Ankle Fracture Season is Among Us!

With the snow and ice fast approaching the number of patients heading to the emergency room with suspected ankle fractures is quickly rising! In previous Blogs we’ve talked about ankle fractures, but this week I want to talk about a different type of fracture associated with ankle injuries: the 5^th metatarsal base fracture!

The 5^th metatarsal bone is a long bone in the foot that connects the rearfoot to the 5^th toe. It is one of five metatarsal bones in the foot, each corresponding to a digit. Fractures of the 5^th metatarsal base (the end of the bone closest to the ankle) are commonly associated with classic ankle injuries where the foot turns inward.

There is a muscle that passes along the outside of the ankle and inserts into the 5^th metatarsal bone at its base called the peroneus brevis (PB). With an ankle sprain or injury where the foot turns inward, the PB contracts and pulls on the 5^th metatarsal base, sometimes so strong that it avulses, or pulls a piece of bone away from the rest of the metatarsal bone. Therefore, when you twist your ankle and have not suffered an ankle fracture, you may not be completely ‘home-free;’

You should be suspicious of a 5^th metatarsal base fracture any time that you are suspicious of an ankle injury. However, residual pain along the outside of the foot along the 5^th metatarsal bone is a good indicator of injury to that area. Try sliding your finger along the outside border of your foot from your 5^th toe back towards your heel. Along the way you should feel a “bump” which is the landmark of your 5^th metatarsal base. Pain in that are can be indicative of a fracture, as that is the most likely place where the PB would have pulled off a piece of bone. Be particularly suspicious if the pain in that area has not improved several days after your ‘ankle twisting incident.’

Fractures of the 5^th metatarsal base are particularly tricky to treat because the blood supply to that area of the bone is delicate. In the area of such fractures, two blood supplies are coming together, and disruption of their connection via fracture can permanently hinder the healing process, as blood supply is imperative to bone healing. Keeping that in mind, early detection of a 5^th metatarsal base fracture is important so that immobilization can be initiated as soon as possible. The goal of immobilization is to decrease motion at the site of the fracture to encourage healing making the delicate blood supply less of a factor!

There are several ways in which immobilization of the fracture site can be initiated and the choice depends on the severity of the fracture. If the fracture is well aligned and shows no gapping between fragments, conservative treatment with immobilization in a short leg cast is indicated. If the fracture is displaced and there is significant gapping between the fragments, the fracture is unlikely to heel unless the fragments are brought back closer together. In this case, surgery may be indicated to place a pin or screw across the fracture site and immobilize the fragment with the “hardware.” A short leg case is still indicated to ensure that the patient remains non-weightbearing and minimizes the risk on non-healing.

In either scenario, 4-6 weeks in a cast should be expected so that the bone has time to heal. Once healing is noted and pain in the area of the fracture is severely decreased or absent, transition into a walking cast and eventually back into a comfortable supportive sneaker can be allowed.

Next time you twist your ankle, don’t be fooled into thinking is just an ankle injury, unless you’ve been cleared by your Podiatrist and no 5^th metatarsal base fracture has been suffered!

Getting Ready to String Up Some Holiday Lights?

You Might Just be Making Your Heel a Little Nervous!

Believe it or not, the number of heel bone (calcaneal) fractures that Foot and Ankle specialist see in their office tends to increase around this time of year. Certainly we get an increase in ankle fractures when the snow starts to arrive, but often people wonder about why heel fracture numbers go up. I’ll tell you a little secret: people start climbing ladders to hang holiday lights, and if they fall off the ladder and manage to land on their feet, they might just fracture their heel bone!

Calcaneal fractures are high-energy injuries, meaning that there needs to be a large force to create a fracture. If you think about it, falling off a ladder and landing on your heels creates a large force, as the entire weight of your body crashes into the concrete! Another common mechanism of injury for calcaneal fractures are motor vehicle accidents; another high-energy pattern. Therefore, patients who suffer from a calcaneal fracture must be evaluated fully for other injuries and fractures created during this force. The most commonly associated injury (although not common at all) is a lumbar spine (lower back) fracture. The force into the calcaneus tends to travel up the body and compacts the lower back making it more susceptible to injury.

If you have fallen from a ladder recently and suspect any kind of lower extremity injury, it is important to see you Podiatrist! They can evaluate you, take x-rays and rule out a fracture if you’re suspecting one. If there is a fracture present, they can initiate treatment as soon as possible to get you on the road to recovery! Symptoms that one might notice include severe pain! In addition there may be a distinct “black-and-blue” mark extending from the heel into the arch of the foot. As you know, we Podiatrist’s have names for everything, and call that “black-and-blue” a Mondor’s sign. In addition you will have difficulty moving the foot up and down at the ankle joint and pain with moving your foot inwards and outwards. A comparison of your feet from behind will reveal a slightly wider heel/foot on the affected side when compared to the non-affected foot.

Once you have been evaluated, any other injuries to the body have been ruled out, and x-rays confirm the diagnosis of a calcaneal fracture, the decision then becomes whether surgery is indicated or not, in order to repair the calcaneus. The answer to this question and the recommendation that your Podiatrist will make will be largely based on the location of the fracture, how far the pieces of the fracture are away from where they belong and if the Subtalar joint (the one that sits underneath the ankle) is disrupted.

In the best-case scenario, the fracture will be minimally displaced and the Subtalar joint will be unaffected, sparing you from surgical correction. In this instance, you will need to be casted for 6-8 weeks with crutches to avoid that any weight is put onto the affected foot. After those 6-8 weeks, when healing can be confirmed via x-ray, you will slowly be transitioned into a walking cast and finally back to a supportive sneaker.

In the worst-case scenario, the fracture will be largely displaced and the Subtalar joint will be severely affected, indicating surgical correction for realignment. The goal of surgical intervention is to repair the Subtalar joint with the hope that the height of the calcaneus can be regained and normal function of that joint can be restored. In order to accomplish this, a metal plate with several screws will be inserted against the heel bone to bridge the area and allow for healing in the corrected positioning. The length of time that you will be casted and non-weight bearing with crutches is closer to 12 weeks, again with transition to a walking cast and finally backs to a sneaker over the next several weeks. The treatment course for a severe fracture like this is about 6 months until you are able to return to normal activity, while the long-term effects last a lifetime.

Patients who suffer calcaneal fractures where the joint is involved, typically require an additional surgery down the line. The indication for this surgery is post-traumatic osteoarthritis, which we discussed over the last several weeks. PTOA is virtually impossible to avoid with this type of fracture pattern, but the initial surgery is important in managing PTOA in the long-term. It has been reported that patients who have initial reduction of their calcaneal fracture as indicated, do better down the line with managing their PTOA and although they end up having a joint fusion (a joint that will no longer move) they are more pain-free than their counterparts!

Scope it out!

Last week we reviewed the topic of Post-Traumatic Osteoarthritis. We defined the condition of PTOA as an arthritic condition that occurs within a joint sometime after the joint has been injured. Proper realignment of the initially injured joint helps to cut down on the occurrence and progression of PTOA, but sometimes it is inevitable!

There are several injuries, specific to the lower extremity that are infamous for causing PTOA, and they are as follows:

- Ankle fractures: PTOA in the ankle joint

- Heel bone fractures: PTOA in the Subtalar joint (the joint just below the ankle)

- Midfoot fractures: PTOA within the joints across the middle of the foot

This week, I wanted to focus on Arthroscopy as a treatment modality for PTOA in the ankle joint, following an ankle joint fracture. Arthroscopy is a procedure that utilizes a small camera to access and view the joint on a larger monitor, while allowing the surgeon to “scope” the joint and remove debris from the joint space. The end result and goal of Arthroscopy is to decrease the patient’s joint pain secondary to PTOA and to allow the joint to glide more easily through its typical range of motion.

When you suffer from PTOA, the joint becomes clouded with debris coming in the form of lose cartilage pieces, or in the form of synovitis. Synovitis describes inflammation of the “joint synovium;” a.k.a. the joint fluid that helps with easy gliding of the joint surfaces. Each of these components leads to painful range of motion in patients, thus eliminating or decreasing their presence within the joint space, through Arthroscopy, can be very beneficial!

The joint will be prepared with a distraction device, meaning an external device will be applied to both your leg and foot, with a gentle pull placed on each side, to increase the ankle joint space. This allows for easier insertion of instruments and for better visualization of the joint damage, so that debris is not missed during the procedure.

Local anesthetic will be injected into the ankle joint, with continual sterile saline flushing through the joint space during the procedure. The saline is important to create a “fishbowl-like” appearance of the joint, essentially floating the pieces of debris inside the joint that might otherwise adhere to the joint surfaces making it difficult to remove them.

The typical approach to Ankle Arthroscopy is from the front of the leg through two small incisions, measuring about 1cm in length. A camera will be inserted into one of the incisions entering the ankle joint capsule. In the other incision, a small cannula (hallow tube) will be inserted, which can be used to feed surgical instruments into the joint, helping to clear debris. A small ‘burr’ is the typical instrument of choice used by surgeons performing these procedures. The burr rotates back and forth eating debris as it is moved around the joint. Envision Pac-Man!

Post-operatively you will have two sutures in place, one over each of the small incision sites. Depending on surgeon preference, you will be placed in am immobilization device and will be required to remain non-weight bearing until your first follow-up appointment. Physical therapy is often initiated in patients who undergo Ankle Arthroscopy to help strengthen the muscles surrounding the ankle joint while improving joint function and getting you back on your feet, with range of motion to the ankle joint that is much less painful than prior to your “scope!”

There are risks to any procedure, although the risks of arthroscopy are minimal and rare. However, you should discuss all options for treating your Ankle Joint PTOA with your Podiatrist prior to any surgical intervention.

Another Useful Tool from BioMedix!

Last week we discussed PAD and the non-invasive vascular studies that can be completed in our office to help with diagnosing PAD. Through the BioMedix Collaborative Care Network, communication between your medical team can be facilitated. Chronic Venous Insufficiency (CVI) is another vascular related problem (covered on the BioMedix Website) that non-invasive vascular studies can help to diagnose, but it differs from Peripheral Arterial Disease in its location within the body’s blood vessels. As the name implies, CVI is a condition that results from damage to the veins or venous flow within the body, where as we learned last week, PAD is disease of the arteries.

Veins located throughout the body are responsible for bringing blood from locations furthest from the heart back up to the heart, for recycling and re-oxygenation by the lungs. This prepares the blood to again circulate through the body and carry oxygen out to the tissues. Located within the bodies veins are tiny one-way valves which when the blood is being transported back up to the heart, help pump the blood upwards while closing off with each beat of the heart to prevent backflow of the blood with gravity. When those valves become damaged, patients suffer from Chronic Venous Insufficiency, where the body has difficulty pumping blood through its veins back up towards the heart.

Patients will slowly notice an onset of symptoms including painful, swollen and “heavy feeling” legs. They will notice that their legs begin to feel tired or restless at the end of a long day, which is something they have not experienced before. In addition, patients may start to notice varicose veins and veins bulging through the skin as the pressure building up within them predisposes them to enlargement.

Other associated symptoms and conditions may include skin discoloration, dry scaly skin along the legs and feet and breakdown of the skin if the buildup of extra fluid in the legs becomes too great. Breakdown of the skin typically presents in the form of a “Venous Stasis Ulceration,” which basically means what we’ve been saying: the ulceration is caused by blood located within the venous system of the body that is stuck in the legs and leads to ulceration.

Risk factors for the development of CVI are varied, but some can depend largely on hereditary and the nature of the patient, meaning those that have a family history of CVI or are women over the age of 30 are at a greater risk for development. In addition, patients with a history of blood clots, multiple pregnancies or who do lots of heavy lifting and endure long periods of standing also have an increased risk.

If you present to your Podiatrist with a variety of the risk factors and symptoms consistent with Chronic Venous Insufficiency, your diagnosis may be made by clinical examination alone. However, it is important to undergo Vein Studies to help rule out any larger problems, such as blood clots, in addition to selecting the most appropriate treatment regimen.

We mentioned last week that Advanced Footcare Centers LLP collaborates with BioMedix through a Collaborative Care Network, where vascular testing can be completed and communication can electronically occur between your medical team (Podiatrist, Primary Care Physician and Vascular Surgeons). In addition to including testing for Peripheral Arterial Disease, BioMedix also collaborates on testing and treating Chronic Venous Insufficiency.

The most accurate test is called a Venous Duplex Ultrasound. The test takes an ultrasonic picture of the veins in the body to detect any acute or chronic blockages in addition to evaluating the status of your veins one-way valves. Once any acute blood clot has been ruled out and Chronic Venous Insufficiency has been diagnosed, there are a variety of treatment options available. Some treatments can be done by you at home, such as maintaining a healthy diet and exercising regularly to increase the competency of your legs muscle pump to help bring blood back to the hear easier. Compression stockings are often encouraged for patients without any history of congestive heart failure and for those patients that stand for long periods of time, as the compression will help the legs bring blood back up towards the heart rather than becoming stuck in the legs. Medications such as diuretics can be used to decrease some of the fluid build-up, but as always, before any of these treatments are initiated, consult your Podiatrist and your Primary Care Physician.

For more information on Chronic Venous Insufficiency, please click on the link below, which will direct you to the BioMedix Collaborative Care Network!

http://www.biomedix.com/patients/CVI_patient_resources.asp

Non-Invasive Vascular Studies: Take One!

Several months ago I blogged about Peripheral Arterial Disease (April 23, 2010: The Triad That Leads to P.A.D.), which is a disease of the circulatory system where blood flow to the periphery of the body, mainly the legs, is compromised or blocked secondary to a build-up of plaque within the vessel walls. The major risk factors that increase a patient’s chances of developing plaque build-up and subsequent Peripheral Arterial Disease are three: High Blood Pressure, High Cholesterol, and Smoking. Diabetes can also contribute to the disease, but keep in mind that although Peripheral Arterial Disease is commonly seen in the diabetic patient, it is not limited to that patient population alone.

In that blog it was mentioned that non-invasive Vascular Studies could be completed when pulses in the feet were non-palpable to your Podiatrist. These non-invasive tests can help to determine the amount of blood flow, while predicting blockages or occlusions within the main vessels carrying blood to the legs, feet and toes.

The first and most basic test that is typically ordered is called an “Ankle-Brachial Index,” or ABI as it is referred to in the medicine world. This test is performed using a simple blood pressure cuff, first applied around the arm to determine the blood pressure in the arm, and next applied to the calf to determine the blood pressure in the leg. The test is performed with the patient lying flat on a bed, usually on their back and will only take a few minutes to perform. The test is also painless, although some patients may experience minimal discomfort with inflation of the blood pressure cuff, which will be relieved upon deflation.

A second test, and one that is typically performed in conjunction with an ABI, is called a Pulse Volume Recording (PVR). As the heart beats, blood is “pulsed” throughout the body and when measured in the lower extremities by the PVR test, the values obtained can help indicate areas where the blood flows best and areas where there may be disruptions in blood flow. The test is performed by applying multiple blood pressure cuffs at intervals down the legs, and jas with ABI testing; it is a painless exam and is tolerated well by most all patients.

Together the information obtained in the ABI and PVR tests can help determine how well blood is flowing down into the legs and will indicate if there is narrowing or blockage of the vessels in any areas. It will also help determine how progressed your Peripheral Arterial Disease is and will guide treatment of the disease specifically for you!

At Advanced Footcare Centers, LLP Ankle Brachial Indices and Pulse Volume Recordings are completed in the office and your information is electronically sent via BioMedix PADnet, through our Collaborative Care Network. The Collaborative Care Approach ensures that the appropriate physicians managing your care, including a vascular surgeon and your primary care physician, all have access to the information obtained via these tests. Thus, they can work together on finding the best solution to managing your early or progressed Peripheral Arterial Disease.

For more information on the Collaborative Care Network with PADnet and BioMedix, of for more information on Peripheral Arterial Disease, click on the link below. If you have questions or concerns about the blood flow to your extremities, contact your Advanced Footcare Center Podiatrist today!

http://www.biomedix.com/collaborative_care_model.asp

Fun for the Podiatric Surgeon; Not So Much Fun for the Patient!

As a human being, I never want to see anyone get injured, but as a medical professional, if no one ever did, I would be out of a job! So sometimes, injuries are fun to see, as it presents a challenge for determining the best option for treatment. About a week ago a patient came into the Emergency Room with a Type II Gustillo Anderson fracture of the 1^st, 2^nd and 3^rd toes after a car jack slipped and landed onto his foot. (Hopefully you’ll understand what all that means by the conclusion of today’s Blog) It wasn’t much fun for the patient, and I felt bad for the guy as he was a really nice man, but getting to treat his injury was fun!

An open fracture is any fracture that is accompanied by a break in the skin in the area of the boney fracture. The broken bone does not necessarily need to be protruding from the skin, but it often will be. These types of injuries are not exclusive to the lower extremity, but when found there are typically associated with high-energy injuries. Meaning any injury where there is a strong force or impaction as would be the case in falls from a height or motor vehicle accidents for example, or in the case of this patient, direct force to the foot from the car jack.

There are two main ways to look at an open fracture: was the break in the skin caused by something from the outside penetrating inward, or was the break in the skin caused by a bone from inside the body pushing outward? In terms of treatment and managing the fracture site, the answer to this makes little difference, but if the break in the skin was caused by something outside (like a nail or bullet) penetrating inward, you would want to consider whether the patient has an updated tetanus vaccination and what bacteria are commonly associated with the type of object that has penetrated the skin.

If you haven’t picked up on it yet, in the medical profession we love to classify things! Some of our classification systems make little sense, but it gives us a way to communicate with our colleagues in a succinct manner. For open fractures, the classification system used most often is the Gustillo and Anderson Classification. It evaluates open fractures based on: soft tissue coverage and injury to blood vessels, muscles and/or nerves. The classification is as follows:

Type I: An open fracture less than 1cm in size with little soft tissue involvement and no crush of the bone.

Type II: An open fracture that is greater than 1cm in size with minimal soft tissue damage.

Type III: An open fracture that is greater than 5cm in size with extensive soft tissue damage including damage to muscle, nerve and blood vessels.

Open fractures are typically surgical emergencies from a Podiatric Medicine standpoint, meaning we would like to take the patient to the Operating Room within the first 24 hours. Type III injuries would be taken to the operating room sooner than a Type I injury. The goal in taking these patients for a surgical procedure is to clean out the soft tissue eliminating as much dirt and bacteria as possible, to reduce/realign the fracture fragments into their correct “pre-injury” position and to close the skin if possible preventing further infection. If all the goals of surgical intervention are met, it will help decrease the risk of further tissue damage as well as decrease swelling, pain and bacterial spread, getting the patient on the road to recovery!

If we revisit the patient I saw in the ER last week, we can recall that he had a Gustillo-Anderson Type II injury. If we refer to the classification system, we know that the open part of the injury along the digits was larger than 1cm with minimal soft tissue damage. His injury was an “outside to in” type injury, but luckily, the car jack did not break through his shoe, thus there was no foreign body present. He was given a broad-spectrum antibiotic (to cover the most common types of bacteria) and was taken to the OR the following day. One of the bones in the big toe suffered a crush injury and had very little soft tissue coverage, meaning it was in many small pieces and would have been difficult to approximate the skin edges, thus the bone was removed. The bones within 2^nd and 3^rd toes had one fracture line each, so they were reduced and the soft tissue coverage over them was adequate, thus they were closed.

Open fractures are not something we see on a daily basis, and certainly can be detrimental to the patient depending on the severity of injury, but they do provide a welcomed challenge to the Podiatric Surgeon!

For more information on foreign body injuries, refer to our Blog from June 28 entitled: Think Twice Before Kicking Off Those Summer Shoes!

Should Little Girls Wear High Heels?

This past weekend I was at a wedding and just before the bride entered, the cutest 3 year old girl in a white “frilly” dressing, with a green sash and sparkly high-heels walked down the isle spreading flowers in her path. I should have been “oohing and ahhing” at how cute she was, but I couldn’t get over the fact that she was wearing heels!

Several months ago a featured segment on a National Morning News broadcast, addressed the issue of girls from as young as 3 years old wearing high heels. It was mentioned in the segment that these young girls are still undergoing developmental changes, and wearing heels could have implications on proper growth. That is in fact true! The last bones in the foot to solidify, changing over from cartilaginous material to solid bone can take place up to the age of 18 years. Wearing heels at such a young age could have serious implications on growth!

The mechanics of heels are many. They can:

1. Increase pressures on the ball of the foot

2. Increase ankle instability leading to injury

3. Tighten the heel cord creating changes in gait including "toe walking"

4. Induce changes on growth plates, which don't close until late in the teen years, causing developmental complications.

5. Predispose an already destined foot type toward the development of bunion and hammertoe deformities.

Aside from injury to your child’s foot, which should be avoided at all costs, tightening of the heel cord most certainly creates changes in gait including “toe walking.” However, that’s not the only problem that a tight heel cord can induce. If you remember, throughout several previous blogs, including the ones on plantar fasciitis and retrocalcaneal exostosis (“pump bump”), tightening of the musculature in the back of the leg, which is essentially the heel cord, can contribute to multiple foot issues and pain both in the back of the foot and on the plantar surfaces of the foot.

We’ve talked about the mechanics of bunion deformities before and that your foot-type predisposes you to the development of bunions and in fact, hammertoes, all of which proper and supportive shoe gear can help to prevent or slow the progression of. If you’re child wears heels from the age of 3 and has a foot type that pre-disposes them to bunion and hammertoe deformities, they will more than likely develop these deformities much sooner in life, with correction necessary in their early teen years.

Although heels may look "cute," there are plenty of flat shoes out there these days that are also cute! Kids love sparkly and 'jazzy' things, so why not find some sneakers or ballet flats that fall into that category? It simply isn’t worth the risk of injury, developmental complications or the formation of bunions and hammertoes to wear high heels for the fun of it.

In the event that your child wants to wear heels for special events, that’s okay. It is, however, recommended that you limit wear to 4 hours or less and choose heels with a wider toe box and a more stable heel. This will help prevent crushing of the toes as well as help decrease the instability typically associated with a ‘skinnier’ high heel.