New York State Medical Treatment Guidelines for
Ankle and Foot Fractures in workers compensation patients
The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Ankle and Foot Fractures.
These Workers Compensation Board guidelines are intended to assist healthcare professionals in making decisions regarding the appropriate level of care for their patients with ankle and foot disorders.
The guidelines are not a substitute for clinical judgement or professional experience. The ultimate decision regarding care must be made by the patient in consultation with his or her healthcare provider.
Ankle and Foot Fractures
A patient with an ankle injury should undergo an initial evaluation to look for conditions that need to be treated right away. These ailments include vascular disease and open fracture. Joint dislocation, compartment syndrome, and compromise.
In general, non-operative treatment is used for undisplaced or minimally displaced injuries. While surgical intervention is used to address misplaced or unstable wounds. ankle complications and foot fractures include discomfort, post-traumatic osteoarthritis, reduced range of motion, prolonged discomfort despite removal of hardware, developing talar instability, and malunions with simultaneous syndesmotic widening
The kind of injury (displaced or nondisplaced) determines the initial course of therapy for foot and ankle fractures. steady, open, or closed) as well as simultaneous soft tissue damage. Closed and stable wounds are generally non-operative treatments.
Emergent debridement is necessary for open fractures, and antibiotic prevention. Most closed unstable fractures need to be operated on. Initiate treatment for skin conditions, compartment syndrome, and significant swelling. integrity degradation due to blisters from fractures.
Diagnostic Studies for Ankle and Foot Fractures in workers compensation patients
- Diagnostic Studies for Ankle and Foot Fractures for X-Rays
Diagnostic Studies for Ankle and Foot Fractures for X-Rays is recommended as a first-line study.
Indications: Suspicion of fracture.
Rationale for Recommendation: The first line of treatment is X-ray.
imaging examination for a possible fracture.
- MRI for Distal Lower Extremity and Ankle Fractures
MRI for Distal Lower Extremity and Ankle Fractures is recommended for the purpose of examining ankle and distal lower limb fractures.
Indications: To assess soft tissue for acute or subacute fracture comminuted or complicated displaced fracture with tissue/ligament damage, or if the fracture’s stability is questionable and an MRI will help with management decision.
Rationale for Recommendation: MRI should not be used as a first-line imaging method. In the event that shifted, comminuted, or MRI might be a crucial diagnostic tool for the unstable fracture examination of potential soft tissue damage involving the distal fibular, fractures of the tibia and malleoli, such as those to the syndesmotic ankle ligament complex, the tibial nerve, the deltoid ligament, or the extensor tendons. MRI is highly suggested in certain specific cases.
- CT for Diagnosis and Classification of Ankle Fractures
CT for Diagnosis and Classification of Ankle Fractures are recommended for the purpose of examining ankle and distal lower limb fractures.
Indications: suspected concealed and complicated ankle fractures; to clarify the location of the fracture. Axial views are advised in addition to any coronal views if intra articular displacement is being taken into account.
Rationale for Recommendation: When using an x-ray, consider using a CT. Despite the bad perceptions, physical evidence points to an occult conspiracy. A fracture is highly likely. CT could be helpful for assessing complicated comminuted fractures that better represent the distal femur involvement of the tibial articular surface, placement of the fragment, and diagnostic a subluxation of.
Ultrasound Imaging for Diagnosing Ankle Fracture
Ultrasound Imaging for Diagnosing Ankle Fracture is recommended for determining whether certain misplaced fractures or suspected malleolar stress fractures have caused soft-tissue damage.
Indications: Evaluation of soft-tissue damage related to specific Displacement fractures to determine a fracture’s stability, particularly the medial and bimalleolar fractures in the deltoid ligaments, and in detection of occult or stress fracture suspicion. also employed for possible stress the distal tibia breaking.
Rationale for Recommendation: Using ultrasound imaging could be helpful. In addition to clinical evaluation of patients in the selection of Further radiological testing is therefore advised in some circumstances. patients.
Medications for Ankle and Foot Fractures
- Pre-Operative Antibiotic Prophylaxis for Ankle Fractures
Pre-Operative Antibiotic Prophylaxis for Ankle Fractures is recommended for ankle fracture surgery, either open or closed.
- Use of Nasal Spray Calcitonin for Post-fracture Osteopenia
Use of Nasal Spray Calcitonin for Post-fracture Osteopenia is not recommended for the prevention of osteopenia following fracture.
- DVT Prophylaxis of Ankle and Foot Fractures
See the section on DVT prevention in Achilles tendon rupture. Section.
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and Acetaminophen
Ibuprofen, naproxen, or other NSAIDs from an earlier generation are suggested as first-line treatments for the majority of patients. For patients who are not candidates for NSAIDs, acetaminophen (or the analogue paracetamol) may be a viable alternative, even if the majority of research indicates it is just marginally less effective than NSAIDs. There is proof that NSAIDs are less dangerous and just as effective in treating pain as opioids, such as tramadol.
- Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Acute Ankle Fracture Analgesia
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Acute Ankle Fracture Analgesia is recommended for the purpose of treating pain brought on by an ankle fracture.
Indications: For an ankle fracture that is post-operative or chronic, NSAIDs are advised as a therapy. agents sold over-the-counter (OTC) may be adequate and ought to be attempted first.
Frequency/Duration: Many Patients may find it reasonable to use as needed.
Indications for Discontinuation: resolution of ankle/foot discomfort, absence effectiveness, or the emergence of unfavourable effects that are necessary discontinuance.
- NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding
NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding is recommended concurrent use of cytoprotective medication classes: Histamine Type 2 receptor blockers, misoprostol, sucralfate, and proton People with a high risk of gastrointestinal bleeding should take pump inhibitors.
Indications: For patients who additionally have a high-risk factor profile, the use of NSAIDs and cytoprotective drugs should be taken into account, especially if longer-term treatment is being discussed.
At-risk Patients having a background of previous gastrointestinal bleeding, older people, people with diabetes, and smokers.
Frequency/Dose/Duration: Misoprostol, proton pump inhibitors, Sucralfate and H2 blockers are advised. dosage and repetitions per manufacturer. There isn’t typically thought to be anything there. varying degrees of effectiveness in preventing gastrointestinal bleeding
Indications for Discontinuation: Intolerance, the emergence of negative effects, or the stopping of NSAIDs.
- NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects is recommended the first-line treatment options of acetaminophen or aspirin seem to be the safest in terms of cardiovascular side effects. It is advised to use non-selective NSAIDs rather than COX-2-specific medications if necessary.
To reduce the chance that an NSAID will negate the protective effects of low-dose aspirin in individuals receiving it for primary or secondary cardiovascular disease prevention, the NSAID should be taken at least 30 minutes after or eight hours before the daily aspirin.
- Acetaminophen Treatment of Acute, Subacute, or Chronic Pain with Acetaminophen Acute Pain From Ankle Fracture
Acetaminophen Treatment of Acute, Subacute, or Chronic Pain with Acetaminophen Acute Pain From Ankle Fracture are recommended for the treatment of acute ankle fracture pain, whether it be acute, subacute, or chronic, especially in individuals who have NSAID contraindications.
Indications: Acute, subacute, and chronic foot/ankle pain in all individuals chronic and following surgery.
Dose/Frequency: Depending on the manufacturer’s guidelines; applicable on a need-to-know basis. Hepatic toxicity is demonstrated when greater than 4 g/day.
Indications for Discontinuation: relief from discomfort, negative effects, or intolerance.
- Limited Use of Opioids for Acute and Postoperative Pain Management
Limited Use of Opioids for Acute and Postoperative Pain Management are recommended for brief (less than seven days) usage for urgent emergency postoperative pain control as a complementary therapy for more efficient Treatments.
Indications: Acute injury and post-op pain treatment require the use of short opioid prescriptions as supplements to more effective treatments (particularly NSAIDs, acetaminophen, elevation, and bracing) necessary, especially at night.
Frequency/Duration: throughout the day as necessary, then only at nighttime later, until entirely weaning off.
Rationale for Recommendation: Some people experience too little pain. NSAIDs can provide relief, therefore using opioids responsibly may be beneficial. especially for use at night. Opioids are advised for limited, specific use in recovering patients, with nighttime use being the main goal Postoperatively.
- Tetanus Immunization Status for Open Fractures
Tetanus Immunization Status for Open Fractures is recommended updating of tetanus immunisation status as Necessary.
Indications: Those wounds that have not healed after more than five years elapsed since the last tetanus shot.
Rationale for Recommendation: Due to the negative implications of not vaccinations can be harmful, tetanus vaccination updates for open wounds is advised. Those with burns or dirty wounds should if it has been more than five years since the last vaccination, requiring vaccination, instead of ten years. Patients who have not finished their vaccination series should receive tetanus immune globulin along with each of the three shots. immunisation.
- Analgesia for Non-Operative Reduction Ankle Fractures
Analgesia for Non-Operative Reduction Ankle Fractures is recommended for performing non-operative closed reduction of ankle fractures.
Rationale for Recommendation: The best strategy should be chosen depending on the expertise and preferences of the doctor, the patient’s history of medication intolerance or level of anxiety, and the availability of supplies and equipment.
Treatments of Ankle and Foot Fractures
Mobilization / Immobilization of Ankle and Foot Fractures
- Cast Immobilization for Ankle Fractures
Cast Immobilization for Ankle Fractures is recommended in order to treat ankle fractures. Any ankle fracture is a sign.
Frequency/Duration: Immobilization generally for six to eight weeks.
Rationale for Recommendation: Cast-induced immobility is advised for all patients, and the application depends on patient and doctor preferences.
- Early Mobilization for Ankle Fractures
Early Mobilization for Ankle Fractures is recommended in the management of postoperative and stable non-operative ankle fractures.
Indications: with or without stabilised malleolar fractures Surgical and properly fixed closed ankle fractures stabilisation, too.
Frequency/Duration: The early mobilisation process can begin. between one and three days after surgery.
Rationale for Recommendation: For the majority of patients with a stable or healed malleolar ankle fracture, early mobilisation is advised.
- Early Postoperative Weight-bearing for Ankle Fractures
Early Postoperative Weight-bearing for Ankle Fractures is recommended early weight bearing after surgical fixation ankle fractures following surgery.
Indications: with or without stabilised malleolar fractures Surgical and properly fixed closed ankle fractures stabilisation, too.
Rationale for Recommendation: premature weight-bearing may produce short-term benefits in functional recovery, do not seem to lead to an increase in unfavourable events.
Immobilization, early mobilisation, and its Use Early Weight-bearing for Fractures of the Ankle
Rehabilitation of Ankle and Foot Fractures
- Electrical Stimulation for Prevention of Muscle Atrophy
Electrical Stimulation for Prevention of Muscle Atrophy is not recommended in order to stop muscular atrophy in care of foot and ankle fractures.
- Therapy for Patients with Functional Deficits after Cast Removal
Therapy for Patients with Functional Deficits after Cast Removal is recommended after the removal of the ankle cast.
- Manual Therapy as Part of a Post-ankle Fracture Rehabilitation Program
Manual Therapy as Part of a Post-ankle Fracture Rehabilitation Program is recommended as a vital component of a rehabilitation programme following an ankle fracture.
- Passive Stretching for Contractures After Immobilization of Ankle Fractures
Passive Stretching for Contractures After Immobilization of Ankle Fractures is not recommended treating contractures following ankle fracture immobilisation.
Frequency/Dose/Duration : The frequency of visits is frequently based on how severe the constraint is. Two to three visits per week are usual throughout the first two weeks of a fitness programme.
With verification of objective functional progress, the total number of visits may range from two to three for mild deficits to twelve to fifteen for more severe deficits.
- Ultrasound to Stimulate Bone Healing for Ankle and Foot Fractures
Ultrasound to Stimulate Bone Healing for Ankle and Foot Fractures is not recommended – for ankle and foot fracture Management.
- Hyperbaric Oxygen for the Management of Ankle or Foot Fractures
Hyperbaric Oxygen for the Management of Ankle or Foot Fractures is not recommended for 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 been managed been ineffective with positive outcomes. There is ongoing discussion on the treatment of certain types of fractures for which there is uncertainty either stable or unstable.
The distal fibula fracture rarely fails to heal, so support for a conservative management experiment using non-displaced and cracks with steady displacement Failure to reduce or a delayed union may require the use of surgery. Frequently, posterior malleolar fractures occur. highly unpredictable and frequently missed.
- Immobilization for Non-displaced Ankle Fractures
Immobilization for Non-displaced Ankle Fractures is recommended for the care of non-displaced individuals and decreases in stable ankle fractures.
- Immobilization and Reduction for Closed Displaced Ankle Fractures
Immobilization and Reduction for Closed Displaced Ankle Fractures is recommended for a few closed displaced non-comminuted ankle fractures.
Indications: Ankle that is not fractured and is dislocated. fractures that are smaller than two to three mm after reduction less than 25% of the posterior malleolus articular width and three minimal involvement.
- Operative Fixation for Closed Displaced Ankle Fractures
Operative Fixation for Closed Displaced Ankle Fractures is recommended for an ankle that is closed and dislocated. Fractures.
Indications: medial lateral fracture that is typically severe participation of the malleoli. ankle that is fractured and dislocated. fractures that have a displacement of more than 2 to 30% of the posterior malleolus articular diameter and 3mm only minor involvement
Rationale for Recommendations: Unless there is a severe the outcomes of an open reduction, systemic comorbidities, and for individuals with malleolar fractures, internal fixation Those younger than 60 are essentially the same, whereas When unstable fractures are not operated on, it results in much worse results.
Consequently, the overall Surgery indications for older individuals shouldn’t change from patients who are younger. therapy for individual fractures depending on the condition of the skin, the quality of the bones, Comorbidities and patient functional demands.
To avert complications, they must be taken into account and treated. concomitant conditions include osteoporosis and diabetes.
Tibial Shaft Fractures (Diaphyseal)
- Operative Fixation for Tibial Shaft Fracture (Closed, Diaphyseal)
Operative Fixation for Tibial Shaft Fracture (Closed, Diaphyseal) is recommended Displaced, comminuted distal tibial shaft Fracture.
Indications: Distal tibial shaft that is displaced and fractured Fracture.
- Cast Immobilization for Tibial Shaft Fractures (Closed, Diaphyseal)
Cast Immobilization for Tibial Shaft Fractures (Closed, Diaphyseal) is recommended in some patients. The tibia has a closed, stable fracture.
- Operative Fixation (i.e., Fracture Plating, Intramedullary Nail) for Distal Tibial Extra-Articular Fractures
Operative Fixation (i.eFracture Plating, Intramedullary Nail) for Distal Tibial Extra-Articular Fractures is recommended in 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 for Distal Tibial Extra-Articular Fractures 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.
Tibial Plafond (Pilon) Fractures
- Non-operative Management of Tibial Plafond and Pilon Fractures
Non-operative Management of Tibial Plafond and Pilon Fractures is Recommended in select patients.
Indications: Stable fracture that is neither displaced, comminuted, or unstable; capacity to achieve proper fracture alignment with closed reduction.
- Operative Management of Tibial Plafond and Pilon Fractures
Operative Management of Tibial Plafond and Pilon Fractures is recommended for some tibial plafond fractures Patients.
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 include referred to as plafond fractures. It is noted that these fractures having significant incidence of complications from surgical weight loss, Fixation.
Syndesmotic Ruptures for Ankle and Foot Fractures
Operative treatment of unstable syndesmotic injury to restore the tibiofibular relationship.
- Operative Fixation for Syndesmotic Ruptures
Operative Fixation for Syndesmotic Ruptures is recommended for unstable syndesmotic rupture.
Indications – ankle fractures that are closed but unstable AO fracture type C, syndesmosis, and/or pathologic widening of the syndesmosis at intraoperative of more than 2mm Testing.
- Non-operative Management of Syndesmotic Injuries
Non-operative Management of Syndesmotic Injuries is recommended for stable syndesmotic injury.
Indications: Absence of other destabilising injury including ankle fracture 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 destabilising injuries. If there is a fracture, fixation is necessary.
For some patients, non-operative care is advised. For non-stable injuries, such as most syndesmotic rupture with concomitant fractures or deltoid ligament injury, surgical treatment is advised.
Fibular Fracture of Ankle and Foot Fractures
Operative Fixation for Displaced Distal Fibula Fractures
Operative Fixation for Displaced Distal Fibula Fractures is recommended for a fractured distal fibula.
Indications: Unsatisfactory closed fracture of the distal fibula shaft Reduction.
Rationale for Recommendation: Surgical fixing 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 Use of Arthroscopy Assisted ORIF for Distal Fibular Fractures
Arthroscopy with ORIF of Distal Fibular Fractures Use of Arthroscopy Assisted ORIF for Distal Fibular Fractures is not recommended for fractures of the distal fibula. Arthroscopy Evaluation During Distal Tibia Fracture Fixation ORIF: Evidence for Use
Deltoid Ligament Repair with ORIF of Lateral Ankle Fracture
Deltoid Ligament Repair with ORIF of Lateral Ankle Fracture Deltoid Ligament Repair Concurrent with ORIF for Unstable Ankle Fractures
Deltoid Ligament Repair with ORIF of Lateral Ankle Fracture Deltoid Ligament Repair Concurrent with ORIF for Unstable Ankle Fractures is recommended for those who suffer with deltoid ligament significant fibular fractures or in patients with disruption simultaneous syndesmotic fixation
Other of Ankle and Foot Fractures
- Pneumatic Compression for Treatment of Ankle and Foot Edema
Pneumatic Compression for Treatment of Ankle and Foot Edema is recommended for patients who have sustained serious postoperative Edema.
Indications: excessive swelling following surgery for an ankle fracture.
- Interferential Therapy for Treatment of Ankle Edema
Interferential Therapy for Treatment of Ankle Edema is not recommended in order to treat postoperative post ORIF for a dislocated malleolar fracture, edema.
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