New York State Medical Treatment Guidelines for
Hindfoot 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 Hindfoot 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.

Hindfoot Fractures (Calcaneaus, Talus)

1. Diagnostic Studies for Hindfoot Fractures in workers compensation patients for X-Rays

   Diagnostic Studies for Hindfoot Fractures in workers compensation patients for X-Rays is Recommended are as a primary investigation for possible acute hindfoot

   Fractures.

   Indications: Suspicion of fracture.

   AP, lateral, and calcaneal views of the talus; AP, lateral, and Mortise, 45° internal oblique Broden views, and talar Canale views neck).

    

2. MRI of Hindfoot Fractures

   MRI of Hindfoot Fractures is recommended Regarding a possible acute occult talus fracture and Calcaneus.

   Indications – usually used only when there is a possibility of a hidden fracture of the lateral process or the talus neck. those patients whose simple pictures show those with an osteochondral lesion and those who are still symptomatic six weeks later should get an MRI evaluation.

    

3. MRI for Follow-up Evaluation of Non-acute Calcaneus Fracture

   MRI for Follow-up Evaluation of Non-acute Calcaneus Fracture is recommended for calcaneus fractures in order to detect problems in patients with non-acute fractures.

   Indications: patient with non-acute fracture and more prolonged pain than 4 months following the injury.

   Rationale for Recommendations: Since certain talus fractures are not visible on radiography, MRI is employed when one is suspected of having a hidden fracture. Avascular necrosis can also be evaluated with MRI. MRI is generally less effective for calcaneus injury than CT scan.

    

4. Bone Scanning for Calcaneus Fracture

   Bone Scanning for Calcaneus Fracture is recommended for the detection of stress and hidden fractures in certain Patients.

   Rationale for Recommendation: If you have a high clinical suspicion but a negative x-ray and CT scan, you might be justified in doing a bone scan. Occult calcaneus fractures and calcaneus stress fractures are diagnosed using bone imaging.

    

5. CT for Diagnosis and Classification of Hindfoot Fractures

   CT for Diagnosis and Classification of Hindfoot Fractures are recommended for the examination of fractures in the rearfoot.

   Indications: For occult and difficult distal extremities, CT is advised. ankle and foot fractures to better understand how the fractures are displaced, Affected joints’ articular involvement and subluxation. If particular Axial views are advised when displacement is taken into to any coronal views, if any. CT is recommended for the assessment of fractures of the subtalar joint suspected. Coronal and axial views.

   Rationale for Recommendation: CT scans are regarded as the best. a benchmark for identifying and classifying calcaneus fractures. For When x-ray pictures show further hindfoot fractures, CT should be taken into account. are negative. However a hidden fracture is suspected based on physical findings strong suspicion CT may also be helpful for complex object evaluation.

   Comminuted fractures, which offer a better representation of the distal tibial involvement of the articular surface, placement of the fragment, and identification of subluxations. The benefits of CT have been established through Evaluation, comminution, and treatment of articular step off and gaping has led observers to alter treatment strategies created from Radiographs.

   Follow-up Visits – Imaging For talus fracture, if clinically suspected in the setting of negative radiographs, follow-up radiographs may be helpful; after approximately seven days there will be resorption at the fracture line, which will then be visible more easily.

   Follow-up radiography at six to eight weeks for confirmed talus fracture, looking for the Hawkins sign, a radiographic subchondral radiolucent band in the talar dome. This sign, visible in the anterior-posterior view, is indicative of viability at six to eight weeks postfracture indicating that avascular necrosis is unlikely to develop.

Medications of Hindfoot 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) and Acetaminophen for Hindfoot Fractures Analgesia

   Non-Steroidal Anti-inflammatory Drugs (NSAIDs) and Acetaminophen for Hindfoot Fractures Analgesia are recommended for hindfoot fracture analgesia.

   Indications: NSAIDs are advised as a kind of treatment for hindfoot fracture analgesia. First, try over-the-counter (OTC) medications to see whether they work.

   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 discontinuation.

    

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

   NSAIDs for Patients at High-Risk of Gastrointestinal Bleeding is recommended Patients who are at a high risk of gastrointestinal bleeding should take misoprostol, sucralfate, histamine type 2 receptor blockers, and proton pump inhibitors concurrently.

   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 – 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 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 Aspirin or acetaminophen as the initial course of treatment seem to be the least harmful in terms of cardiovascular issues.

   Non-selective NSAIDs are used as necessary. preferable to COX-2-specific medications when administering low-dose aspirin for the prevention of primary or secondary cardiovascular disease, to lessen the risk that the NSAID will have the opposite of the desired effects. The NSAID should be taken at least 30 minutes after or 8 of aspirin. a day’s worth of aspirin.

    

4. Acetaminophen for Treatment of Hindfoot Fracture Pain

   Acetaminophen for Treatment of Hindfoot Fracture Pain is recommended for the relief of pain from hindfoot fractures, particularly in patients who should not take NSAIDs.

   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: resolution of discomfort, negative effects, or Intolerance.

    

5. Limited Use of Opioids for Acute and Postoperative Pain

   Limited Use of Opioids for Acute and Postoperative Pain Management are recommended for quick use (less than seven days) in specific patients for adjunctive postoperative and acute pain management to more effective medicines.

   Indications: A painkiller is used to reduce pain following surgery and from recent damage. Prescriptions for short-acting opioids in addition to longer-acting therapies (especially acetaminophen, elevation, bracing, and NSAIDs) essential, particularly at night.

   Frequency/Duration: throughout the day as necessary, then only at nighttime later, until entirely weaning off.

   Rationale for Recommendation: NSAIDs don’t provide enough pain relief for certain individuals, therefore using opioids wisely 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.

    

6. Tetanus Immunization Status for Open Fractures

   Tetanus Immunization Status for Open Fractures is recommended updating the status of tetanus vaccinations 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.

    

7. Pre-Operative Antibiotic Prophylaxis for Ankle Fractures

   Pre-Operative Antibiotic Prophylaxis for Ankle Fractures is recommended for ankle fracture surgery, either open or closed. Evidence for the Preventative Use of Antibiotics in Ankle Fractures

    

8. 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.

   Rationale for Recommendation: calcitonin nasal spray made with salmon not significantly different from placebo in terms of bone. after three months of surgery, mineralization.

DVT Prophylaxis of Hindfoot Fractures

See the Achilles tendon rupture section’s section on DVT prophylaxis.

Rehabilitation of Hindfoot Fractures

Rehab (supervised formal therapy) needed after a work-related injury should be concentrated on regaining the functional ability needed to meet the patient’s daily and work obligations and enable them to return to work, with the goal of returning the injured worker to their pre-injury status to the extent that is practical.

Active therapy calls for the patient to put in an internal effort to finish a particular activity or assignment. The procedures known as passive therapy rely on modalities that are administered by a therapist rather than the patient exerting any effort on their side.

Passive therapies are typically seen as a way to speed up an active therapy programme and achieve concurrently objective functional gains. Over passive interventions, active initiatives should be prioritised.

Instructing the patient to continue both active and passive therapies provided at home as an additional step in the healing process to keep up the improvements.

To facilitate functional gains, assistive devices may be used as an adjuvant measure in the rehabilitation strategy.

1. Diathermy for Management of Edema Associated with Calcaneus Fracture

   Diathermy for Management of Edema Associated with Calcaneus Fracture is not recommended for treating edoema brought by by calcaneus fractures.

    

2. Diathermy for the Control of Edema: Evidence Physical and occupational therapy therapeutic exercise

   Diathermy for the Control of Edema: Evidence Physical and occupational therapy therapeutic exercise are recommended to enhance strength and range of motion while functioning.

   Frequency/Dose/Duration – With verification of continued objective functional progress, the total number of visits may be as low as two to three for individuals with minor functional deficits or as high as 12 to 15 for those with more severe deficits.

   When functional impairments persist, longer than 12 to 15 visits could be suggested if there is proof of functional development with a specific goal in mind (such as increasing range of motion or performance ability) activities at work).

   A house is included in the rehabilitation strategy. A fitness regimen should be created and carried out in addition to the treatment.

Fracture Care of Hindfoot Fractures

Talus Fractures

All non-displaced, non-reducible fractures. Referral to specialist is indicated for all injuries due to the high potential for poor outcomes of these injuries. Emergent referral for talar neck fractures.

1. Non-operative Management of Non-displaced Talar Fractures

   Non-operative Management of Non-displaced Talar Fractures is not recommended for talar fractures without displacement (head, neck, body).

    

2. Operative Management of Displaced Talar Fractures

   Operative Management of Displaced Talar Fractures is recommended for every fractured talus that has moved (head, neck, body, lateral process).

   Indications: every single non-displaced, irreducible fracture. Due to the high likelihood of negative effects, referral to a specialist is advised for all injuries. urgent referral for fractures of the talar neck.

   Rationale for Recommendations:Referral to experts is advised for the majority, if not all, talus fractures due to the crucial function the talus plays in locomotion and the possibility of considerable impairment and complications with these fractures.

    

3. Non-Operative Management of Osteochondral Lesions of the Talus

   Non-Operative Management of Osteochondral Lesions of the Talus is recommended for select patients.

   Indications:For initial care of lateral lesions that radiographically appear to be a compression lesion with no visible fragment or with a fragment that is visible but still connected, a non-operative approach is recommended.

   Management: Immobilisation with a cast or brace for six to twelve weeks, followed by strengthening and developing pain-free range-of-motion activities

    

4. Operative Treatment for Talar Osteochondral Lesions

   Operative Treatment for Talar Osteochondral Lesions is recommended after a first round of cautious management. It is advised to use osteochondral autograft and microfracture.

   Rationale for Recommendations:First, it is advised to try prudent management. It is reasonable to try protected weight bearing for six to twelve weeks.

Calcaneus Fractures of Hindfoot Fractures

1. Cast Immobilization for Select Calcaneus Fractures

   Cast Immobilization for Select Calcaneus Fractures is recommended for some types of calcaneus fractures.

   Indications:Non-displaced fracture, extra articular displacement, and intra articular displacement.

    

2. Operative Management for Select Calcaneus Fractures

   Operative Management for Select Calcaneus Fractures is recommended for some types of calcaneus fractures.

   Indications:displaced intra-articular fractures and extra-articular fractures that cannot be reduced.

   Rationale for Recommendations:Both surgical and nonsurgical therapy have a sizable potential for negative outcomes, such as secondary late fusion, fasciotomy and compartment syndrome, DVT and pulmonary embolism, and late-term arthrodesis.

    

3. Use of Pneumatic Compression Device for Treatment of Calcaneus Fractures

   Use of Pneumatic Compression Device for Treatment of Calcaneus Fractures is recommended for patients who have experienced severe edoema following closed calcaneus fractures.

   Indications: Candidates for surgery include those with significant edema following closed displaced calcaneus fractures. Utilise in non-surgical patients to lower risk of further problems

   Frequency/Duration:Continuous pedal compression device utilised until swelling goes down enough to permit surgery or non-operative management.

   Rationale for Recommendation:For the treatment of acute calcaneus fractures in some individuals who have considerable edoema, pneumatic compression is advised.

What our office can do if you have Hindfoot Fractures

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