Getting Ready to String Up Some Holiday Lights?

You Might Just be Making Your Heel a Little Nervous!

Believe it or not, the number of heel bone (calcaneal) fractures that Foot and Ankle specialist see in their office tends to increase around this time of year. Certainly we get an increase in ankle fractures when the snow starts to arrive, but often people wonder about why heel fracture numbers go up. I’ll tell you a little secret: people start climbing ladders to hang holiday lights, and if they fall off the ladder and manage to land on their feet, they might just fracture their heel bone!

Calcaneal fractures are high-energy injuries, meaning that there needs to be a large force to create a fracture. If you think about it, falling off a ladder and landing on your heels creates a large force, as the entire weight of your body crashes into the concrete! Another common mechanism of injury for calcaneal fractures are motor vehicle accidents; another high-energy pattern. Therefore, patients who suffer from a calcaneal fracture must be evaluated fully for other injuries and fractures created during this force. The most commonly associated injury (although not common at all) is a lumbar spine (lower back) fracture. The force into the calcaneus tends to travel up the body and compacts the lower back making it more susceptible to injury.

If you have fallen from a ladder recently and suspect any kind of lower extremity injury, it is important to see you Podiatrist! They can evaluate you, take x-rays and rule out a fracture if you’re suspecting one. If there is a fracture present, they can initiate treatment as soon as possible to get you on the road to recovery! Symptoms that one might notice include severe pain! In addition there may be a distinct “black-and-blue” mark extending from the heel into the arch of the foot. As you know, we Podiatrist’s have names for everything, and call that “black-and-blue” a Mondor’s sign. In addition you will have difficulty moving the foot up and down at the ankle joint and pain with moving your foot inwards and outwards. A comparison of your feet from behind will reveal a slightly wider heel/foot on the affected side when compared to the non-affected foot.

Once you have been evaluated, any other injuries to the body have been ruled out, and x-rays confirm the diagnosis of a calcaneal fracture, the decision then becomes whether surgery is indicated or not, in order to repair the calcaneus. The answer to this question and the recommendation that your Podiatrist will make will be largely based on the location of the fracture, how far the pieces of the fracture are away from where they belong and if the Subtalar joint (the one that sits underneath the ankle) is disrupted.

In the best-case scenario, the fracture will be minimally displaced and the Subtalar joint will be unaffected, sparing you from surgical correction. In this instance, you will need to be casted for 6-8 weeks with crutches to avoid that any weight is put onto the affected foot. After those 6-8 weeks, when healing can be confirmed via x-ray, you will slowly be transitioned into a walking cast and finally back to a supportive sneaker.

In the worst-case scenario, the fracture will be largely displaced and the Subtalar joint will be severely affected, indicating surgical correction for realignment. The goal of surgical intervention is to repair the Subtalar joint with the hope that the height of the calcaneus can be regained and normal function of that joint can be restored. In order to accomplish this, a metal plate with several screws will be inserted against the heel bone to bridge the area and allow for healing in the corrected positioning. The length of time that you will be casted and non-weight bearing with crutches is closer to 12 weeks, again with transition to a walking cast and finally backs to a sneaker over the next several weeks. The treatment course for a severe fracture like this is about 6 months until you are able to return to normal activity, while the long-term effects last a lifetime.

Patients who suffer calcaneal fractures where the joint is involved, typically require an additional surgery down the line. The indication for this surgery is post-traumatic osteoarthritis, which we discussed over the last several weeks. PTOA is virtually impossible to avoid with this type of fracture pattern, but the initial surgery is important in managing PTOA in the long-term. It has been reported that patients who have initial reduction of their calcaneal fracture as indicated, do better down the line with managing their PTOA and although they end up having a joint fusion (a joint that will no longer move) they are more pain-free than their counterparts!

Scope it out!

Last week we reviewed the topic of Post-Traumatic Osteoarthritis. We defined the condition of PTOA as an arthritic condition that occurs within a joint sometime after the joint has been injured. Proper realignment of the initially injured joint helps to cut down on the occurrence and progression of PTOA, but sometimes it is inevitable!

There are several injuries, specific to the lower extremity that are infamous for causing PTOA, and they are as follows:

- Ankle fractures: PTOA in the ankle joint

- Heel bone fractures: PTOA in the Subtalar joint (the joint just below the ankle)

- Midfoot fractures: PTOA within the joints across the middle of the foot

This week, I wanted to focus on Arthroscopy as a treatment modality for PTOA in the ankle joint, following an ankle joint fracture. Arthroscopy is a procedure that utilizes a small camera to access and view the joint on a larger monitor, while allowing the surgeon to “scope” the joint and remove debris from the joint space. The end result and goal of Arthroscopy is to decrease the patient’s joint pain secondary to PTOA and to allow the joint to glide more easily through its typical range of motion.

When you suffer from PTOA, the joint becomes clouded with debris coming in the form of lose cartilage pieces, or in the form of synovitis. Synovitis describes inflammation of the “joint synovium;” a.k.a. the joint fluid that helps with easy gliding of the joint surfaces. Each of these components leads to painful range of motion in patients, thus eliminating or decreasing their presence within the joint space, through Arthroscopy, can be very beneficial!

The joint will be prepared with a distraction device, meaning an external device will be applied to both your leg and foot, with a gentle pull placed on each side, to increase the ankle joint space. This allows for easier insertion of instruments and for better visualization of the joint damage, so that debris is not missed during the procedure.

Local anesthetic will be injected into the ankle joint, with continual sterile saline flushing through the joint space during the procedure. The saline is important to create a “fishbowl-like” appearance of the joint, essentially floating the pieces of debris inside the joint that might otherwise adhere to the joint surfaces making it difficult to remove them.

The typical approach to Ankle Arthroscopy is from the front of the leg through two small incisions, measuring about 1cm in length. A camera will be inserted into one of the incisions entering the ankle joint capsule. In the other incision, a small cannula (hallow tube) will be inserted, which can be used to feed surgical instruments into the joint, helping to clear debris. A small ‘burr’ is the typical instrument of choice used by surgeons performing these procedures. The burr rotates back and forth eating debris as it is moved around the joint. Envision Pac-Man!

Post-operatively you will have two sutures in place, one over each of the small incision sites. Depending on surgeon preference, you will be placed in am immobilization device and will be required to remain non-weight bearing until your first follow-up appointment. Physical therapy is often initiated in patients who undergo Ankle Arthroscopy to help strengthen the muscles surrounding the ankle joint while improving joint function and getting you back on your feet, with range of motion to the ankle joint that is much less painful than prior to your “scope!”

There are risks to any procedure, although the risks of arthroscopy are minimal and rare. However, you should discuss all options for treating your Ankle Joint PTOA with your Podiatrist prior to any surgical intervention.