W. Va. Code R. § 85-20-45

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 85-20-45 - Treatment Guidelines: Foot and Ankle Injuries

45.1. Injuries to the foot and ankle usually relate to a specific traumatic event and have a predictable clinical course depending on the severity index of the initial injury. For simplicity, injuries will be discussed relative to the anatomic region of the foot and ankle (ankle, hind foot, midfoot, forefoot or phalanges).

45.2. The appropriate diagnostic criteria is as follows:

a. Pertinent historical and physical findings:

1. Onset of pain and/or swelling is related to a single event, either a twisting injury, fall or direct blunt trauma. The degree of the injury can be judged quickly by determining which one can bear weight and the degree of initial swelling. The more severe injuries will have greater swelling, inability to bear weight, and may have obvious deformity.

45.3. Diagnostic test and examination considerations are as follows:

a. If differentiation between a soft tissue ligamentous injury and a fracture is required, x-rays in several planes are appropriate in all cases;

b. CT scans may be indicated in hind foot injuries to define subtle fractures, tarsal coalitions or the degree of displacement in three planes in acute injuries;

c. Bone scans are occasionally indicated in long standing pain problems to rule out stress fracture or inflammatory causes of foot pain (after four weeks of pain with normal X-rays).

d. MRI rarely indicated - should require specialty consultation; and

e. EMG and vascular studies (non-invasive arterial perfusion or arteriography at the request of the specialist).

f. Inappropriate diagnostic tests:

1. Thermogram.

g. Indications for specialty referral:

1. Displaced fractures;

2. Neurovascular compromise; and

3. Pain and swelling greater than three weeks.

45.4. The appropriate treatment is as follows:

a. Non-operative.

1. Sprains (No fracture seen on x-ray)

A. Rest, ice compression and elevation(RICE);

B. Crutches and splinting (one through three days);

C. Early mobilization as pain allows. This may involve active supervised physical therapy;

D. Usual course - several days to three weeks; and

E. Referral to specialist required if no improvement by three weeks.

2. Fractures.

A. Simple non-displaced:

1. Ankle -- Specialty referral - Will require special splinting or casting for three to six weeks and may require an additional two to four weeks of physical therapy rehabilitation.

2. Hind foot - Same as ankle.

3. Midfoot - Same as ankle but course is usually two to four weeks shorter.

4. Forefoot - Specialty referral not required special shoe or cast may be necessary. Usually resolved in three to six weeks.

5. Phalanges - Same as forefoot, simple taping and/or modified shoe usually all that are necessary.

3. Displaced fractures. Specialty referral is mandatory. Non-operative treatment requires casting for three to six weeks followed by up to four weeks of rehabilitation.

b. Operative. All operative decisions require specialty referral.

1. Sprains. Indicated when there is a complete dislocation/ subluxation without a fracture anywhere in the ankle, hindfoot, or midfoot. May be indicated in the forefoot.

2. Fractures.

A. Simple - may be indicated in ankle.

B. Displaced - Usually indicated in ankle, hindfoot, midfoot, and forefoot. Displaced phalange fractures can sometimes be treated non-operatively.

W. Va. Code R. § 85-20-45