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

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

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

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

5. Anatomy

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

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

8. Ankle Sprains

9. Ankle Sprains
Chiodo, et al

10. 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

11. 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 Mar;35(3):201-6.

12. 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

13. Syndesmosis Injury

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

15. 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

16. 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

17. 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

18. Ankle Fractures
All ankle fractures are not the same

19. Ankle Fractures
All ankle fractures are not the same

20. Ankle Fractures
All ankle fractures are not the same

21. Ankle Fractures
All ankle fractures are not the same

22. Ankle Fractures
All ankle fractures are not the same

23. 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:

24. 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

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

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

27. Ankle fracture surgery

28. Ankle fractures “When can I drive?”
Marecek, et al. Driving after orthopaedic surgery. JAAOS
Goodwin, et al. Driving after orthopedic surgery. Orthopedics
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

29. 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

31. 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 May 29(4):
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

32. Foot Injuries
5th metatarsal fractures

33. Foot Injuries
5th metatarsal fractures
Lisfranc injuries

34. Foot Injuries 5th metatarsal fractures Lisfranc injuries
Foot crush injuries

35. 5th Metatarsal Fractures

37. 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

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

39. Lisfranc Injury

40. Lisfranc Injury

41. 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

42. 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

43. 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):
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

44. 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

45. 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

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

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

48. Review
Ankle sprains

49. Review
Ankle sprains
Ankle fractures

50. Review
Ankle sprains
Ankle fractures
5th Metatarsal fractures

51. Review Ankle sprains Ankle fractures 5th Metatarsal fractures
Lisfranc Injuries

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

53. Thank You