New York State Medical Treatment Guidelines for Ankle and Foot Fractures in workers compensation patients

The guidelines for Ankle and Foot Fractures have been established by the New York State Workers Compensation Board to aid physicians, podiatrists, and healthcare professionals in delivering suitable treatment.

These guidelines from the Workers Compensation Board aim to support healthcare professionals in determining the most fitting level of care for patients with ankle and foot disorders.

It’s important to note that these guidelines don’t replace clinical judgment or professional expertise. The final decision regarding care should be a collaborative one, involving the patient and their healthcare provider.


Ankle and Foot Fractures

A patient with an ankle injury requires an initial assessment to identify conditions requiring immediate attention, such as vascular disease, open fractures, joint dislocation, compartment syndrome, and compromise.

Typically, non-operative treatment is employed for undisplaced or minimally displaced injuries, while surgical intervention addresses displaced or unstable wounds. Complications of ankle and foot fractures may include pain, post-traumatic osteoarthritis, limited range of motion, persistent discomfort despite hardware removal, talar instability development, and malunions with simultaneous syndesmotic widening.

The choice between operative and non-operative treatment is influenced by the nature of the injury (displaced or nondisplaced), stability (steady, open, or closed), and concurrent soft tissue damage. Closed and stable fractures generally undergo non-operative treatments.

For open fractures, emergent debridement and antibiotic prophylaxis are essential. Most closed unstable fractures usually require surgical intervention. Treatment initiation is crucial for addressing skin conditions, compartment syndrome, significant swelling, and maintaining integrity by managing blisters resulting from fractures.


Diagnostic Studies for Ankle and Foot Fractures in workers compensation patients

Diagnostic Studies for Ankle and Foot Fractures:

X-Rays for Ankle and Foot Fractures are recommended as the primary diagnostic study.

Indications: Suspicion of a fracture.

Rationale for Recommendation: X-rays are the initial imaging examination to detect a possible fracture.

MRI for Distal Lower Extremity and Ankle Fractures is recommended to assess ankle and distal lower limb fractures.

Indications: To examine soft tissue for acute or subacute fractures, comminuted or complicated displaced fractures with tissue/ligament damage, or when the fracture’s stability is in question, and MRI will aid in management decisions.

Rationale for Recommendation: MRI should not be the first-line imaging method. However, in specific cases like shifted, comminuted, or unstable fractures involving potential soft tissue damage, MRI becomes a crucial diagnostic tool.

CT for Diagnosis and Classification of Ankle Fractures is recommended for examining ankle and distal lower limb fractures.

Indications: Suspected concealed and complicated ankle fractures; to clarify the fracture’s location. Axial views are advised, especially if intra-articular displacement is being considered.

Rationale for Recommendation: When an X-ray suggests a possible fracture, using CT can be beneficial, especially in assessing complicated comminuted fractures involving the distal femur, the tibial articular surface, fragment placement, and diagnosing a subluxation.

Ultrasound Imaging for Diagnosing Ankle Fracture:

Ultrasound Imaging for Diagnosing Ankle Fracture is recommended to assess whether specific displaced fractures or suspected malleolar stress fractures have caused soft-tissue damage.

Indications: Evaluation of soft-tissue damage related to particular displaced fractures, determining a fracture’s stability, especially in medial and bimalleolar fractures involving the deltoid ligaments, and detecting potential occult or stress fractures. Additionally, it is used for suspected stress fractures in the distal tibia.

Rationale for Recommendation: The utilization of ultrasound imaging can be beneficial, particularly in cases where clinical evaluation alone is inconclusive. Further radiological testing is advised in certain circumstances to aid in the selection of appropriate treatment for patients.


Medications for Ankle and Foot Fractures

Pre-Operative Antibiotic Prophylaxis for Ankle Fractures:

It’s recommended to use pre-operative antibiotic prophylaxis for ankle fracture surgery, whether it’s an open or closed procedure.

Use of Nasal Spray Calcitonin for Post-fracture Osteopenia:

Using Nasal Spray Calcitonin for Post-fracture Osteopenia isn’t advised for preventing osteopenia after a fracture.

DVT Prophylaxis for Ankle and Foot Fractures:

Refer to the DVT prevention section in the Achilles tendon rupture part.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Acetaminophen:

For most patients, starting with ibuprofen, naproxen, or other NSAIDs is recommended. If NSAIDs aren’t suitable, acetaminophen (or its analogue paracetamol) could be an alternative, despite research suggesting it’s slightly less effective than NSAIDs. There’s evidence supporting that NSAIDs are less risky and just as effective in treating pain compared to opioids like tramadol.

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Acute Ankle Fracture Analgesia:

It’s recommended to use NSAIDs to alleviate pain associated with an ankle fracture.

Indications: NSAIDs are suggested for post-operative or chronic ankle fractures; over-the-counter (OTC) options may suffice and should be tried first.

Frequency/Duration: Patients may find it reasonable to use NSAIDs as needed.

Indications for Discontinuation: Discontinue when ankle/foot discomfort resolves, effectiveness is lacking, or unfavorable effects necessitate cessation.

NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding:

Using NSAIDs for patients at high risk of gastrointestinal bleeding is recommended along with cytoprotective medications such as Histamine Type 2 receptor blockers, misoprostol, sucralfate, and proton pump inhibitors.

Indications: Consider NSAIDs and cytoprotective drugs for patients with a high-risk profile, especially for extended treatment.

Patients at risk: Those with a history of previous gastrointestinal bleeding, the elderly, diabetics, and smokers.

Frequency/Dose/Duration: Follow the recommended dosage and repetitions provided by the manufacturer. Effectiveness in preventing gastrointestinal bleeding may vary.

Indications for Discontinuation: Discontinue in case of intolerance, emergence of adverse effects, or cessation of NSAIDs.

NSAIDs for Patients at Risk for Cardiovascular Adverse Effects:

It is recommended to consider acetaminophen or aspirin as the first-line treatment options due to their perceived safety regarding cardiovascular side effects. Non-selective NSAIDs are preferred over COX-2-specific medications if NSAID use is necessary. To minimize the potential negation of low-dose aspirin’s protective effects, NSAIDs should be taken at least 30 minutes after or eight hours before daily aspirin.

Acetaminophen Treatment of Acute, Subacute, or Chronic Pain with Acetaminophen Acute Pain From Ankle Fracture:

Acetaminophen is recommended for the treatment of acute ankle fracture pain, whether it is acute, subacute, or chronic, especially in individuals with NSAID contraindications.

Indications: Applicable for acute, subacute, and chronic foot/ankle pain in all individuals, including post-surgery.

Dose/Frequency: Follow the manufacturer’s guidelines; use on an as-needed basis. Caution is needed to avoid hepatic toxicity, demonstrated when exceeding 4 g/day.

Indications for Discontinuation: Discontinue when pain relief is achieved, adverse effects occur, or intolerance is noted.

Limited Use of Opioids for Acute and Postoperative Pain Management:

Limited use of opioids is recommended for short-term (less than seven days) treatment of acute and postoperative pain. They should be used as complementary therapy for more effective treatments.

Indications: Opioids are advised for short-term pain control in acute injuries and postoperative cases, especially as a supplement to more effective treatments like NSAIDs, acetaminophen, elevation, and bracing.

Frequency/Duration: Use throughout the day as needed, gradually tapering off and transitioning to nighttime use until entirely weaned off.

Rationale for Recommendation: Opioids should be used cautiously and for specific purposes, such as short-term postoperative pain control, especially at night, in recovering patients. This responsible use complements more effective treatments, like NSAIDs, and aims to minimize the risk of opioid dependence.

Tetanus Immunization Status for Open Fractures:

It is recommended to update tetanus immunization status as necessary, especially for wounds that have not healed after more than five years since the last tetanus shot.

Indications: Open wounds, particularly those that haven’t healed after more than five years since the last tetanus shot.

Rationale for Recommendation: Updating tetanus immunization status is advised due to the potential negative implications of not being vaccinated. For individuals with burns or dirty wounds, vaccination is recommended if more than five years have elapsed since the last vaccination, rather than waiting for the traditional ten-year interval. Patients who haven’t completed their vaccination series should receive tetanus immune globulin along with each of the three shots.

Analgesia for Non-Operative Reduction Ankle Fractures:

It is recommended to provide analgesia for performing non-operative closed reduction of ankle fractures.

Rationale for Recommendation: The choice of the best strategy for analgesia should consider factors such as the expertise and preferences of the doctor, the patient’s history of medication intolerance or anxiety levels, and the availability of supplies and equipment.


Treatments of Ankle and Foot Fractures

Cast Immobilization for Ankle Fractures:

It is recommended to use cast immobilization for ankle fractures as a standard treatment.

Frequency/Duration: Typically, immobilization is advised for a duration of six to eight weeks.

Rationale for Recommendation: Cast-induced immobility is recommended for all patients with ankle fractures, and the specific application depends on the preferences of both the patient and the doctor.

Early Mobilization for Ankle Fractures:

It is recommended to incorporate early mobilization in the management of postoperative and stable non-operative ankle fractures.

Indications: Applicable for surgically stabilized or properly fixed closed ankle fractures, with or without malleolar involvement.

Frequency/Duration: Early mobilization can commence between one and three days after surgery.

Rationale for Recommendation: Early mobilization is advisable for the majority of patients with stable or healed malleolar ankle fractures.

Early Postoperative Weight-bearing for Ankle Fractures:

It is recommended to allow early weight-bearing after surgical fixation for ankle fractures following surgery.

Indications: Applicable for surgically stabilized or properly fixed closed ankle fractures, with or without malleolar involvement.

Rationale for Recommendation: Early weight-bearing might offer short-term benefits in functional recovery and does not appear to lead to an increase in unfavorable events.

In summary, the recommendations emphasize the importance of individualized approaches based on the patient’s condition and the specifics of the ankle fracture.


Rehabilitation of Ankle and Foot Fractures

Electrical Stimulation for Prevention of Muscle Atrophy:

It is not recommended to use electrical stimulation for preventing muscle atrophy in the care of foot and ankle fractures.

Therapy for Patients with Functional Deficits after Cast Removal:

It is recommended to provide therapy for patients who experience functional deficits after the removal of the ankle cast.

Manual Therapy as Part of a Post-Ankle Fracture Rehabilitation Program:

Manual therapy is recommended as an essential component of a rehabilitation program following an ankle fracture.

Passive Stretching for Contractures After Immobilization of Ankle Fractures:

It is not recommended to use passive stretching for treating contractures following the immobilization of ankle fractures. The frequency of visits for stretching depends on the severity of the constraint, ranging from two to three visits per week during the first two weeks of the fitness program.

Ultrasound to Stimulate Bone Healing for Ankle and Foot Fractures:

The use of ultrasound to stimulate bone healing for ankle and foot fractures is not recommended in their management.

Hyperbaric Oxygen for the Management of Ankle or Foot Fractures:

Hyperbaric oxygen is not recommended for the management of ankle or foot fractures.


Fracture Care of Ankle and Foot Fractures

Malleolar Ankle Fractures:

In the past, non-displaced and stable fractures have often been effectively managed with positive outcomes. Ongoing discussions persist regarding the treatment of specific fractures, where uncertainty exists about their stability.

For distal fibula fractures, conservative management experiments using non-displaced and steadily displaced fractures have shown positive results, as these fractures rarely fail to heal. However, failure to reduce or delayed union may necessitate surgical intervention. Posterior malleolar fractures frequently occur, presenting challenges due to their unpredictability and the commonality of being overlooked.

Immobilization for Non-displaced Ankle Fractures:

The recommendation is for immobilization in the care of non-displaced and stable ankle fractures.

Immobilization and Reduction for Closed Displaced Ankle Fractures:

For closed displaced non-comminuted ankle fractures, immobilization and reduction are recommended. This is indicated for ankle fractures that are not only dislocated but also smaller than two to three mm after reduction, involving less than 25% of the posterior malleolus articular width, with minimal three mm involvement.

Operative Fixation for Closed Displaced Ankle Fractures:

Operative fixation is recommended for closed and dislocated ankle fractures. Indications include severe participation of the malleoli in medial-lateral fractures, and fractures that are dislocated with a displacement of more than 2 to 30% of the posterior malleolus articular diameter, with only minor three mm involvement.

Rationale for Recommendations:

The outcomes of open reduction, internal fixation for malleolar fractures remain essentially the same for individuals younger than 60. It is crucial to consider overall surgery indications for older individuals, and therapy for individual fractures should be tailored based on skin condition, bone quality, comorbidities, and patient functional demands. Attention to concomitant conditions such as osteoporosis and diabetes is vital to prevent complications.


Tibial Shaft Fractures (Diaphyseal)

Operative Fixation for Tibial Shaft Fracture (Closed, Diaphyseal):

Operative fixation is recommended for displaced, comminuted distal tibial shaft fractures.

Indications: Displaced and fractured distal tibial shaft.

Cast Immobilization for Tibial Shaft Fractures (Closed, Diaphyseal):

Cast immobilization is recommended in some patients with a closed, stable fracture of the tibia.

Operative Fixation (i.e., Fracture Plating, Intramedullary Nail) for Distal Tibial Extra-Articular Fractures:

Operative fixation, such as fracture plating or intramedullary nail, is recommended for select patients.

Indications: Open fractures, initial shortening greater than 15mm, and angular deformity following initial manipulation greater than 5 in any plane.

Cast Immobilization for Distal Tibial Extra-Articular Fractures:

Cast immobilization is recommended for distal extra-articular tibial fractures under specific conditions.

Indications: Closed uncomplicated fractures with an initial shortening of 15mm and an angular deformity of 5 in either plane following the initial manipulation.

Non-operative Management of Tibial Plafond and Pilon Fractures:

Non-operative management is recommended in select patients.

Indications: Stable fractures that are neither displaced, comminuted, nor unstable; the ability to achieve proper fracture alignment with closed reduction.

Operative Management of Tibial Plafond and Pilon Fractures:

Operative management is recommended for some tibial plafond fractures.

Indications: Displaced, comminuted, or inability to obtain acceptable fracture alignment with closed reduction.

Rationale for Recommendations: Fractures in the distal lower leg that press the talus against the articular surface are referred to as plafond fractures. It is noted that these fractures have a significant incidence of complications from surgical weight loss fixation.

Syndesmotic Ruptures for Ankle and Foot Fractures

Operative Fixation for Syndesmotic Ruptures:

Operative fixation is recommended for unstable syndesmotic rupture.

Indications: Closed but unstable AO fracture type C ankle fractures, syndesmosis, and/or pathologic widening of the syndesmosis at intraoperative testing of more than 2mm.

Non-operative Management of Syndesmotic Injuries:

Non-operative management is recommended for stable syndesmotic injury.

Indications: Absence of other destabilizing injuries, including ankle fractures or deltoid ligament injury.

Rationale for Recommendations: Some experts believe that not all syndesmotic ankle injuries result in ankle instability and may not require correction if there are no associated destabilizing injuries. If there is a fracture, fixation is necessary. For some patients, non-operative care is advised. Surgical treatment is recommended for non-stable injuries, such as most syndesmotic ruptures with concomitant fractures or deltoid ligament injury.


Fibular Fracture of Ankle and Foot Fractures

Operative Fixation for Displaced Distal Fibula Fractures:

Operative fixation is recommended for a fractured distal fibula.

Indications: Unsatisfactory closed fracture of the distal fibula shaft reduction.

Rationale for Recommendation: Surgical fixation is indicated for distal fibular fractures that are unstable and displaced.


Arthroscopy with ORIF of Distal Fibular Fractures

Arthroscopy with ORIF of Distal Fibular Fractures:

The use of arthroscopy-assisted ORIF for distal fibular fractures is not recommended. Arthroscopy evaluation during distal tibia fracture fixation ORIF lacks evidence for use.


Deltoid Ligament Repair with ORIF of Lateral Ankle Fracture

Deltoid Ligament Repair with ORIF of Lateral Ankle Fracture:

It is recommended to perform deltoid ligament repair concurrently with ORIF for unstable ankle fractures, especially in cases with significant fibular fractures or in patients with simultaneous syndesmotic fixation disruption.


Other of Ankle and Foot Fractures

Pneumatic Compression for Treatment of Ankle and Foot Edema:

It is recommended for patients who have experienced significant postoperative edema, especially following surgery for an ankle fracture.

Interferential Therapy for Treatment of Ankle Edema:

It is not recommended to use interferential therapy for treating postoperative edema, particularly after open reduction internal fixation (ORIF) for a dislocated malleolar fracture.


What our office can do if you have Ankle and Foot Fractures

We have the expertise to assist you with your workers’ compensation injuries. We empathize with the challenges you’re facing and are committed to addressing your medical needs while adhering to the guidelines established by the New York State Workers Compensation Board.

Recognizing the significance of your workers’ compensation cases, we are here to guide you through the complexities of interactions with the workers’ compensation insurance company and your employer.

We acknowledge the stress you and your family may be experiencing during this time. If you wish to arrange an appointment, please reach out to us. We are dedicated to making the process as smooth and convenient for you as possible.

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