Treatment of Foot and Ankle Trauma

1. Overview
2. Complicated Injuries and Innovative Treatments

Overview

As recently as 15 years ago, the chances were good that a traumatic foot or ankle injury resulting from a high impact motor vehicle accident or fall from a height would not have been treated. According to David S. Levine, MD, an orthopaedic surgeon at HSS, in those days before airbags and shoulder harnesses became standard equipment, and EMT technicians had limited training, many of these individuals would not have survived their other traumatic injuries. Those that did were likely to receive state-of-the-art care for injuries to the head, chest and abdomen. But the same patients were less likely to receive adequate or sufficiently aggressive care for their foot and ankle injuries. Typically, treatment consisted of placing the injured extremity in a cast and waiting for it to heal, a course that often led to deformity and disability.

Today, however, thanks to innovations in automobile manufacturing and the increased skills and technology available for use in pre-hospital care, more trauma patients than ever are surviving their accidents and go on to receive treatment for all of their injuries. Moreover, with these advances has come the emergence of a new specialty within orthopaedic medicine-surgeons who specialize in the care of foot and ankle trauma-and in the development of new techniques for the complicated injuries they treat.

"While foot and ankle trauma is not life-threatening, it does have the potential to be life-altering," explains Dr. Levine. A fracture of the foot or ankle that heals in a deformed position can cause problems that include swelling, pain, inability to bear weight, inability to wear shoes, or to work. If the injury results in a foot that is not plantigrade-meaning that the full sole of the foot rests on the ground when standing or walking-it may develop sores or ulcerations on the portion of the foot that is bearing excessive pressure.

In order to prevent such an outcome, orthopaedic surgeons initiate treatment as early as possible. Often, this consists of stabilizing the foot and/or ankle in an external fixator, a metal frame that is put in place with pins inserted into the bone. The frame preserves proper length of the joint and can be left in place as treatment for other injuries continues. "Before we can address the foot or ankle injury further, we need to wait for the swelling to go down, a process that may take up to three weeks," says Dr. Levine.

Because there is naturally a pooling of fluid in the foot, massive swelling after injury is common. In addition to the obstacle presented by swelling, patients who also have diabetes or heart disease, or are smokers may have impaired circulation due to constricted blood vessels, a problem that impairs the body's own defenses and makes surgery more risky.

Once the swelling has diminished sufficiently, the surgeon uses a range of techniques, which may include additional external fixation with pins, or permanent internal fixation devices. "With the initial use of the external fixator, and the appropriate timing of surgery, we can eliminate the need for casting, which often results in a straight but stiff limb" explains Dr. Levine "Some people mistakenly believe that the cast allows the patient to bear weight, but this is not the case. The patient should not bear weight until the bones heal." Moreover, patients who recover without a cast do so more quickly since they are able to begin a physical therapy program within two to four days following surgery. Exercises and techniques are introduced to prevent stiffness and reduce fluid retention.

Complicated Injuries and Innovative Treatments

Foot and ankle trauma encompass a range of injuries that include fractures of one or more of the bones that make up the foot and ankle, as well as damage to ligaments, tendons and nerves. Owing to the high-impact of these injuries the fractures are often comminuted, which means that the bone is broken or shattered into many pieces. Patients may also have an open fracture-in which the bone protrudes through the skin, which increases the risk of infection.

Cases in which the heel or calcaneous bone is fractured are particularly complicated to treat. When possible, the surgeon uses small plates and screws to hold the bone together and allow it to heal. If it is badly damaged, the surgeon may recommend an arthrodesis or fusion.

Heel (calcaneous bone) fracture treated with plates and screws.

In a small percentage of cases, when there is very severe injury to the heel bone, accompanied by serious problems with pain, infection and difficulty in wound care, amputation may be considered. "Although many people initially regard this surgery as the worst possible outcome, for some patients amputation offers the best option for restoring function," explains Dr. Levine. "Rather than saving a limb and enduring great discomfort and disability, these patients undergo reconstructive surgery, are fitted with a prosthesis and can return to many of the activities they enjoy, free from pain."

Injuries to the mid-foot also require highly specialized treatment. This portion of the foot is made up of numerous bones that are packed tightly together and held in place by ligaments and other soft tissues. During normal function, the mid-foot remains rigid-motion is required primarily in the heel and ball of the foot. Lisfranc injuries-named for a surgeon in Napoleon's army-occur when the mid-foot ligaments are damaged, disrupting the arrangement of bones that are ordinarily maintained in an arched position. The foot becomes flat and pronates, giving the patient a post-traumatic flatfoot, a condition that causes pain, difficulty in wearing shoes, and in some cases, pressure sores.

Lisfranc fracture right mid-foot.

In the past, patients were put in a cast in an effort to allow the ligaments to heal. This treatment yielded little benefit since the ligaments did not respond as hoped. Subsequent treatment advances employed the use of pins inserted through the skin; more recently, a surgery in which the bones are held in place with screws has also come into use. However, orthopaedic surgeons like Dr. Levine often elect to fuse the bones of the mid-foot, making it completely rigid (where there was once limited mobility), and eliminating both the possibility of "settling" into a flat foot, and associated pain. "Not everyone is using this technique," says Dr. Levine. "But we think this is an area where fusion provides the best outcome." The modest loss of mobility that results in the mid-foot does not affect most activities.

Lisfranc fracture treated with pins and screws

Fractures of the fifth metatarsal represent another injury that can present special treatment challenges. This frequently seen fracture may accompany other traumatic injury or can result from a low-impact injury, such as falling off a heel-less shoe, stepping into a pothole or falling off a curb.

While fractures of the fifth metatarsal can often be treated without surgery, in a modest percentage of cases, these small injuries can result in significant problems. Because blood supply to this part of the foot is limited, the injury may heal poorly or not at all (a non-union). Subsequent treatment-including internal fixation of the bone or a bone graft-may be necessary.

Healing problems may also occur with stress fractures, the result of repeated overload on a specific area of the foot, such as a dancer, runner, or basketball player might experience. On x-ray, stress fractures appear as a hairline crack as opposed to other fractures in which the pieces of the bone are out of their normal position. While the vast majority can be treated non-surgically, in about one out of 50 cases, surgical intervention is needed. The orthopaedic surgeon may have to place a screw in the bone to stabilize it during healing. "It may be that the use of a drill during this procedure also stimulates healing," says Dr. Levine.

Even with appropriate treatment of foot and ankle fractures and restoration of mechanical function of the joints, if the initial injury is traumatic, patients can experience another long-term medical problem. "If the cartilage was irreparably damaged by the injury, osteoarthritis will develop," explains Dr. Levine. "Unfortunately, this can't be prevented and additional treatment may be needed." As with many other orthopaedic injuries, the best hope for such problems may lie in the future when cartilage regeneration techniques-now in their infancy-may provide a solution.

For the treatment of all foot and ankle trauma Dr. Levine advises seeking the care of an orthopaedic surgeon who specializes in this part of the body, and understands the specific risks and complications inherent in its treatment.

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posted 12/2/2003

Summary prepared by Nancy Novick • Diagnostic imaging examinations provided by HSS Radiologists