The guidelines established by the New York State Workers Compensation Board aim to aid physicians, podiatrists, and other healthcare professionals in delivering suitable treatment for Hindfoot Fractures.
Designed as a resource for healthcare practitioners, these guidelines provide assistance in determining the optimal level of care for patients with ankle and foot disorders. However, it is important to note that these guidelines are not a replacement for clinical judgment or professional expertise. The final decision regarding care should be a collaborative one, made by the patient in consultation with their healthcare provider.
Hindfoot Fractures (Calcaneaus, Talus)
For the diagnostic studies of Hindfoot Fractures in workers’ compensation patients, the following recommendations are made:
- Indications: Suspicion of fracture.
- Recommended Views: AP, lateral, and calcaneal views of the talus; AP, lateral, and Mortise, 45° internal oblique Broden views, and talar Canale views neck.
MRI of Hindfoot Fractures:
- Indications: Usually employed when there is a possibility of a hidden fracture of the lateral process or the talus neck. Patients with simple X-rays indicating an osteochondral lesion or those who remain symptomatic six weeks later should undergo MRI evaluation.
MRI for Follow-up Evaluation of Non-acute Calcaneus Fracture:
- Indications: Patients with non-acute fracture and prolonged pain exceeding 4 months following the injury.
- Rationale: MRI is used to detect problems in patients with non-acute calcaneus fractures, evaluating avascular necrosis and assessing healing progress.
Bone Scanning for Calcaneus Fracture:
- Rationale: If there is a high clinical suspicion despite negative X-ray and CT scan, a bone scan may be justified for detecting occult calcaneus fractures and calcaneus stress fractures.
These diagnostic studies aim to provide a comprehensive evaluation of Hindfoot Fractures, ensuring accurate diagnosis and appropriate treatment planning for workers’ compensation patients.
CT for Diagnosis and Classification of Hindfoot Fractures:
- Indications: Recommended for examining fractures in the rearfoot, especially for occult and challenging distal extremities, ankle, and foot fractures. Useful for better understanding fracture displacement, articular involvement, subluxation of affected joints, and assessment of subtalar joint fractures.
- Views: Coronal and axial views are advised, with axial views being particularly important when displacement needs evaluation.
- Rationale: CT scans are considered the benchmark for identifying and classifying calcaneus fractures. They offer a detailed representation of distal tibial involvement, articular surface placement, and subluxation identification. CT is recommended when X-rays show negative results but a hidden fracture is suspected based on physical findings, especially in cases of comminuted fractures.
- Follow-up Visits – Imaging: For talus fractures, if clinically suspected with negative radiographs, follow-up radiographs may be useful. After approximately seven days, resorption at the fracture line becomes more visible. Follow-up radiography at six to eight weeks for confirmed talus fractures is advised to check for the Hawkins sign, indicating viability and reducing the likelihood of avascular necrosis development.
These recommendations for CT usage in the diagnosis and classification of Hindfoot Fractures aim to provide a comprehensive assessment, aiding in treatment planning and follow-up evaluations for workers’ compensation patients.
Medications of Hindfoot Fractures
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Acetaminophen:
Ibuprofen, Naproxen, or other NSAIDs:
- First-Line Treatment: Recommended as the initial treatment for the majority of patients.
- Substitute for Acetaminophen: Considered a viable alternative for individuals who cannot take NSAIDs, although evidence suggests that acetaminophen is only marginally less effective.
NSAIDs versus Acetaminophen for Hindfoot Fractures Analgesia:
- Recommendation: Suggested for hindfoot fracture analgesia. Start with over-the-counter medications to assess effectiveness.
- Frequency/Duration: Patients may use as needed.
- Indications for Discontinuation: Discontinue with resolution of ankle/foot discomfort, lack of effectiveness, or the emergence of unfavorable effects.
NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding:
- Recommendation: Recommended for patients at high risk of gastrointestinal bleeding. Use cytoprotective drugs concurrently.
- Indications: Consider cytoprotective drugs for those with a high-risk profile, especially if NSAID treatment is prolonged. High-risk individuals include those with a history of gastrointestinal bleeding, the elderly, diabetics, and smokers.
- Frequency/Dose/Duration: Follow manufacturer’s recommendations for Misoprostol, proton pump inhibitors, Sucralfate, and H2 blockers. Effectiveness in preventing gastrointestinal bleeding may vary.
- Indications for Discontinuation: Discontinue in case of intolerance, unfavorable effects, or cessation of NSAID use.
These recommendations aim to guide the use of NSAIDs and Acetaminophen for effective pain management, taking into account individual risks and preferences in workers’ compensation cases involving hindfoot fractures.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects:
- Initial Course of Treatment: Aspirin or acetaminophen is recommended as the initial treatment to minimize the risk of cardiovascular issues.
- Non-Selective NSAIDs: Use non-selective NSAIDs as necessary, preferably over COX-2-specific medications, especially when administering low-dose aspirin for cardiovascular disease prevention. NSAID should be taken at least 30 minutes after or 8 hours before aspirin.
Acetaminophen for Treatment of Hindfoot Fracture Pain:
- Recommendation: Recommended for pain relief from hindfoot fractures, particularly in patients who cannot take NSAIDs.
- Indications: Applicable for acute, subacute, and chronic foot/ankle pain in all individuals, including postoperative cases.
- Dose/Frequency: Follow manufacturer’s guidelines, as needed. Demonstrate caution as hepatic toxicity is observed with doses exceeding 4 g/day.
- Indications for Discontinuation: Discontinue with pain resolution, negative effects, or intolerance.
Limited Use of Opioids for Acute and Postoperative Pain Management:
- Recommendation: Recommended for short-term use (less than seven days) in specific patients for adjunctive postoperative and acute pain management when more effective medicines are insufficient.
- Indications: Use for pain reduction following surgery and recent damage. Prescribe short-acting opioids alongside longer-acting therapies, especially at night.
- Frequency/Duration: Use throughout the day as necessary, then only at night later, until complete weaning off.
- Rationale for Recommendation: NSAIDs may not provide sufficient pain relief for certain individuals, and judicious opioid use may be beneficial, especially for nighttime recovery.
These guidelines offer a nuanced approach to pain management, considering individual patient needs, risks, and the limitations of different medications in cases involving hindfoot fractures.
Tetanus Immunization Status for Open Fractures:
- Updating Tetanus Status: It is recommended to update tetanus vaccinations as necessary, particularly for wounds that have not healed after more than five years since the last tetanus shot.
- Indications: Apply this recommendation to wounds that remain unhealed for more than five years after the last tetanus vaccination.
- Rationale: Due to the potential negative implications of lacking tetanus vaccinations, updating the status for open wounds is advised. For patients with burns or dirty wounds, consider vaccination if it has been more than five years since the last dose, rather than the standard ten years.
- Incomplete Vaccination Series: Patients who have not completed their vaccination series should receive tetanus immune globulin along with each of the three shots.
Pre-Operative Antibiotic Prophylaxis for Ankle Fractures:
- Pre-Operative Use: Antibiotic prophylaxis is recommended for ankle fracture surgery, regardless of whether the fracture is open or closed.
- Evidence Support: Evidence supports the preventive use of antibiotics in ankle fractures, particularly before surgery to reduce the risk of infections.
Use of Nasal Spray Calcitonin for Post-fracture Osteopenia:
- Not Recommended: The use of nasal spray calcitonin for preventing osteopenia following a fracture is not recommended.
- Rationale: Calcitonin nasal spray, particularly salmon calcitonin, has shown no significant difference from a placebo in terms of bone mineralization after three months of surgery. The efficacy is not substantial enough to recommend its use in this context.
DVT Prophylaxis of Hindfoot Fractures
Rehabilitation of Hindfoot Fractures:
Overview: Rehabilitation following a work-related hindfoot fracture should aim to restore functional abilities necessary for daily and work responsibilities, ultimately returning the injured worker to their pre-injury status as much as possible.
Active vs Passive Therapy:
- Active Therapy: Involves internal effort from the patient to complete specific activities or tasks. Prioritize active initiatives over passive interventions for optimal outcomes.
- Passive Therapy: Relies on modalities administered by a therapist, serving to complement active therapy and accelerate functional gains.
- Continuation of Therapies: Encourage patients to continue both active and passive therapies at home to sustain improvements.
- Assistive Devices: May be utilized to aid functional gains as a supplementary measure in the rehabilitation strategy.
Diathermy for Edema Associated with Calcaneus Fracture:
- Not Recommended: Diathermy is not recommended for managing edema associated with calcaneus fractures.
Physical and Occupational Therapy:
- Recommended Interventions: Therapeutic exercises, including physical and occupational therapy, are recommended to enhance strength and range of motion during functional activities.
- Frequency/Dose/Duration: The total number of therapy visits may vary based on the severity of deficits, ranging from two to three visits for minor deficits to 12 to 15 visits for more severe cases.
- Long-Term Consideration: For persistent functional impairments, a longer duration of therapy (beyond 12 to 15 visits) may be suggested if there is evidence of continued functional improvement with specific goals in mind.
Incorporation of Home Exercises:
- Home Fitness Regimen: A home exercise regimen should be developed and implemented as part of the overall rehabilitation strategy to support ongoing recovery.
Note: For details on DVT prophylaxis, refer to the Achilles tendon rupture section.
Fracture Care of Hindfoot Fractures
- Non-Displaced, Non-Reducible Fractures:
- Recommendation: Referral to a specialist is indicated for all injuries due to the high potential for poor outcomes.
- Special Consideration: Emergent referral for talar neck fractures.
- Non-Operative Management of Non-Displaced Talar Fractures:
- Not Recommended: Non-operative management is not recommended for talar fractures without displacement (head, neck, body).
- Operative Management of Displaced Talar Fractures:
- Recommendation: Operative management is recommended for every fractured talus that has displacement (head, neck, body, lateral process).
- Indications: Referral to a specialist is advised for all injuries, given the high likelihood of negative effects. Urgent referral for fractures of the talar neck.
- Rationale: Referral to specialists is crucial for talus fractures due to the talus’s essential role in locomotion and the potential for significant impairment and complications.
- Non-Operative Management of Osteochondral Lesions of the Talus:
- Recommendation: Non-operative management is recommended for select patients.
- Indications: Initial care for lateral lesions appearing as compression lesions with no visible fragment or a visible fragment still connected.
- Management: Immobilization with a cast or brace for six to twelve weeks, followed by strengthening and pain-free range-of-motion activities.
- Operative Treatment for Talar Osteochondral Lesions:
- Recommendation: Operative treatment is recommended after cautious initial management.
- Advised Procedures: Osteochondral autograft and microfracture are recommended.
- Rationale: Prudent management is initially recommended, including protected weight bearing for six to twelve weeks.
Note: For detailed and specific medical advice, consultation with a healthcare professional is essential.
Calcaneus Fractures of Hindfoot Fractures
- Cast Immobilization for Select Calcaneus Fractures:
- Recommendation: Cast immobilization is recommended for certain types of calcaneus fractures.
- Indications: Non-displaced fracture, extra-articular displacement, and intra-articular displacement.
- Operative Management for Select Calcaneus Fractures:
- Recommendation: Operative management is recommended for specific types of calcaneus fractures.
- Indications: Displaced intra-articular fractures and extra-articular fractures that cannot be reduced.
- Rationale: Both surgical and nonsurgical therapies carry potential risks, such as secondary late fusion, compartment syndrome, DVT and pulmonary embolism, and late-term arthrodesis.
- Use of Pneumatic Compression Device for Treatment of Calcaneus Fractures:
- Recommendation: The use of a pneumatic compression device is recommended for patients with severe edema following closed calcaneus fractures.
- Indications: Candidates for surgery with significant edema after closed displaced calcaneus fractures. Use in non-surgical patients to reduce the risk of further complications.
- Frequency/Duration: Continuous use of a pedal compression device until swelling reduces enough to permit surgery or non-operative management.
- Rationale: Pneumatic compression is advised for the treatment of acute calcaneus fractures in individuals with considerable edema.
Note: This summary provides general information and should not replace professional medical advice. For personalized recommendations, consult with a healthcare professional.
What our office can do if you have Hindfoot Fractures
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