Heel fractures are a fairly common workplace injury in heavy laborers or those working at heights. It is estimated that approximately 70 percent of these injuries occur on the job. The vast majority are caused by a fall over six feet. Most heel fractures extend into the surrounding joints and are displaced. The patient will have immediate pain, swelling, and will not be able to bear weight. Compartment syndrome of the foot is possible. Routine x-rays include AP, lateral, axial and an oblique view. CT scanning is mandatory if surgical fixation is planned. Associated injuries are common and lumbar compression fractures may occur in up to 10 percent.
Treatment for these complex injuries remains difficult. However, for displaced fractures in the hands of an experienced surgeon, open reduction and internal fixation results in the opportunity for a superior outcome over non-operative treatment. Surgery is often delayed 10 to 21 days to allow swelling to subside and the soft tissues to stabilize. After surgery a patient is immobilized for approximately three weeks to allow the wound to heal. Range of motion is then started but weight bearing is delayed for eight to ten weeks following surgery. Return to work varies greatly among patients but may be several months for return to full duty with no standing or walking restrictions. Post-operative problems can still occur even in experienced hands. The most common is wound healing problems and flap necrosis. Heavy smokers are at an increased risk for this problem. Neuroma formation and stiffness may also occur. Even in good to excellent result, patients may lose subtalar (side-to-side) motion. The major late development is post-traumatic arthritis of the subtalar joint. Surgical fixation decreases this risk but certainly doesn’t eliminate it. Loss of subtalar motion affects the ability of an individual to work on uneven surfaces or ground. If arthritis pain cannot be controlled with anti-inflammatory medications or orthotics, a subtalar fusion is required.
Worker’s compensation patients don’t do as well as those not injured on the job. Only 25 percent had a good to excellent result versus 88 percent of non-worker’s compensation patients. Functional outcome scores also are insignificantly lower in the worker’s compensation individuals. Long-term data suggests that up to 70 percent will have difficulty on uneven surfaces, 30 percent have difficulty walking greater than one mile. Pain is found in94 percent of patients (mild-57 percent, moderate-37 percent, and severe-6 percent). Overall, 74 to 90 percent of patients return to work with some restrictions. Impairment ratings are based on the loss of motion at the subtalar joint, post-traumatic arthritis, possible arthrodesis and the possible need for brace use.
Calcaneus fractures that are displaced and intra-articular (approximately 75 percent) are significant injuries that may result in major alterations of an individual’s previous function. The best opportunity for maximal improvement rests in the hands of those orthopadeic surgeons who are experienced in dealing with those complex fractures.