Put Your Best Foot Forward Bradley Kellum, M.D. Capital Orthopedics and Sports Medicine Center September 30, 2016

Objectives Review common work comp related orthopedic ankle and foot injuries, treatment, and outcomes

Purpose of Feet Standing  lose independence Walking  lose ability to exercise Balance  fall risk Shock absorbers  pain

Anatomy 26 bones (1/4 of the bones of the human body) 33 joints >100 muscles, tendons, and ligaments

Anatomy

Most common foot/ankle WC injuries Ankle sprains Ankle fractures 5th metatarsal fractures Lisfranc injuries Foot crush injuries

Ankle Sprains 27,000 ankle sprains per day in the US Injury causing damage or tearing of the ligaments of the ankle

Ankle Sprains

Ankle Sprains Chiodo, et al

Ankle Sprains Xrays are negative Ankle sprain diagnosis: Grade 1 – partially torn but structural integrity intact Grade 2 – more tearing and abnormal motion at ankle Grade 3 – completely torn with laxity (usually unable to bear weight) Conservative treatment yields excellent results Goals: stable ankle, pain free, return to work

Ankle Sprains Conservative treatment: Early functional rehab Boot vs brace 6 weeks West Point Cadet study: Grade 1 – 8 days of disability Grade 2 – 15 days of disability Grade 3 – unknown Slightly better clinical and functional outcomes when using brace only Prado, et al. A Comparative, Prospective, and Randomized Study of Two Conservative Treatment Protocols for First-episode Lateral Ankle Ligament Injuries. FAI. 2014 Mar;35(3):201-6.

Ankle Sprains Syndesmosis Concomitant injuries: Talus bone bruising 28% Talus and medial malleolus bruising 8% Peroneus brevis tendon injury 8% Avulsion fx of distal fibula 3% Syndesmosis

Syndesmosis Injury

Syndesmosis injury Caused by forceful external rotation of the foot Occur in about 10% of ankle sprains Difficult to diagnose: Xray - widening

Syndesmosis injury Caused by forceful external rotation of the foot Occur in about 10% of ankle sprains Difficult to diagnose: Xray – widening MRI – signal enhancement

Syndesmosis injury Caused by forceful external rotation of the foot Occur in about 10% of ankle sprains Difficult to diagnose: Xray – widening MRI – signal enhancement Arthroscopy – direct visualization

Syndesmosis Treatment WHY IS THIS IMPORTANT? Treatment changes Ankle sprain – early functional rehab/weight bearing Syndesmosis with no widening – NON WEIGHTBEARING for 4 weeks followed by PT (doubles recovery time compared to standard ankle sprain) Syndesmosis with widening – Surgery then NWB for 4-6 weeks followed by PT

Ankle Fractures All ankle fractures are not the same

Ankle Fractures All ankle fractures are not the same

Ankle Fractures All ankle fractures are not the same

Ankle Fractures All ankle fractures are not the same

Ankle Fractures All ankle fractures are not the same

Ankle fracture Treatment Goals: Stable and functional ankle Minimize risk of post traumatic arthritis Relieve pain Return patient to work force There are many different classifications:

Ankle fracture Treatment Goals: Stable and functional ankle Minimize risk of post traumatic arthritis Relieve pain Return patient to work force Most useful classification: Stable vs Unstable

Ankle fracture Stable Treatment: Boot or cast for 4 weeks Then advance weight bearing

Ankle fracture Unstable Treatment: Surgery NWB for 4-6 weeks Then advance wb in boot

Ankle fracture surgery

Ankle fractures “When can I drive?” Marecek, et al. Driving after orthopaedic surgery. JAAOS. 2013 Goodwin, et al. Driving after orthopedic surgery. Orthopedics. 2013 Braking function returns to normal 9 weeks after surgical management of an ankle fracture Foot surgery pts can expect to return to driving 6 weeks postoperatively

How do ankle fractures do over time How do ankle fractures do over time? -Patient questionnaires assessing physical function were completed at discharge from orthopedic care (~4.5 months) and 20 months postop -Patients improve function beyond 4-6 months following an unstable ankle fracture but physical and functional effects remain compared to general population

Long term effects of ankle fractures van der Sluis CK, et al. Long term physical, psychological and social consequences of a fracture of the ankle. Injury. 1998. May 29(4):277-80. 68 pts., 6 year follow up 89% of pts returned to work (slightly more than severely injured pts) Ankle fracture patients returned to work in 3 months 52% of pts had psychological complaints due to ankle fracture

Foot Injuries 5th metatarsal fractures

Foot Injuries 5th metatarsal fractures Lisfranc injuries

Foot Injuries 5th metatarsal fractures Lisfranc injuries Foot crush injuries

5th Metatarsal Fractures

5th Metatarsal Fractures Exam: pain isolated to 5th MT area Treatment: Conservative Partial weight bearing Non weight bearing stiff soled shoe vs boot Clinically improves 4-6 weeks Xray healing 3-6 months

Nonunion of 5th MT fracture Check calcium/vit d Bone stimulator is an option May need surgery

Lisfranc Injury

Lisfranc Injury

Lisfranc Treatment 20% of these injuries are missed Anatomic reduction is essential for optimal outcome Threshold for surgery is very low Surgical options: ORIF vs Fusion

Lisfranc Surgery ORIF  Non weight bearing for 6 weeks Slowly advance weight in boot for 6 weeks Remove hardware between 3 and 4 months postop Fusion  Non weight bearing for min 8 weeks Slowly advance weight bearing

Lisfranc outcomes Calder JDF, Saxby TS, Whitehouse SL: Results of isolated Lisfranc injuries and the effect of compensation claims. J Bone Joint Surg [Br] 2004;86(4):527-30. 46 pts with 2 year follow up Delay in treatment over 6 months or presence of a work comp claim are associated with poor prognosis Age, gender, mechanism of injury, or occupation prior to injury do not effect outcome

Foot Crush Injuries “I dropped a frozen chicken on my foot 4 months ago and still can not walk” -Most literature deals with mangling foot injuries

Foot crush injury Xray  normal MRI  normal CT  normal EMG/NCV  normal Vascular studies  normal Hypersensitivity, diffuse pain, pain with sheets rubbing the skin at night  CRPS or RSD

Foot Crush Injuries Myerson, et al. JOT. 1994  foot crush injuries result in unpredictable outcomes and prolonged morbidity Poor results – delay in treatment CRPS Workers Compensation Hong, et al. FAI. 2015  foot crush injuries resulted in medical leave ranging from 0 to 421 days

Foot Crush Injury Multispecialty treatment is essential Pain management for CRPS Physical Therapy

Review Ankle sprains

Review Ankle sprains Ankle fractures

Review Ankle sprains Ankle fractures 5th Metatarsal fractures

Review Ankle sprains Ankle fractures 5th Metatarsal fractures Lisfranc Injuries

Review Ankle sprains Ankle fractures 5th Metatarsal fractures Lisfranc Injuries Foot crush Injuries

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