NON OPERATIVE TREATMENT OF FRACTURES OF THE FOOT AND ANKLE

NON OPERATIVE TREATMENT OF FRACTURES OF THE FOOT AND ANKLE

Fractures of the foot and ankle are injuries requiring not only local treatment but a holistic approach as they affect the mobility of the injured athlete. The decision of the type of treatment depends mainly on the characteristics of the fracture and secondary on the demands and compliance to treatment.

Ankle fractures need operative treatment if stability is in doubt. Rehabilitation if non operative treatment is decided can be divided in three periods. In the first period –inflammatory phase – pain control, maintenance of range of movement and reduction of the inflammatory response to trauma (edema) are the main goals. The next phase is aimed at restoration of full range of movement, muscle strengthening and neuromuscular control (proprioception) in single planes. The last period objectives are muscle power, neuromuscular control in multiple planes and training-sport specific exercises. Depending on the fracture type initial immobilization with a below knee cast, non weight bearing for 2 weeks, can be substituted for an aircast boot, partial weight bearing for the next four weeks. Full weight bearing is allowed after clinical and radiological fracture healing. There may be fractures requiring immobilization until union is documented and protection from early movement or exercise should be avoided.

Lateral talar process fractures are treated with a below knee cast for 4 weeks followed by a walking cast for 2 weeks. Mobility status is non weight bearing for the first 4 weeks and as pain allows afterward. Range of movement, muscle strengthening and proprioception exercises are initiated after the 4th week. Alternative to this protocol is application of an aircast boot for six weeks with partial weight bearing allowed from the beginning. Patients progress to full weight bearing when there is evidence of radiological union. Posterior process fractures are treated nonoperatively with below knee cast for 4 weeks if there is no involvement of the subtalar joint or the fragment is small and not comminuted.

Talar neck fractures that can be treated non operatively are only those classified as type I according to Hawkins classification. Early weight bearing is avoided. Below knee cast is applied initially and exchanged to an aircast boot after the 4 week. Range of movement and strengthening exercises are commenced and weight bearing is allowed after the 3 month. There is always a risk of avascular necrosis and consequent collapse of the talar body if blood supply is further compromised with early weight bearing.

Regarding the calcaneal fractures it is only the nondisplaced ones that may be amenable to non operative treatment (ie Type I both in Crosby-Fitzgibbons and Sanders classification). Formal fracture immobilization may not be required on the first instance. Elevation and edema control are the first important interventions. Aircast boot locked in neutral position is applied and early active range of movement exercises are encouraged. It is imperative to prevent contractures in equinus. Weight bearing is not allowed for the first three months. Control of comorbidities that may impair fracture healing should be addressed if possible (smoking, peripheral artery disease, diabetes).

Undisplaced metatarsal fractures can be treated non operatively. If displacement is less than 3 mm or angulation less than 10o non operative treatment is also indicated. Below knee cast with weight bearing as tolerated is the option for nondisplaced fractures. Fractures of the 5th metatarsal should be treated according to the exact location of the fracture. Avulsion fractures of the base are treated without immobilization and weight bearing as symptoms allow. Jones fractures require immobilization in a below knee cast for 6-8 weeks non weight bearing. There is a higher risk of non union compared to type I and III fractures of the 5th metatarsal. Type III fractures are usually stress fractures and the first treatment option is non operative with immobilization non weight bearing until evidence of fracture healing. Fractures-dislocations of the tarsometatarsal joints (Lisfranc injuries) are treated mainly operatively if diastasis is diagnosed on the x-rays. Fractures at the base of the metatarsals should always raise the suspicion of ligament injury and modify the rehabilitation regime.

Fractures of the phalanxes are treated non operatively with buddy strapping and early weight bearing as pain allows. It is only the fractures that involve the articular surface and lead to instability that are treated operatively.

Recent Announcements

Monday, 20 Feb 2017

5th Congress of ECOSEP & 2nd UAE FA Football Medicine Update 25th-27th November 2017 Dubai

read more

Monday, 05 Sep 2016

5th ANNUAL PODIATRIC SPORTS MEDICINE CONFERENCE In association with EUROPEAN COLLEGE OF SPORTS & EXERCISE PHYSICIANS INSPIRING CLINICAL EXCELLENCE – THINKING BEYOND BIOMECHANICS

read more

Recent Articles

Platelet Rich Plasma (PRP)

An innovative treatment, for  Musculoskeletal Pathologies , PRP uses your own blood for healing muscle, tendon and ligament injuries. 

A common form of healing is scarring which affects function . Most of the Current therapies  treating sports Injuries  do not change the intrinsically poor healing properties. Given this situation, biologically based strategies involving the stimulation of cell activities through the delivery of Growth Factors have attracted considerable interest. 

Platelet Rich Plasma is derived by placing a small amount of your blood in a filtration system which separates red blood cells from platelets. The high concentration of platelets (containing a high level of Growth Factor) is then injected into the injured tissue which initiates the body’s natural healing response.

read more

Extra Shockwave Therapy & Treatment

At European SportsCare, Extracorporeal Shockwave Therapy (ECSWT) is available for the treatment of musculoskeletal softtissue pathology such as Tendon, Ligament, Muscle and bone. Shockwave Therapy is a non-invasive treatment provided by fully trained Consultants providing this treatment for more than 15 years. It is available as an out-patient treatment in one of our comfortable consultation rooms at 68 Harley Street.

read more

Acute Lateral Ankle Sprains In Track & Field Athletes: A Proposal Of An Expanded Classification

We present a longitudinal observational study on classification of acute lateral ankle ligament injuries in track & field athletes, based on objective criteria. These very common and sometimes troublesome sports injuries are treated functionally but there is a lack in international literature in predicting the time needed for full recovery.

read more

Ten year follow-up study comparing conservative versus operative treatment of anterior cruciate ligament ruptures. A matched-pair analysis of high level athletes

Objective: To compare long term outcome of highly active patients with anterior cruciate ligament ruptures treated operatively versus non-operatively.

Design: We reviewed high level athletes with an anterior cruciate ligament rupture on either MRI or arthroscopic evaluation more than 10 years previously, who were treated conservatively. They were pair-matched with patients who had had an anterior cruciate ligament reconstruction with bone-patella-tendon-bone, with respect to age, gender and Tegner activity score before injury.Participants: In total 50 patients were pair-matched.

Results: We found no statistical difference between the patients treated conservatively or operatively with respect to osteoarthritis or meniscal lesions of the knee, as well as activity level, objective and subjective functional outcome. The patients who were treated operatively had a significantly better stability of the knee at examination.

Conclusion: We conclude that the instability repair using

a bone-patella-tendon-bone anterior cruciate ligament reconstruction is a good knee stabilising operation. Both treatment options however show similar patient outcome at 10 year follow up.

read more

ACL injuries. Diagnosis, treatment and rehabilitation

The ability to recognize the ACL deficient knee is lacking, even among orthopaedic surgeons. The history of an acute ACL tear is remarkably constant, because the injury is often non contact, and patients usually report a twist on the flexed knee, turning to the same side as the injured knee, although hyperextension or direct injury is the cause in some sports. Patients often remember a loud pop, but, because there are no nociceptors in the ACL, pain is not an immediate feature in the isolated lesion. Players may attempt to continue to play, but they usually stop because the knee feels insecure. Pain ensues in association with a hemarthrosis: 70% of acute hemarthroses of the knee are associated with a tear of the ACL. The diagnosis must be confirmed before treatment is offered.

read more