulty walking or experience pain despite changing shoes, you may be a candidate for surgery. Bunion surgery realigns bone, ligaments, tendons, and nerves so your big toe can be brought back to its correct position. There are several different techniques that can be performed to ease your pain; see a foot and ankle orthopedic surgeon to discuss your options.

Most bunion surgeries are outpatient procedures, meaning you can go home the same day as surgery. Recovery occurs over 3-6 months and may include persistent swelling and stiffness.

Broken Foot or Broken Toes

Nearly one-fourth of all the bones in your body are in your feet, which provide you with both support and movement. A broken (fractured) bone in your forefoot (metatarsals) or in one of your toes (phalanges) often is painful but rarely disabling. Most of the time, these injuries heal without surgery. Since a dislocation can be mistaken for a toe fracture, it is important to obtain X-rays to ensure a correct diagnosis.

Symptoms

Pain, swelling, and bruising are the most common signs of a fracture in the foot. If you have a broken toe, you may be able to walk but this usually aggravates the pain. If the pain, swelling, and discoloration continue for more than 2-3 days, or if pain interferes with walking, something could be seriously wrong; see your foot and ankle orthopedic surgeon as soon as possible. If you delay getting treatment, you could develop persistent foot pain and arthritis. Pain also can change the way you walk (your gait), which could lead to painful calluses on the bottom of your foot or other issues.

Causes

Stress fractures frequently occur in the bones that extend from your toes to the middle of your foot (metatarsals). Stress fractures are like tiny cracks in the bone surface. They can occur with sudden increases in physical activity, such as running or walking for longer distances or times, improper training techniques, or changes in training surfaces. They may be related to the shape of the foot, an overly tight calf muscle or heel cord (Achilles), or metabolic or nutritional factors.

Traumatic fractures result from a sudden force, such as a fall, dropping a heavy object on your foot, or a twisting injury. If the fractured bone does not break through the skin, it is called a closed fracture. These fractures may be stable with no shift in bone alignment or displaced with bone ends that no longer line up.

Several types of fractures can occur to the forefoot bone on the side of the little toe (fifth metatarsal). Ballet dancers may break this bone during a misstep or fall from a pointe position. An ankle-twisting injury may tear the tendon that attaches to this bone and pull a small piece of the bone away. A more serious injury in the same area is a Jones fracture, which occurs near the base of the bone and disrupts the blood supply to the bone. This injury may take longer to heal or require surgery.

Diagnosis

Your foot and ankle orthopedic surgeon will examine your foot to pinpoint the central area of tenderness and compare the injured foot to the normal foot. You should tell your surgeon when the pain started, what you were doing at the time, and if there was any injury to the foot. X-rays will show most fractures of the forefoot and should be obtained standing if possible to improve diagnostic accuracy. A CT scan or MRI may be needed if the fracture enters a joint, or if X-rays fail to reveal an injury.

Treatment

See your foot and ankle orthopedic surgeon as soon as possible if you think that you have a broken bone in your foot or toe. Until your appointment, keep weight off the painful area and apply ice to reduce swelling. Use an ice pack or wrap the ice in a towel so it does not come into direct contact with the skin. Apply the ice for no more than 20 minutes at a time. Take acetaminophen or ibuprofen to help relieve the pain. Wear a wider shoe with a stiff sole to remove stress from the injury site.

Rest is the primary treatment for stress fractures in the foot. Stay away from the activity that triggered the injury, or any activity that causes pain at the fracture site, for 3-4 weeks. Substitute another activity that puts less pressure on the foot, such as swimming. Gradually, you will be able to return to activity. Your surgeon, physical therapist, or coach may be able to help you pinpoint the training errors that caused the initial problem so you can avoid a recurrence.

If you have a displaced fracture, the bone ends must be realigned and the bone kept immobile until healed. If you have a broken toe, the doctor will “buddy tape” the broken toe to an adjacent toe, with a gauze pad between the toes to absorb moisture. You should replace the gauze and tape as often as needed. Remove or replace the tape if swelling increases and the toes feel numb or look pale. If you have diabetes with neuropathy or peripheral neuropathy (loss of sensation in the toes), do not tape the toes together. You may need to wear a rigid, flat-bottom orthopedic shoe for several weeks.

If you have a broken bone in your forefoot, you may have to wear a short-leg walking cast, a brace or a rigid, flat-bottom shoe. It could take 6-8 weeks for the bone to heal, depending on the location and extent of the injury. After a week or so, your foot and ankle orthopedic surgeon may request another set of X-rays to ensure that the bones remain properly aligned. Many of these fractures are treated successfully without surgery, although in severe injuries, pins or screws may be required to hold the bones in place while they heal. Surgery often is not needed to treat fractures in the toes or forefoot. However, when it is necessary, it has a high degree of success.

Recovery

The forefoot and toes tend to heal slowly, so it can take months for a fracture to heal. In the toes, swelling can continue for a long time even when patients are not having other symptoms.

Risks and Complications

Risks associated with these fractures are specific to the injury. If the fracture goes into a joint, it could lead to arthritis. If the skin is broken at the time of the injury, you could develop an infection.

On occasion, the bone does not heal. In other cases, pain or swelling can remain. For these reasons, it is important to have further follow up with your surgeon if you continue to have symptoms.