The New York State workers compensation board has developed these guidelines to help physicians, podiatrists, and other healthcare professionals provide appropriate treatment for Forefoot and Midfoot 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.

Diagnostic Studies for Forefoot and Midfoot Fractures in workers compensation patients

1. Diagnostic Studies for Forefoot and Midfoot Fractures in workers compensation patients for X-Rays is recommended as a first-line investigation for possible midfoot or forefoot fractures.

   Indications:Look for any fractures in the forefoot or midfoot

   Rationale for Recommendation:Fractures can be detected with an X-ray, fracture plane(s) direction, the extent of the involvement of the if they are sufficiently large, the interphalangeal and metatarsal phalangeal joints might change management to favour surgery (see below). a fracture In the case of negative radiographs, pursue a clinical suspicion Radiographs could be beneficial; after roughly seven days, there should. The fracture line resorption will then be apparent.

    

2. MRI for Suspected Acute Forefoot and Midfoot Fractures

   MRI for Suspected Acute Forefoot and Midfoot Fractures is recommended for occult suspicion and stress fracture in certain patients.

   Indications:typically used when there is a suspicion of an undetected condition or stress fracture although some consider CT to be superior to the fore or midfoot.

   Rationale for Recommendation:MRI should not be the first treatment option. test. MRI could be a crucial diagnostic tool for the analysis of Possible navicular and tarsometatarsal joint injuries (Lisfranc injury) and for the early detection of a possible stress fracture. MRI is also employed to assess avascular necrosis and a potential hidden fracture.

    

3. Bone Scanning for Forefoot and Midfoot Fractures

   Bone Scanning for Forefoot and Midfoot Fractures is recommended typically used when there is a suspicion of an undetected condition or stress fracture although some consider CT to be superior to the fore or midfoot.

   Indications:usually used when there is a possibility that the tarsal and metatarsal bones may have fractured occultly.

   Rationale for Recommendation :For the majority of patients with forefoot and midfoot fractures, bone scans are not necessary for assessment. For patients who have a high clinical suspicion but a negative x-ray or CT scan, a bone scan may be justified.

CT Imaging

CT for Diagnosis and Classification of Forefoot and Midfoot Fractures

CT for Diagnosis and Classification of Forefoot and Midfoot Fractures is recommended in a small number of people for forefoot and fractures in the midfoot

Indications: To better understand fracture displacement, articular involvement, and subluxation of afflicted joints, tarsal and metatarsal bone fractures that have fractured or broken into many pieces are evaluated. This is typically used as a backup diagnostic technique to x-rays.

Rationale for Recommendation: CT should not be a first-line treatment. test. CT might be a crucial diagnostic method to get more clarity. subluxation, articular involvement, and fracture displacement is advised for some people with afflicted joints.

Medications for Forefoot and Midfoot Fractures

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. A viable substitute for acetaminophen (or its homolog paracetamol) NSAIDs for individuals who are not NSAID candidates, despite the majority of evidence hints that acetaminophen is just marginally less effective.

There is proof that NSAIDs are equally as effective as opioids, such as tramadol, for relieving pain. impairing.

1. Non-Steroidal Anti-inflammatory Drugs (NSAIDs)

   Non-Steroidal Anti-inflammatory Drugs (NSAIDs) is recommended for managing pain from metatarsal or phalangeal fractures.

   Indications:NSAIDs are advised as a kind of treatment for phalangeal or metatarsal fracture pain that is acute, subacute, chronic, or postoperative. First, try over-the-counter (OTC) medications to see whether they work.

   Frequency/Duration: Many patients could find it reasonable to use as needed.

   Indications for Discontinuation: Resolution of ankle/foot discomfort, ineffectiveness, or emergence of side effects requiring termination.

    

2. NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding

   NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding is recommended concurrent use of histamine type 2 receptor blockers, proton pump inhibitors, misoprostol, sucralfate, and other cytoprotective classes of medications for individuals at high risk of gastrointestinal bleeding.

   Indications: Cytoprotective drugs should be taken into consideration for patients with a high-risk factor profile who also have indications for NSAIDs, especially if a prolonged course of treatment is planned. Patients who have a history of gastrointestinal bleeding in the past, the elderly, diabetics, and smokers are at risk.

   Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers recommended. Dose and frequency per manufacturer. There is not generally believed to be substantial differences in efficacy for prevention of gastrointestinal bleeding.

   Indications for Discontinuation:Intolerance, the emergence of unfavourable effects, or stopping using NSAIDs.

    

3. 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. Non-selective NSAIDs are suggested as an alternative to COX-2-specific drugs when necessary.

   When taking low-dose aspirin for the main or secondary prevention of cardiovascular disease, an NSAID should be taken at least 30 minutes after or eight hours before the aspirin. This will lessen the likelihood that the NSAID will counteract the protective effects of the aspirin.

    

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

   Acetaminophen for Treatment of Acute, Subacute, or Chronic Phalangeal or Metatarsal Fracture Pain is Recommended to treat severe, mild, or persistent illnesses Specifically in patients, pain related to phalangeal or metatarsal fractures Contraindications to NSAIDs.

   Indications: Acute, subacute, and chronic foot/ankle pain in all individuals chronic and following surgery.

   Dose/Frequency:As per the manufacturer’s recommendations; can be used as required. Over four gm/day, there is evidence of liver toxicity. Indications for Discontinuation:displacement of fracture/joint dislocation 2mm.

Treatments for Forefoot and Midfoot Fractures

1. Nonoperative Management for Non-Displaced TarsalMetatarsal Injury (Lisfranc)

   Nonoperative Management for Non-Displaced TarsalMetatarsal Injury (Lisfranc) is recommended for select patients.

   Indications:displacement of fracture/joint dislocation 2mm.

   Management:Cast that is not weight-bearing for six weeks.

    

2. Operative Management for Displaced Tarsal-Metatarsal Injury (Lisfranc)

   Operative Management for Displaced Tarsal-Metatarsal Injury (Lisfranc) is recommended for a tarsal-metatarsal injury that is unstable.

   Indications: joint dislocation greater than 2 mm and fracture joint displacement.

   Management:The healing process could begin with therapy and last for four to five months. removing hardware before starting a full activity

   Rationale for Recommendations:Therapy could be the first step in the healing process, which might persist for four to five months. hardware removal before a full activity is started. Evidence for the Management of Lisfranc Injuries

    

3. Non-Operative Management for Non-Displaced Metatarsal Fractures

   Non-Operative Management for Non-Displaced Metatarsal Fractures is recommended for non-displaced metatarsal fractures. Indications: Shaft fractures with a dorsal angulation of less than 10, without displacement or with displacement of up to 3 to 4 mm in either the dorsal or plantar directions.

    

4. Operative Management for Displaced Metatarsal Shaft Fractures

   Operative Management for Displaced Metatarsal Shaft Fractures is recommended for misaligned metatarsal shaft fractures. foot and ankle conditions: Indications:Several metatarsals may fracture, coupled with a shaft fracture near the metatarsal head, if they become dislocated..

   Management: Internal fixation with screws, plates, or percutaneous pinning; four to six weeks of no weight bearing. weight-bearing progression over the following four to six weeks in a walking cast or fracture shoe/boot. after radiographic proof of union, full weight-bearing in stiff-soled footwear.

   Rationale for Recommendations: The physical and radiographic findings determine the best immobilisation or fixation approach.

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

   Non-operative Management for Proximal Fifth Metatarsal Fractures (Including Joints and Avulsion) is Recommended for select patients.

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

   Management: Play the same movie for one and six weeks. Jones fracture: immobilisation in a non-weight-bearing short-leg cast for one to six weeks; then, until union, in a walking cast or hard-sole shoe.

    

5. Operative Management for Fifth Displaced Metatarsal Shaft Fractures (Jones, Avulsion)

   Operative Management for Fifth Displaced Metatarsal Shaft Fractures (Jones, Avulsion) is Recommended for select patients.

   Indications:Avulsion of tuberosity: step-off on the articular surface that is displaced by more than 1 to 2 mm, or more than 30% of the articular surface that is cuboid; Jones Patient/provider preference is a fracture

   Management: Evidence for the Management of Proximal Fifth Metatarsal Injuries

   Rationale for Recommendations:The physical and radiographic findings determine the best immobilisation or fixation approach.

    

6. Immobilization for Distal, Middle, or Proximal Phalanx

   Immobilization for Distal, Middle, or Proximal Phalanx are recommended for the care of specific patients.

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

   Management:Closed reduction following digital or hematoma block, post-reduction film obtained, repeated at one and six weeks, and toe splinted with buddy taping to adjacent toe until nontender (three to four weeks), omitting hallux. Consider further immobilisation with a postoperative shoe or cast-boot.

    

7. Operative Management for Distal, Middle, or Proximal Phalanx Fractures

   Operative Management for Distal, Middle, or Proximal Phalanx Fractures are Recommended for the care of specific patients.

   Indications:Great toe displacement fractures that were difficult to reduce and couldn’t be held with a tape splint..

   Rationale for Recommendations: Therefore, the immobilisation or fixation strategy is determined by the radiological and physical findings. It usually only affects multiple toe fractures or displaced fractures of the great toe.

    

8. Non-operative Management for Lower Extremity Stress Fractures

   Non-operative Management for Lower Extremity Stress Fractures is recommended -for lower extremity stress fractures at low risk. for lower extremity stress fractures at low risk.

   Indications:stress fractures that are not displaced.

   Management: All non-displaced stress fractures are initially treated with conservative measures.

    

9. Operative Management for Lower Extremity Stress Fractures

   Operative Management for Lower Extremity Stress Fractures is recommended for displaced or non-responding lower extremity stress fractures, such as navicular stress fractures, that cannot be treated nonoperatively.

   Rationale for Recommendations: Responses to stress fractures in most cases, respond to activity limitation. Activity Restrictions are consequently advised. Those stress fractures that do not react or that have moved are handled effectively. Sometimes, experts will choose to treat a certain patient first. Non-operatively treated mildly displaced fractures.

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

We have the experience to help you with their workers compensation injuries. We understand what you are going through and will meet your medical needs and follow the guidelines set by the New York State Workers Compensation Board.

We understand the importance of your workers compensation cases. Let us help you navigate through the maze of dealing with the workers compensation insurance company and your employer.

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