Calcaneus Fracture (Broken Heel)

Introduction

The calcaneus, commonly known as the heel bone, is the largest bone in the foot and plays a crucial role in supporting body weight and facilitating movement. A fracture of the calcaneus, often referred to as a broken heel, is a severe injury that can dramatically impact mobility, comfort, and quality of life. Although not as common as other types of fractures, a calcaneus fracture is significant due to the bone’s size, function, and the forces typically required to break it. This guide will explore the key aspects of calcaneus fractures, including their causes, symptoms, diagnosis, treatment, and the recovery process.

What is a Calcaneus Fracture?

A calcaneus fracture is a break in the heel bone, located at the back of the foot below the ankle. These fractures can vary widely in severity, from small cracks to complex breaks involving multiple pieces of bone. They are generally classified as either intra-articular (involving the joint surface) or extra-articular (not affecting the joint).

• Intra-articular fractures affect the subtalar joint, which connects the calcaneus to the talus bone above and are more likely to lead to long-term complications like arthritis.
• Extra-articular fractures occur outside the joint and may involve the body, anterior process, or tuberosity of the calcaneus.

Causes of Calcaneus Fractures

Calcaneus fractures usually result from high-energy trauma or forceful impacts. The most common causes include:

• Falls from a height: Landing on the feet after falling from a significant height, such as from a ladder, roof, or a tree, is the leading cause.
• Motor vehicle accidents: The heel can be injured when the foot is forcefully pressed against the floorboard during a collision.
• Sports injuries: Activities involving jumping, such as basketball, rock climbing, or gymnastics, can sometimes result in a broken heel, though these are less common.
• Direct blows: A heavy object falling on the heel or a direct kick to a hard surface can cause a fracture.

Low-energy mechanisms, such as twisting the ankle or repetitive stress, rarely cause calcaneus fractures but may result in stress fractures, especially in athletes or military recruits.

Symptoms of a Calcaneus Fracture

The symptoms of a broken heel can range from mild to severe, depending on the extent of the injury. Common signs and symptoms include:

• Severe pain in the heel and hindfoot, especially when bearing weight
• Swelling, bruising, and tenderness around the heel
• Inability to walk or put weight on the affected foot
• Deformity of the heel or foot, with possible widening or flattening
• Open wounds or bone protruding from the skin in more severe injuries (open fractures)
• Numbness or tingling (if nerves are affected)

In some cases, symptoms may be subtle, leading to delayed diagnosis and treatment.

Diagnosis of Calcaneus Fractures

Prompt and accurate diagnosis is critical for effective management. The diagnostic process includes:

• Physical examination: The healthcare provider will assess the foot for swelling, bruising, deformity, and range of motion, and check for open wounds or nerve injury.
• X-rays: X-ray imaging is the first step in visualizing the fracture, determining the location and number of fracture fragments, and assessing joint involvement.
• CT scan: Computed tomography (CT) scan provides detailed cross-sectional images, especially useful in complex or intra-articular fractures for surgical planning.
• MRI or bone scan: These may be used to detect stress fractures or assess soft tissue injuries when other imaging is inconclusive.

The doctor will also evaluate for other injuries, such as spine or pelvic fractures, which can occur in high-energy trauma.

Treatment Options

Treatment depends on the type, severity, and location of the fracture, as well as the patient’s overall health and activity level.

Non-Surgical Treatment

Extra-articular fractures, non-displaced fractures, or those where the bone pieces remain properly aligned may be managed without surgery.

• Immobilization: The foot may be placed in a cast, splint, or boot to keep the bone stable while it heals, typically for 6-8 weeks.
• Non-weight bearing: Patients are advised to avoid putting any weight on the injured foot, often using crutches or a walker.
• Pain management: Medications and icing help control pain and inflammation.
• Physical therapy: Gradual rehabilitation is started after immobilization to restore strength, flexibility, and range of motion.

Surgical Treatment

Surgery is recommended for displaced or intra-articular fractures, open fractures, or when the bone fragments are not properly aligned. Surgical options include:

• Open reduction and internal fixation (ORIF): The bone fragments are repositioned and held together with plates and screws.
• Percutaneous fixation: Minimally invasive surgery using small incisions and pins or screws.
• External fixation: A frame is placed outside the body, connected to the bone via pins, used in severe or open fractures when soft tissue is too damaged for internal fixation.

Complications of surgery may include infection, wound healing problems, nerve injury, or hardware irritation.

Complications and Risks

Calcaneus fractures are at risk for various complications, especially with delayed or inadequate treatment:

• Chronic pain or instability
• Arthritis in the subtalar joint
• Stiffness and loss of motion
• Heel deformity (widening, flattening, high-arched foot)
• Infection, particularly with open fractures or surgical wounds
• Blood clots (deep vein thrombosis)
• Nerve or blood vessel injury
• Delayed or non-union of the fracture

Smoking, diabetes, and poor circulation increase the risk of complications and delayed healing.

Recovery and Rehabilitation

Recovery from a calcaneus fracture is a long-term process that requires patience and commitment. The timeline varies depending on the severity of the injury, treatment method, and individual factors.

• Initial healing: Bone healing typically takes 8-12 weeks. Non-weight bearing is usually maintained for at least 6 weeks.
• Rehabilitation: Physical therapy begins with gentle exercises to restore movement, followed by strengthening and balance training.
• Return to activity: Full recovery may take six months to a year, and some individuals may experience lingering stiffness, swelling, or discomfort.

The long-term outlook depends on the extent of joint involvement, quality of reduction (realignment), and adherence to rehabilitation.

Prevention

• While not all calcaneus fractures can be prevented, especially those caused by accidents, some strategies may reduce risk:
• Maintaining bone health through adequate calcium, vitamin D, and weight-bearing exercise
• Using safety equipment and harnesses when working at heights
• Practicing caution in high-risk environments, such as construction sites
• Wearing appropriate footwear for sports and activities
• Ensuring good lighting and clear walkways at home and work

Nursing Care of Patients with Calcaneus Fracture (Broken Heel)

Nursing care for patients with a broken heel requires a holistic approach, incorporating pain management, wound care, mobility assistance, education, and psychosocial support.

Assessment of the Patient

Initial Evaluation

• History Taking: Obtain a detailed account of the injury, including the mechanism of trauma, the time of occurrence, and any associated symptoms such as bleeding or loss of consciousness in the case of significant falls.
• Physical Examination: Inspect for swelling, bruising, deformity, open wounds, and assess for neurovascular compromise by checking pulses, capillary refill, and sensation in the foot.
• Pain Assessment: Evaluate pain intensity using standardized pain scales (e.g., Numeric Rating Scale) and note location and any exacerbating or relieving factors.
• Imaging and Diagnostics: Facilitate necessary imaging studies such as X-rays, CT scans, or MRI as directed, and monitor for any signs of compartment syndrome, which is a rare but severe complication.

Ongoing Observation

• Monitor vital signs regularly, being alert for signs of shock or infection.
• Assess the affected limb for changes in color, temperature, movement, and sensation.
• Document edema, wound drainage, and the integrity of casts or splints, if present.

Pain Management

Pain associated with a calcaneus fracture can be severe and persistent, especially in the initial phase.

Pharmacologic Interventions:

• Administer analgesics as prescribed, including NSAIDs, acetaminophen, or opioids if warranted for severe pain.
• Consider adjunctive medications, such as muscle relaxants or nerve pain modulators if neuropathic symptoms are present.

Non-Pharmacologic Strategies:

• Application of ice packs for short periods to reduce swelling and numb pain (ensure proper skin protection).
• Elevation of the affected foot above heart level to decrease edema and discomfort.
• Encouragement of relaxation techniques and guided imagery for anxiety and pain reduction.

Immobilization and Limb Protection

Immobilization is essential to allow healing and prevent further injury. The type of immobilization depends on the severity and type of fracture.

Casting or Splinting:

• Monitor the fit and comfort of the cast or splint regularly.
• Check for signs of compromised circulation, such as numbness, tingling, increased pain, or bluish coloration of the toes.
• Educate the patient and family about cast care, emphasizing the importance of keeping the cast dry and not inserting objects inside it.

Surgical Intervention:

• If open reduction and internal fixation (ORIF) or other surgical procedures are performed, monitor the surgical site for bleeding, drainage, and signs of infection.
• Ensure sterile technique during dressing changes and follow wound care protocols as per surgical orders.
• Monitor for hardware complications and report any abnormal findings promptly to the medical team.

Mobility and Rehabilitation

Maintaining mobility is vital for preventing complications such as deep vein thrombosis (DVT), muscle atrophy, and joint stiffness. However, weight-bearing should only be permitted according to the orthopedic surgeon’s instructions.

• Non-Weight Bearing: Initially, most patients will be advised to avoid putting any weight on the affected foot. Assist with the use of crutches, walkers, or wheelchairs as appropriate.
• Early Mobilization: Encourage movements of the unaffected limbs and gentle toe flexion and extension to promote circulation.
• Physical Therapy: Collaborate with physical therapists to implement a rehabilitation plan focusing on gradual weight-bearing, strengthening, and gait training as healing progresses.
• Prevention of Complications: Regularly assess for signs of DVT (calf pain, swelling, redness), pressure ulcers, and muscle wasting.

Wound and Skin Care

Proper wound management is important, particularly after surgical intervention or with open fractures.

• Monitor surgical incisions or open wounds for redness, swelling, increased pain, or purulent discharge (signs of infection).
• Follow protocols for dressing changes, ensuring a sterile environment and gentle technique to avoid trauma to healing tissues.
• Inspect skin under and around casts or devices for pressure areas or breakdown.
• Educate patients on signs of infection and when to seek immediate medical attention.

Prevention and Management of Complications

Calcaneal fractures are associated with several potential complications.

• Infection: Especially in open or surgical fractures. Monitor for fever, erythema, and wound drainage.
• Compartment Syndrome: Watch for severe pain that is out of proportion, pallor, pulselessness, paralysis, and paresthesia.
• DVT and Pulmonary Embolism: Encourage leg exercises, use compression devices if prescribed, and monitor for symptoms.
• Pressure Ulcers: Reposition the patient regularly and ensure the use of pressure-relieving devices.
• Joint Stiffness and Muscle Atrophy: Encourage prescribed exercises as soon as safely possible.

Patient Education

Education empowers the patient and their support system, aiding recovery and preventing avoidable complications.

• Cast and Wound Care: Instructions on keeping casts dry, checking for fit, and reporting abnormalities.
• Mobility: Safe use of assistive devices, importance of not bearing weight until cleared, and gradual increase in activity.
• Medications: Adherence to prescribed painkillers, anticoagulants (if ordered), and any antibiotics.
• Warning Signs: Symptoms such as increased pain, swelling, fever, or numbness that require prompt medical attention.
• Lifestyle Modifications: Smoking cessation, healthy nutrition to aid bone healing, and avoiding activities that could endanger recovery.

Psychosocial Support

A calcaneal fracture and the resulting immobility can lead to emotional distress, anxiety, and concerns about recovery and future mobility.

• Provide Emotional Support: Listen empathetically to the patient’s concerns and fears; encourage expression of emotions.
• Connect to Resources: Refer to counseling, social work, or support groups as needed.
• Encourage Family Involvement: Family members can provide crucial assistance and motivation during the recovery process.

Discharge Planning and Follow-Up

Effective discharge planning ensures continuity of care and reduces the risk of rehospitalization.

• Coordinate Follow-Up Appointments: Ensure timely orthopedic, physiotherapy, and wound review visits.
• Equip the Patient: Provide clear written instructions and demonstrate essential tasks like cast care and safe mobility.
• Home Safety Assessment: Recommend modifications to prevent falls, such as removing hazards and installing grab bars.
• Community Resources: Provide information on home nursing, transportation, and equipment rental if necessary.

REFERENCES

1. Breed M, Fitch R. Calcaneus Fracture. In: Knoop KJ, Stack LB, Storrow AB, Thurman R, eds. The Atlas of Emergency Medicine. 5th ed. McGraw-Hill; 2021.
2. Davis D, Seaman TJ, Newton EJ. Calcaneus Fractures. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430861/
3. Foot Health Facts. Fractures of the Calcaneus (Heel Bone Fractures). https://www.foothealthfacts.org/conditions/fractures-of-the-calcaneus-(heel-bone-fractures.
4. Williams CG, Coffey MJ, Shorten P, Lyions JD, Laughlin RT. Staged subtalar fusion for severe calcaneus fractures with bone loss. Open Orthop J. 2013;7:614-8. doi:10.2174/1874325001307010614
5. Merck Manual, Consumer Version. Fractures of the Heel Bone. https://www.merckmanuals.com/home/injuries-and-poisoning/fractures/fractures-of-the-heel-bone?query=calcaneus%20fractures. Updated 12/2022.
6. Li Y, Bao RH, Jiang ZQ, Wu HY. Complications in operative fixation of calcaneal fractures. Pak J Med Sci. 2016;32(4):857-62. doi: 10.12669/pjms.324.10225

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