New York State Medical Treatment Guidelines for Forefoot and Midfoot Fractures in workers compensation patients

The guidelines set by the New York State workers compensation board are designed to aid physicians, podiatrists, and healthcare professionals in delivering suitable treatment for Forefoot and Midfoot Fractures. They serve as a resource to help healthcare providers make informed decisions about the optimal level of care for individuals with ankle and foot disorders.

It’s crucial to note that these guidelines are not a replacement for clinical judgment or professional expertise. The ultimate decision about the course of care should be a collaborative effort between the patient and their healthcare provider.


Diagnostic Studies for Forefoot and Midfoot Fractures in workers compensation patients

Diagnostic Studies for Forefoot and Midfoot Fractures in workers compensation patients for X-Rays are recommended as a primary investigation for potential midfoot or forefoot fractures. Indications: Examine the forefoot or midfoot for any fractures.

Rationale for Recommendation: X-rays can detect fractures, determine the direction of the fracture plane(s), and assess the extent of involvement of the interphalangeal and metatarsophalangeal joints. If fractures are significant, they may influence the management approach, potentially favoring surgical intervention (see below). In cases of negative radiographs, pursuing clinical suspicion with additional radiographs around seven days may reveal resorption at the fracture line.

MRI for Suspected Acute Forefoot and Midfoot Fractures is recommended for occult suspicion and stress fractures in specific patients. Indications: Typically used when there is suspicion of an undetected condition or stress fracture, although some consider CT to be superior for the fore or midfoot.

Rationale for Recommendation: MRI should not be the initial diagnostic choice. However, it can be a crucial tool for analyzing potential navicular and tarsometatarsal joint injuries (Lisfranc injury) and early detection of possible stress fractures. MRI is also utilized for assessing avascular necrosis and potential hidden fractures.

Bone Scanning for Forefoot and Midfoot Fractures is recommended, typically when there is suspicion of an undetected condition or stress fracture, although some consider CT to be superior for the fore or midfoot. Indications: Usually employed when there is a possibility of occult fractures in the tarsal and metatarsal bones.

Rationale for Recommendation: For the majority of patients with forefoot and midfoot fractures, bone scans are usually unnecessary. However, in cases where there is a high clinical suspicion despite negative x-ray or CT findings, a bone scan may be justified.


CT Imaging

CT for the Diagnosis and Classification of Forefoot and Midfoot Fractures is recommended for a limited number of individuals with forefoot and midfoot fractures.

Indications: Utilized to enhance understanding of fracture displacement, articular involvement, and subluxation in cases of tarsal and metatarsal bone fractures that exhibit multiple fragments. CT serves as a supplementary diagnostic tool following X-rays.

Rationale for Recommendation: CT is not typically the primary diagnostic option. However, in specific cases where further clarity on subluxation, articular involvement, and fracture displacement is required for individuals with affected joints, CT may be considered as a valuable diagnostic method.


Medications for Forefoot and Midfoot Fractures

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

Ibuprofen, naproxen, or other NSAIDs from an earlier generation are recommended as primary treatments for most patients. NSAIDs are considered a preferable option to acetaminophen, although evidence suggests that acetaminophen is only marginally less effective.

There is evidence supporting the effectiveness of NSAIDs, such as tramadol, in relieving pain without causing impairment.

Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Pain Management in Metatarsal or Phalangeal Fractures NSAIDs are recommended for treating acute, subacute, chronic, or postoperative pain associated with metatarsal or phalangeal fractures.

Indications: NSAIDs are advised for the management of pain in cases of acute, subacute, chronic, or postoperative phalangeal or metatarsal fractures. Initial use of over-the-counter (OTC) medications is recommended to assess their efficacy.

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

Indications for Discontinuation: Discontinuation criteria include the resolution of ankle/foot discomfort, ineffectiveness, or the emergence of side effects necessitating cessation.

NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding
NSAIDs for patients at high risk of gastrointestinal bleeding are recommended in conjunction with histamine type 2 receptor blockers, proton pump inhibitors, misoprostol, sucralfate, and other cytoprotective medications.

Indications: Cytoprotective drugs should be considered for patients with a high-risk factor profile who require NSAIDs, particularly if a prolonged course of treatment is planned. Individuals with a history of gastrointestinal bleeding, the elderly, diabetics, and smokers are at increased risk.

Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, and H2 blockers are recommended with dosages and frequencies per manufacturer guidelines. There is generally no substantial difference in efficacy for preventing gastrointestinal bleeding.

Indications for Discontinuation: Discontinuation criteria include intolerance, the emergence of unfavorable effects, or the decision to stop using NSAIDs.


NSAIDs for Patients at Risk for Cardiovascular Adverse Effects

For individuals at risk of cardiovascular adverse effects, the recommended first-line treatment options are acetaminophen or aspirin, which appear to be safer in terms of cardiovascular side effects. Non-selective NSAIDs are suggested as an alternative to COX-2-specific drugs when necessary.

When taking low-dose aspirin for primary or secondary prevention of cardiovascular disease, it is advised to take an NSAID at least 30 minutes after or eight hours before aspirin. This precaution helps minimize the likelihood of the NSAID counteracting the protective effects of aspirin.

Acetaminophen for the Treatment of Acute, Subacute, or Chronic Phalangeal or Metatarsal Fracture Pain

Acetaminophen is recommended for the treatment of severe, mild, or persistent pain, specifically in patients with pain related to phalangeal or metatarsal fractures and contraindications to NSAIDs.

Indications: Acute, subacute, and chronic foot/ankle pain in all individuals, including those with chronic pain and post-surgery.

Dose/Frequency: Follow the manufacturer’s recommendations; use as needed. Liver toxicity is evident at doses exceeding four grams per day.

Indications for Discontinuation: Discontinue in the case of fracture displacement or joint dislocation greater than 2 mm.


Treatments for Forefoot and Midfoot Fractures

Nonoperative Care for Non-Displaced Tarsal-Metatarsal Injury (Lisfranc)

It’s advisable for certain individuals to undergo nonoperative management for non-displaced Tarsal-Metatarsal Injury (Lisfranc).

Conditions: When the fracture/joint dislocation is less than 2 mm.

Treatment: Utilizing a non-weight-bearing cast for a duration of six weeks.


Surgical Management for Displaced Tarsal-Metatarsal Injury (Lisfranc)

For unstable cases of tarsal-metatarsal injury, surgical management is the recommended course.

Indications: In instances of joint dislocation exceeding 2 mm and fracture joint displacement.

Procedure: The recovery process may initiate with therapy, spanning four to five months, followed by the removal of hardware before engaging in full-fledged activities.

Basis for Recommendation: Therapy serves as an initial phase in the recovery process, persisting for a considerable period, with the removal of hardware preceding full activity. Supported by evidence on Lisfranc injury management.


Non-Surgical Approach for Non-Displaced Metatarsal Fractures

The preferred strategy for non-displaced metatarsal fractures involves non-operative management.

Indications: Applicable to shaft fractures featuring dorsal angulation below 10 degrees, with no displacement or a displacement of up to 3 to 4 mm either dorsally or plantarly.


Surgical Management for Displaced Metatarsal Shaft Fractures

For metatarsal shaft fractures presenting misalignment, a surgical approach is recommended.

Indications: In cases where several metatarsals fracture, coupled with a shaft fracture near the metatarsal head leading to dislocation.

Procedure: Internal fixation involving screws, plates, or percutaneous pinning, accompanied by four to six weeks of non-weight-bearing, followed by gradual weight-bearing over the subsequent four to six weeks using a walking cast or fracture shoe/boot. Full weight-bearing can commence in stiff-soled footwear once radiographic evidence confirms union.

Rationale for Recommendation: Optimal immobilization or fixation is determined based on physical and radiographic findings.


Non-Surgical Management for Proximal Fifth Metatarsal Fractures (Including Joints and Avulsion)

A non-operative approach is recommended for specific cases of proximal fifth metatarsal fractures.

Indications: Non-displaced fractures, a 1 to 2 mm step-off on the articular surface, or less than 30% articular surface involvement with a cuboid; avulsion of the tuberosity; Jones fracture. Patient/provider preference may influence the decision.

Procedure: Conservative treatment, such as non-weight-bearing for one to six weeks. For Jones fractures, immobilization in a non-weight-bearing short-leg cast is advised for one to six weeks, followed by transitioning to a walking cast or hard-sole shoe until union is confirmed.


Operative Care for Fifth Displaced Metatarsal Shaft Fractures (Jones, Avulsion)

Selective operative management is recommended for certain patients with fifth displaced metatarsal shaft fractures, including Jones fractures or avulsion injuries.

Indications: Avulsion of the tuberosity with a step-off on the articular surface displaced by more than 1 to 2 mm, or more than 30% involvement of the articular surface with the cuboid; Jones fracture. Patient/provider preference may also play a role in the decision-making process.

Management: Supported by evidence concerning the management of proximal fifth metatarsal injuries.

Rationale for Recommendations: The optimal immobilization or fixation approach is determined based on physical and radiographic findings.


Immobilization for Distal, Middle, or Proximal Phalanx Fractures

Immobilization is recommended for specific patients with distal, middle, or proximal phalanx fractures.

Indications: In cases where less than 25% of the articular surface is involved, and the fracture is closed, non-displaced, or stable after reduction.

Management: Closed reduction following digital or hematoma block, obtaining a post-reduction film, repeated at one and six weeks, and toe splinted with buddy taping to the adjacent toe until non-tender (for three to four weeks), excluding the hallux. Further immobilization with a postoperative shoe or cast-boot may be considered.


Operative Care for Distal, Middle, or Proximal Phalanx Fractures

Operative management is recommended for specific patients with distal, middle, or proximal phalanx fractures.

Indications: Especially applicable to displaced fractures of the great toe that were challenging to reduce and couldn’t be adequately held with tape splinting.

Rationale for Recommendations: Hence, the strategy for immobilization or fixation is determined by both radiological and physical findings, usually in the context of multiple toe fractures or displaced fractures of the great toe.


Non-operative Approach for Stress Fractures in the Lower Extremity

For lower extremity stress fractures at low risk, a non-operative management approach is recommended.

Indications: Applicable to stress fractures that are not displaced.

Management: Conservative measures are initially employed for all non-displaced stress fractures.


Operative Care for Lower Extremity Stress Fractures

Operative management is recommended for displaced or non-responsive lower extremity stress fractures, including navicular stress fractures, that do not show improvement with nonoperative treatment.

Rationale for Recommendations: In most cases, stress fractures respond well to activity limitation, and activity restrictions are therefore advised. However, for stress fractures that do not respond or have displacement, effective management may involve surgical intervention. In certain situations, healthcare professionals may opt for non-operative treatment, particularly for mildly displaced fractures.


What our office can do if you have Forefoot and Midfoot Fractures as a result of a workers compensation injury

We possess the expertise to assist you with your workers’ compensation injuries. We comprehend the challenges you are facing and are committed to addressing your medical requirements 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 dealing with the workers’ compensation insurance company and your employer.

We acknowledge that this period can be stressful for you and your family. If you wish to schedule an appointment, please reach out to us, and we will strive to make the process as convenient for you as possible.




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