Calcaneus Fractures

Key Points:

  • Fractures of the pediatric calcaneus are rare injuries and are frequently missed.
  • The most common etiology is a forceful axial load to the hindfoot, frequently occurring during a fall.
  • Calcaneus fractures in children younger than 10 years of age, are usually extra-articular.
  • Older children are more likely to have intra-articular involvement and associated injuries remote to the foot.
  • Most calcaneus fractures can be treated non-operatively with immobilization. Those with intra-articular involvement are managed similar to adult fracture patterns.

Description:

Calcaneus fractures are uncommon and frequently missed injuries, especially in very young children.  Falls are the most common mechanism of injury.  The majority of the fractures can be treated with a period of immobilization and a period of protected weight-bearing.  While young children often sustain extra-articular fractures, older children and adolescents are more likely to have intra-articular involvement and associated injuries remote to the foot.  Generally, most calcaneus fractures have a favorable prognosis in the pediatric population. 
 

Epidemiology:

The overall incidence of calcaneus fractures in children is relatively rare, with reported incidence of 1 in 100,000 fractures. (Wiley, 1984)  The type of fracture varies with patient age.  Children younger than 14 years typically have extra-articular fractures while older adolescents often sustain intra-articular injuries. 

Clinical Findings:

Patients usually present with a history of a fall and pain in the heel.  A good history needs to be obtained to ascertain the height of the fall and the amount of energy involved.  This information can also alert the clinician to look for other injuries to the lower extremities and the spine.  The area needs to be inspected
for swelling, open wounds and other areas of tenderness.  A complete neurologic and vascular evaluation needs is essential. 

Imaging Studies:

Calcaneus fractures have been commonly missed as radiographic abnormalities are often more subtle than in adults. (Wiley, 1984; Laliotis, 1993; Schmidt, 1982) The majority of missed fractures are extra-articular.(Schmidt, 1982)
 
Prior to radiographic assessment, one needs to be familiar with the normal ossification centers and accessory bones in the pediatric foot.  The initial workup for a suspected calcaneus fracture involves anterior posterior (AP), lateral and an axial view.  The AP view allows assessment of the talonavicular and the calcaneocuboid joints.  The posterior facet can be seen on the lateral and Bohler’s angle is measured on this view.  Bohler’s angle is the angle between a line drawn between the highest points of the anterior and posterior facets and a line drawn tangential to the highest point on the calcaneal tuberosity.  The normal value in adults is between 20 and 40 degrees.  It is typically less in children and
might require comparison the contralateral side to determine the measurement abnormal.  An axial view is used to assess the calcaneal body, the sustenaculum tali and the posterior facet.  This view can demonstrate the position of the hindfoot.  The Broden view allows for further assessment of the posterior facet. This image is taken with the leg internally rotated 40 degrees and the x-ray beam
angled between 15-40 degrees toward the head. (Broden, 1949) In the older population, a CT scan can be useful for assessment and quantifying intra-articular involvement, similar to adult fracture-type patterns as described by Sanders. (Sanders, 1993)

Etiology:

The injury occurs from an axial load to the hindfoot, often sustained during a fall from height. Younger children with calcaneus fractures typically fall from a lower height than adolescents with these injuries.   The latter group usually sustains higher energy injuries with falls usually greater than 10 feet. (Wiley, 1984) Direct mechanisms of injury include, lawn mower accidents and motor vehicle collisions. 

Treatment:

In younger children, most calcaneal fractures can be treated non-operatively with 4-6 weeks of immobilization in a short leg cast or splint. (Wiley, 1984; Schmidt, 1982; Mora, 2001; Schantz, 1987) Children younger than 10 years of age with extra-articular fractures are particularly amenable to non-operative care. 
 
In older children, extra-articular fractures are also amenable to non-operative care with immobilization and protected weight bearing although a longer period of immobilization and may be required  (up to 12 weeks in a short leg non-weightbearing cast).  The treatment of intra-articular fractures, particularly in the patient nearing skeletal maturity is typically open reduction and internal fixation similar to adults.  This allows for restoration the articular surface, calcaneal height and width of the heel. 
 
Pediatric calcaneus fractures generally have good outcomes following treatment, though few long-term studies have been conducted.  Some have described some mild radiographic changes, but no functional deficits. (Wiley, 1984; Mora, 2001; Schantz, 1987)

Complications:

There are few complications with calcaneus fractures.  (Mora, 2001) The most frequent complication is residual pain and arthosis of the subtalar joint.  This early arthrosis is more frequently seen following intra-articular fractures, similar to the adult population.  Compartment syndrome of the foot following injury and wound complications following open treatment can also occur.   Skin necrosis and fracture blisters are a concern with injuries of greater severity.  Delaying operative intervention until the swelling has subsided may minimize wound healing problems. 

References:

  1. Broden, B., Roentgen examination of the subtaloid joint in fractures of the calcaneus. Acta radiol, 1949. 31(1): p. 85-91. 
  2. Laliotis, N., et al., Toddler's fracture of the calcaneum. Injury, 1993. 24(3): p. 169-70. 
  3. Mora, S., et al., Pediatric calcaneal fractures. Foot Ankle Int, 2001. 22(6): p. 471-7. 
  4. Sanders, R., et al., Operative treatment in 120 displaced intraarticular calcanealfractures. Results using a prognostic computed tomography scan classification. ClinOrthop Relat Res, 1993(290): p. 87-95. 
  5. Schantz, K. and F. Rasmussen, Calcaneus fracture in the child. Acta Orthop Scand, 1987.58(5): p. 507-9. 
  6. Schmidt, T.L. and D.S. Weiner, Calcaneal fractures in children. An evaluation of thenature of the injury in 56 children. Clin Orthop Relat Res, 1982(171): p. 150-5. 
  7. Wiley, J.J. and A. Profitt, Fractures of the os calcis in children. Clin Orthop Relat Res,1984(188): p. 131-8.

Top Contributors:

Keith Gettys MD
Anthony Riccio MD