Resources

If you are reading this information because you have a foot or ankle fracture, first, I want to express that I’m sorry about your misfortune. Second, I want to let you know that I will do my best to help you to the best possible outcome. My goals are to 1) get the fracture to heal in an alignment as close to the pre-injury alignment as possible, and 2) to minimize risks and maximize your potential to return to your pre-injury functional status. To this end, I have developed this resource to inform you about foot and ankle fractures, and answer as many questions that you might have about your fracture as possible.
Variations on a theme – not all foot and ankle fractures are the same! The severity of fractures can vary, depending on 1) the amount of force or energy that caused the fracture and how fragmented the bone is, 2) whether the bone was exposed through the skin, 3) the specific bone or location in the foot or ankle, 4) whether a joint was disrupted, and 5) whether a growth center was disrupted. Furthermore, fractures heal at different rates, depending on 1) your age, 2) your circulation, 3) the specific bone involved, 4) your health, 5) medications that you might be taking, 6) whether you smoke, and 7) how protected the fracture is while healing.

Therefore, some fractures may require minimal immobilization and weight bearing is allowed, while others may require surgery, extensive casting, and non-weight bearing. Some fractures will heal with no long-term consequences, while others may result in long-term problems, even with the best of care. Because of these complexities, I will discuss the nature of your fracture, the risks involved, and the appropriate management of your fracture with you. If you have any remaining questions or concerns, please contact us .

Step 1 – Treating a foot or ankle fracture, make sure the fracture is in satisfactory alignment.

Some fractures are virtually non-displaced, meaning that the pre-injury alignment of the bone has not changed. Lay terminology might refer to these types of fractures as “hairline”. In non-displaced fractures, step 1 is accomplished and the treatment can move on to step 2. Other fractures might involve varying degrees of displacement or shifting. Some bones and locations in the foot or ankle have a good tolerance of mild displacement, so that no additional “setting” of the fracture is required. However, other displaced fractures demand restoration to an alignment as close as possible to the pre-injury alignment. Examples include those that involve disruption of important joints, or those that involve growth centers in pre-adolescent children. In some of these types of fractures, surgery may be required to restore the alignment, while in others, non-surgical “setting” or “reduction” of the fracture is sufficient to restore proper alignment.

Step 2 – Treating a foot or ankle fracture, stabilize the fracture, so that it does not shift out of place or displace.

In some cases, the surgical implantation of bone screw and plates are utilized to stabilize your fracture. In most cases, fractures are stabilized with some form of immobilization, whether surgery was performed or not. Immobilization may vary from a fiberglass cast to a foot and leg splint, to a removable walking cast, to buddy splinting two toes together. I will advise you on which method of immobilization (stabilization) is best for your fracture.

Step 3 – Treating a foot or ankle fracture, stabilize the fracture long enough for the body’s healing process to mend the fracture.

Foot and ankle fractures typically take a minimum of 6-8 weeks to calcify enough to become internally stable enough to begin to reduce the need for external stabilization. It is at this time that it will be safe to progress you to the next level of recovery. However, fractures will take 3 months or more to completely heal and remodel. Therefore, even though I will begin to eliminate external stabilization of your fracture, the fracture will still be “healing”. Because fractures take 3 months or more to completely heal and remodel, you may experience some tenderness and swelling for at least 3 months or more following the fracture.

Step 4 – Treating a foot or ankle fracture, restore function.

Many foot and ankle fractures require some type of rehabilitation to return to full function, particularly when the foot and ankle have been in a cast for weeks. In most cases, I will give you instructions on the type, frequency, and duration of rehabilitation activities. These activities may include range of motion exercises, icing, contrast baths, and strength work that you perform on your own. In some cases, working formally with a physical therapist may be required, for which I make a referral. Rehabilitation activities may be started once your cast is removed. In most cases, rehabilitation activities will last for another 2-12 months

Fracture risks

You should be aware that while foot and ankle fractures typically heal without complications, they are not entirely without risks. Complications of fractures may include:

Failure of bone healing (delayed or non-healing of bone)
Malalignment and deformity (malunion of bone)
Growth disturbance (particularly with growth center injuries)
Stiffness
Arthritis
Limp
Chronic pain
Chronic swelling
Prolonged recovery
Deep vein thrombosis
Pulmonary embolism
Compartment syndrome
Complex regional pain syndrome (CRPS or RSD)
Nerve injury
Numbness
Weakness
Loss of muscle control
Tendon injury or disruption of tendon function
Circulation disturbance of soft tissues or bone (including avascular necrosis of bone)
Gangrene
Loss of toes, foot, or limb
Infection
Wound or scar problems (poor or slow healing, thick scar, sensitive scar, unsightly scar)
Intolerance of hardware or implanted materials
Failure or breakage of hardware or implanted materials
Transfer of pain, fracture, or callus to new site
Change in shoe size or inability to wear desired footwear

What can impair fracture healing can I help my fracture to heal?

There are a number of factors that can impair bone healing. It is possible for these factors to severely slow the bone healing process or even result in non-healing of your fracture:

Smoking
Premature weight bearing (when non-weight bearing has been recommended)
Excess weight bearing (when weight bearing is allowed)
Some medications (such as Prednisone and anti-inflammatory medications)
Poor circulation
Some medical conditions

Of primary importance is to not smoke when you are trying to heal a fracture, adhere to non-weight bearing (if recommended), and to rest and elevate your limb as much as possible during the healing period.

Medications and supplements

Please let me know about all prescription or non-prescription medications or supplements that you are taking. Some medications and supplements may have the potential to cause impaired bone healing, such as:

Prednisone or other corticosteriods
Anti-inflammatories and Aspirin (Aspirin, ibuprofen, naproxen, indomethacin, sulindac, nabumetone, piroxicam, and many others)

Do not take these types of medications while your fracture is healing, unless I specifically clear you to do so.

Smoking

Smoking will impair the healing of your fracture, leading to a prolonged healing period, or even non-healing of your fracture. Furthermore, smoking is a factor in the development of osteoporosis, which can lead to fractures. If you smoke, it is imperative that you stop. If you smoke, learn more about quitting .

Alcohol

Alcohol does not mix well with pain medication that you might be taking following your fracture. Alcohol can lead to inadvertent falls and disruption of your fracture alignment. Alcohol can interfere with your body getting the appropriate nutrients that it needs to heal properly. Alcohol is a factor in the development of osteoporosis, which can lead to fractures. Please limit your alcohol intake or eliminate it completely while your recover from your fracture. If you need help quitting, please talk to primary care doctor or me about programs that we have to help you, or visit the Health Education Department .

Diet and supplements

There is no scientific evidence for dietary supplements boosting the healing of a fracture in a person otherwise consuming a healthy diet. However, if a person has dietary deficiencies, there may be some benefit from supplementation or correcting the deficiencies. The bottom line is that my feeling is that when it comes to supporting or boosting fracture healing, being attentive to the food, drink, and supplements rarely hurts, and may even be of some help in some cases. Therefore, I have the following recommendations:

Maintain a diet that provides adequate calories and good quality protein.
Do not attempt to restrict your caloric intake (diet) while healing your fracture.
Discontinue any weight loss or diet pills while healing your fracture.
Take a daily multivitamin.
Make sure that your daily supply of Vitamin D is 400 IU (800 IU in the elderly or if you are never exposed to sunlight).
Make sure that your daily supply of calcium meets the following recommendations (avoid grossly exceeding these recommendations, as more than 2500mg per day can lead to problems, like kidney stones):

Age (and if applicable, sex)	Recommended Daily Calcium
Children (4-8 yo)	800mg
Pre-teens and teens (9-18yo)	1300mg
Adult males	1000mg
Pre-menopausal adult women	1000mg
Post-menopausal adult women	1500mg

Bone stimulation

There are various types of bone stimulators that are available now. These small, portable devices can be used to help stimulate slow healing or non-healing fractures to heal completely. I will utilize these devices if a fracture is at a high risk for slow healing or non-healing, or when a fracture is well past the time when it should be healed. If I order one for you, you will need to use it for a set amount of time daily for up to several months. Another alternative for treating a fracture that cannot heal on its own is to operate to replace the fracture site with bone graft and stabilize the site with metallic hardware.

Osteoporosis

Osteoporosis can make bones more prone to fracture. Please let me know if you have had other fractures in the last few years, particularly if you are a post-menopausal female. For more information on osteoporosis, please read Preventing Osteoporosis. In some cases, your age and fracture may qualify you into guidelines that specify a detailed work-up for osteoporosis. If so, this work-up will be coordinated by me and/or your primary care physician. Regardless of screening guidelines, if you are concerned about whether you have osteoporosis, please contact your primary care doctor, or talk to me. Lastly, regardless of whether you have osteoporosis, is wise to follow the Vitamin D and calcium recommendations that I have listed above under the diet and supplements section.

Radiographs (x-rays) and other imaging studies

For most fractures, standard radiographs (x-rays) are all that is need to diagnose your fracture and follow the healing of your fracture. In most cases, radiographs are typically ordered at the time of your injury for diagnosis and again at roughly 6-8 weeks after the fracture to assess the healing progress. However, you should be aware that the assessment of healing is not confined to the review of radiographs, since examination of your foot and ankle for stability, swelling, warmth, and pain are equally as important. Less commonly, more elaborate imaging studies may be required for diagnosis, or more importantly, to guide treatment decisions and surgical planning. I will let you know when a special imaging study (such as MRI, CT, or bone scan) is recommended.

Weight bearing status

Equipment – cast, splints, canes, crutches, wheelchairs, and more

You will most likely require some type of assistive equipment while your fracture heals. I will discuss your anticipated needs with you. Some items, such as canes and crutches, can be provided to you directly from our clinic cast room. If we decide that you might need an item such as a walker, wheelchair, or bedside commode, I will order it for you through our Durable Medical Equipment department and they will contract with Apria Healthcare to deliver it to your home. We cannot provide motorized wheelchairs or scooters. Another item that some of our patients have found useful for getting around while remaining non-weight bearing on the operated limb is a knee caddy walker it is not a covered item.

Casts, splints, and postoperative shoes

Most foot and ankle fractures will need to be stabilized with a cast while the fracture heals. Some types of fractures may need nothing more than a postoperative shoe or, in the case of most toe fractures, buddy splinting (taping adjacent toes together). For other fractures, you might be provided with a prefabricated removable Velcro-strap walking cast either initially, or as you transition from a traditional cast back towards regular shoes. I will review the specific casting requirements of your fracture with you. For further information postoperative shoes, removable walking casts (Seton boot), casts, and splints, refer to Tips and Information from the Cast Room .

Buddy splinting

Buddy splinting is a method of stabilizing toe fractures. I usually recommend taping the fractured toe to an adjacent uninjured toe for a total of 6 weeks. You can change the tape as needed. If moisture between the toes is a problem, then place a small wisp of cotton, gauze, or lamb’s wool between the two toes before taping them together. I generally recommend taping the fractured toe to the toe opposite of the original direction of the fracture deformity (for example, if the third toe was deviated towards the forth toe, then after the third toe is set, you will tape it to the second toe). Of course, fractured fifth toe always get taped to the fourth toe.

Care of splints and casts

You should never remove splints or casts unless specifically instructed to do so by me or by my staff working under my orders. Splints and casts must be kept dry. If your splint or cast becomes wet, call the Foot and Ankle Surgery Department 707-570-3120 or the Emergency Department (if after hours or on a weekend). You can also use a hair dryer on low or no heat to help dry out the bandage, splint, or cast – but please inform me.

Bathing with a cast: Splints and casts must remain dry at all times. Therefore, you must take special precautions to keep them dry while you bathe or shower. There are a number of options for keeping your splint or cast dry:

Use an over-the-counter short leg shower protector. You can purchase a Xerosox shower protector.
Use the double garage bag method – garbage bag above the knee, duct tape, another garbage bag to a higher level, duct tape again
Sponge bathe.

If you are also required to be non-weight bearing on the injured limb, bathing and showering unfortunately presents additional hardships for you. Besides using one of the above options, you must take care to avoid weight bearing on the operated limb while getting in and out of the bath or shower, and while showering (if a shower is used). Some patients have benefited in this circumstance from using a small plastic garden chair as a shower chair, in order to sit while showering.

Loose cast: If your cast should become loose before your scheduled appointment with me, please call our department at 707-570-3120 or one of our orthotechs, so that the cast can be removed and a new one applied. It is not uncommon that as swelling associated with the fracture resolves, the cast becomes loose. However, being able to easily move your foot and ankle around within the cast is counterproductive in trying to stabilize the fracture during the healing period.

Tight cast: A cast that feels too tight generally means that you have swollen since the cast was applied. The cause may be that your foot has been below heart level too much, leading to more swelling. As long as your toes are pink and the circulation rapidly returns to your toes after you squeeze them, there is no danger. Try to be attentive to keeping your foot elevated above heart level. If you have concerns about a tight cast, please call our department at 707-570-3120, or call one of our orthotechs.

Preparing your home

Kitchen

Stock the freezer with ice packs. An alternative to ice packs that works very well is a large bag of frozen corn or frozen peas – they can be refrozen and reused for the duration of your recovery.
Place frequently used kitchen equipment and utensils in an easy to reach location.
Remove throw rugs so that you will not slip or trip.
Arrange for help preparing meals or explore Meals on Wheels.

Bedroom

If you live in a two-story home, it could be helpful to prepare a sleeping area for yourself on the ground floor.
Ensure sufficient lighting between your bed and the bathroom.
Keep a flashlight at your bedside.
Place the phone within easy reach at your bedside.
You can cut out one side of a box and put it under your bed linens and blankets if you wish to avoid their pressure on your foot.

Bathroom

Remove throw rugs.
Consider a shower chair or plastic garden chair in your shower.
Purchase a Xerosox short leg shower protector (a device that keeps you leg dry while you shower) at The Depot Store (located in the reception area of the Foot and Ankle Surgery Department).

Living Space

Remove throw rugs or other objects (cords) on the floor the can cause you to trip or slip.
Set-up your couch or a chair so that you will be able to make yourself comfortable and elevate your foot – make sure that you have foot rests to elevate your foot.
Rearrange furniture to allow for clearance of crutches or walker (and wheelchair, if needed).
Place a list of emergency phone numbers and our department phone number next to each phone.
Bring your medications wherever you go.
Plan sedentary projects for while you are recovering – reading, organizing photo albums, etc.
Keep the TV remote control handy.

Wardrobe

Allow ease in dressing by wearing loose-fitting pants, shorts, or skirts.

Driving and Parking

While your fracture is healing, I may or may not allow you to drive. Do not drive after taking pain pills. Do not drive a manual transmission automobile when you have a cast on your left foot/leg. Do not drive at all when you have a cast on your right foot/leg. Since your injured foot/ankle will be lower than your heart, avoid driving or traveling by car any longer than 10-20 minutes in the first few weeks, as this will cause your injured foot/ankle to become more swollen and painful. When travel by automobile is necessary, always bring your required assistive device (cane/crutches/walker/wheelchair) with you. Attempt to park as close to your destination as possible. If you feel that one would be helpful, please talk to me about obtaining a temporary disabled parking placard for your car from the Department of Motor Vehicles. I do have application forms for a Department of Motor Vehicles temporary disabled parking placard. I can complete my section of the application form and turn the form over to you. You would, in turn, complete your section and either, bring in the application into the DMV, or mail it to the DMV to get your parking placard that would allow you to park in disabled parking spaces.

Work Release and Disability Paperwork

If you need a work release, I will complete a standard Kaiser Permanente work release letter for you. You will be provided a copy for your employer. Furthermore, if you intend to file for disability income, you will need to submit a copy of the work release letter to our . Release of Information department will take a copy of the work release letter and on your behalf, submit the necessary paperwork for disability income. All insurance forms and disability paperwork should be submitted directly to the Release of Information department rather than to me. Kaiser Permanente Santa Rosa’s Release of Information department is located on the first floor of the main hospital building, across from the main elevators.

Pain management

Every person is different in how they experience and tolerate pain. Therefore, the degree of pain that patients experience following a foot or ankle fracture can range from little or no pain to pain that requires regular use of pain relievers. There are a number of methods that can help you alleviate pain, including the use of narcotic pain medications, acetaminophen (Tylenol), elevation, ice packs, and relaxation techniques. Rest and elevation are a must following a foot or ankle fracture, not only to keep pain to a minimum, but also to help the healing process and keeping swelling to a minimum. I routinely do not advise anti-inflammatory medications after many foot or ankle fractures, but I will let you know if these medications are safe in your specific situation. Oral narcotic pain medications usually are composed of acetaminophen mixed with a narcotic. Because the oral narcotic medications have acetaminophen in their composition, and acetaminophen can be harmful to your liver if taken in excess, you should generally limit yourself to no more than 8 narcotic pain pills per day. For the same reason, you should not combine taking narcotic pain medications and over-the-counter Tylenol (acetaminophen) together. Narcotic pain medications also have the potential to cause constipation, so you should make sure that you are taking in plenty of fluids, and that you are consuming extra fiber in your diet. Furthermore, the narcotic pain medications can cause drowsiness, so you should not drive, operate potentially dangerous machinery, or engage in important decision-making while taking these medications. The pain following a foot or ankle fracture usually peaks within 24-48 hours following the injury and tends to gradually get better thereafter. However, if you were to neglect elevating your foot, the foot and ankle will become more painful and swollen. It is important to keep your foot elevated at or above heart level, avoiding letting it down for any period in excess of 10-20 minutes. When trying to gauge the level of pain that you are having, medical personnel will ask you to rate your pain on a 0-10 scale. Use the following scale as your guide in communicating your pain level to doctors and nurses:

0 pain free
1-2 mild
3-4 bearable
5-6 distressing
7-8 severe
9-10 intolerable

Warning signs

Contact the Department of Foot and Ankle Surgery if you experience any of the warning signs below. The Department of Foot and Ankle Surgery phone number is 707-570-3120 and is open 8:30 a.m. to 5 p.m. Monday through Friday. At any other time, please call the Emergency Department at 707-393-4800.

Severe foot pain that is not relieved with elevation, ice, and medication.
Cast accidentally getting wet.
Fever over 100 degrees F, or lymph node tenderness in the groin.
Severe calf pain, shortness of breath, or chest pain.
Adverse reactions to prescribed medications.

Usual recovery time & resuming footwear

The recovery time following a foot or ankle fracture varies widely, depending on factors including how complex the fracture was, your age and general health, and your compliance with instructions (such as weight bearing status, rest, elevation). For most foot and ankle fractures, tenderness and swelling can take 3-4 months to resolve, while for more complicated fractures, the recovery may take a full year (or more).

Resuming footwear

The problems of bone healing and swelling prevent early return to normal footwear following most foot and ankle fractures. Sure, there are a few fractures, such as some toe fractures, where a patient can be expected to resume standard footwear in as little as 2-3 weeks. If the fracture requires a cast, then there is typically a 2-4 week period of weaning back to shoes after the cast is finally removed (a removable walking cast is typically used during this weaning period). Therefore, if the fracture requires a cast for 6 weeks, then you can expect to be in standard shoes no sooner than 8 weeks and perhaps as long as 10 weeks after the injury occurred. I will discuss my expectations for your return to standard footwear with you during your follow-up appointments.

Return to work

Since most foot and ankle fractures require rest and elevation of the operated foot for at least 2 weeks following surgery, it is rare that a patient will be allowed to return to work before 2 weeks following the injury, except with relatively minor fractures, such as some toe fractures. If you work in a sedentary occupation and can arrange your work environment so that you can continue to keep your foot elevated, it might be possible to return to work under these circumstances at approximately two weeks following some foot or ankle fractures. If you work at a job that requires you to be on your feet for a substantial portion of the workday, it is rare that you would be allowed to return to work in less than 8 weeks following many foot or ankle fractures. In more complex injuries, patients may be required to remain off work for as much as 3-6 months. I will discuss my expectations for your return to work with you during your follow-up appointments.

To Conclude

I hope that the information provided here has enhanced your knowledge about how I will be managing your fracture to achieve the best possible outcome for you, and how you can help your cause. Should you have any unanswered questions, please contact us by Kaiser Permanente’s Secure Message e-mail system, or by phone at 707-570-3120.