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Center
for Orthopaedic Surgery and Sports Medicine
Indianapolis,
Indiana
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.
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