Definition and historical importance
The calcaneus or os calcis [6] is the structure through which most of the body weight is transmitted during locomotion. Both names, respectively attributed to Galen and Celsus [7], derive from Calx-Calcis—‘limestone’ in Latin—a loan from the Greek χάλιξ, which indicates a pebble or gravel [8]. Its anatomy was accurately described and illustrated by Andreas Vesalius (1514-1564) in the De Humani Corporis Fabrica Libri Septem (Fig. 2), published in 1543 [9].
Calcaneal fractures account for 2% of all foot and ankle trauma presentations, usually through an axial load caused by a fall from height or other high-energy trauma. The loading force impressed onto the talus which, acting as a wedge, transmits it through the calcaneus, constituted mostly of cancellous bone enveloped by a relatively thin cortex perforated by only a few branches of the posterior tibial artery, dorsalis pedis and perforating peroneal artery. These branches constitute variable extraosseous anastomoses vulnerable to ischemia and complications such as osteomyelitis, avascular necrosis and post-traumatic osteoarthritis [10, 11].
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The oldest archaeological evidence of a calcaneal fracture comes from the remains of a hominin, excavated in Sterkfontein, who had sustained a crush fracture with comminution and wedging of the calcaneus into the talus. The finding suggests that this injury has been relevant to human survival. A broken heel meant the impossibility to escape predators and certain death [12].
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The earliest written historical record on the natural history and treatment of this injury dates to Hippocrates in his vivid description of how heel fractures led to ‘very acute fevers […] tremblings, hiccup, aberration of intellect […] which prove fatal within a few days’. He described his treatment approach with ‘the foot […] raised a little higher than the rest of the body […] such patient will get well in sixty days if he keeps quiet’ [13].
There is no convincing record of premodern attempts at surgical management. A small clue came recently from a far related research field: the pathology of crucifixion. Traditionally, Jesus Christ is portrayed with a long nail driven from anterior to posterior with one foot atop the other.
However, this technique would require greater control by the executioner to keep one foot on top of the other while driving the nail [14]. It seems that the iconographic practice of representing the feet of Jesus crucified separately—that is, fixed by two different nails—was widespread until the twelfth century. Crucifix n. 432, the ‘Master of the Cross’ (1180-1200), part of the Gallerie degli Uffizi collection, is a perfect example of this modality, still formally connected to the Byzantine typology of the ‘Christus Triumphans’. Only much later artists started favouring the iconographic typology of the two feet nailed one over the other, as can be observed in a magnificent crucifix initially attributed to Donatello, dated towards the end of the fifteenth century.
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Countless images of Jesus’s sacrifice have literally enshrined the concept, corroborated in the eyes of the believer by the holy relics brought as proof. Among these is a 12.5-cm-long and 9-mm-thick square nail, with a bell-shaped head tapering to 5 mm towards the end. It is held in the Basilica di Santa Croce in Jerusalem, in Rome. Saint Helen, Emperor Constantine’s mother, acquired it as the nail from the Holy Cross.
However, there is no convincing proof of crucifixion as a mechanism of calcaneal fracture by transfixion: so far, only one specimen was excavated in 1968 in Givat HaMivtar, Israel, a long nail transfixed in the calcaneus of a young man from lateral to medial [2]. This might recall the lateral surgical approach to the calcaneus, as if the executor wanted to avoid injury to the tibialis posterior artery. From one such specimen, it is impossible to draw any conclusions, either on the modalities of crucifixion or on the treatment of calcaneal fractures (Fig. 3).
History remains silent on the issue until the eighteenth century, during which the moniker ‘the lover’s fracture ‘ or Don Juan fractures appeared to describe the most scandalous injury, likely inspired by DeSault. In his memoir, he tells of ‘a man, likely to be arrested by someone who pursued him’, who ‘leapt from a window nearly twelve feet high’, whose ‘feet struck on a beam which lay in his way’, causing a fall from which ‘he was unable to rise again’ [15]. The moniker is a jibe, popular in English-speaking countries, indicating heel fractures suffered by those presumed to have escaped the wrath of a husband by jumping from a window, as portrayed in the well-known painting ‘The Death of Him’, by William Hogarth (Fig. 4) and more recently depicted in a modern key by the British Bansky (1973 or 1974).
Heel fracture was formerly considered rare just ‘because it was not recognized’ [16]. The industrial revolution brought these injuries and their grim prognoses to the forefront due to their economic implications, as ‘ordinarily speaking […] the man who breaks his heel bone is ‘done’, so far as his industrial future is concerned’ [3]. Despite the life-changing consequences of such injuries, little changed in the way of treatment for many centuries.
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