Good evening. On behalf of AOFAS and OTA, I want to welcome you to putting it into practice, addressing common ambulatory fractures in an outpatient setting. Tonight's moderators are Tracy Herrig and Dr. Richard Zell. Joining them tonight are Ashley McCowan, Alexandria Janis, Dr. James Muller, and Dr. Derek Stenquist. You can read their full biographies in the CME Agenda document posted in the chat and in the online course portal. Our faculty disclosures are listed on the screen in front of you, and all relevant financial relationships have been mitigated. 2024 webinars are provided free to AOFAS members and orthopedic residents, fellows, and medical students with funding from the Orthopedic Foot and Ankle Foundation, supported in part by a grant from Stryker. To support education programs like this, we encourage you to donate to the foundation on our website or by texting GIVEAOFAS to 41444. 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We'll send you an email at the conclusion of this broadcast with the link to claim. We are recording this webinar and it will be available for on-demand viewing in the On-Demand Education Center content library in approximately 24 hours. We encourage you to ask questions during the talks. To send your question to the faculty, please use the Q&A tab on your navigation bar. At this point, I will turn the program over to our moderators to begin. Good evening. We'd like to welcome everyone to our latest Putting It Into Practice webinar. Tonight's topic is Common Ambulatory Fractures Seen in the Outpatient Setting. And this webinar is presented tonight in collaboration with our colleagues at the Orthopedic Trauma Association. We have a great faculty and I'm looking forward to each of the speaker's talks. We're going to get started with Dr. James Mueller. He's a foot and ankle orthopedic surgeon in Jackson, Michigan at one of the Henry Ford hospitals. He completed medical school at the Lake Erie College of Osteopathic Medicine in Erie, Pennsylvania, and his residency in orthopedic surgery at Garden City Hospital in Garden City, Michigan. He completed his foot and ankle fellowship at the Cleveland Clinic, and his talk tonight will concentrate on fractures of the midfoot and forefoot. Thank you. Thanks, Dr. Zell. I'll go ahead and share my screen here. Can everyone see the presentation and not the presenter view? All right, great. So just intro slide, ambulatory, midfoot and forefoot fractures, James Mueller, that's me. Nothing to disclose other than I've fused the majority of my Liz Frank patients. So here's a bit of an agenda of what I want to talk about, starting distantly, working with the toes, phalangeal injuries, going backwards, or more proximally, turf toe, sesamoid injuries to the hallux, Liz Frank injuries, and metatarsal injuries, and then giving special attention to that fifth metatarsal. So I figured I'd start with some basic anatomy, just so we're all on the same page. When I'm talking about toes, I'm really talking about the phalanges, and then moving backwards to the metatarsal phalangeal joints, which are these guys right here, metatarsals are these five bones right here, and then moving more proximally to the Liz Frank joints, and the tarsal metatarsal joints. Looking at these on x-rays is a little different. These are two dimensional pictures of a three dimensional object, so sometimes it's tough to discern where each of these joints are. These are non-weight bearing x-rays, typically in my clinic, try to get weight bearing x-rays, it's not always possible in patients who are injured, and that's completely fine, we make do, but you can kind of see the difference, what you can see when you have weight bearing x-rays versus non-weight bearing x-rays. The bones kind of just align in their natural state, and you can really see the columns of the bones and the arches, both the transverse and longitudinal arch, and how they appear during weight bearing activities. So diving right in, let's talk about toe fractures, as I was talking about earlier, these are really just the phalangeal fractures, etiology is typically a crushing type injury, or a stubbing injury, and if you look at the x-rays on the right, this is a patient of mine who, the workplace injury, dropped I think a 500 pound barrel on his foot, and had a crush injury, and he had a partial amputation of his fourth toe, and then crush injuries of his third and fifth toes, and you can kind of see the stellate type fracture pattern that these crush injuries typically cause. The picture on the left is a subungual hematoma that can sometimes occur with these, and typically if there's a subungual hematoma underneath a fracture, or on top of a fracture, it can be considered an open fracture, so just be aware of that. Treatment of these is typically, in my hands at least, non-operative, goals of treatment for me, I want a stable plantar grade foot that fits into shoes, what do I mean by plantar grade foot, I mean that the foot is flat, and sits flat on the ground, fits into commercially available shoe wear. As I said, most of the time I'm treating these non-operatively, either in a post-op shoe, which you can see on the right there, short boot, plus or minus buddy taping, I don't particularly love buddy taping, toes aren't like fingers, it's really hard to get tape around the toes, and I think they kind of splint themselves fairly nicely next to each other as everything's aligned. Obviously some of these need operative intervention, for example, open fractures need an abridement, angular deformities, so if your toes aren't pointing in the normal cascade, they're pointing up, they're pointing down, they're crossing over each other, those are going to be an issue for long-term viability of those toes, they'll cause corns and calluses, rubbing, they'll have issues with shoe gear, and then as I mentioned before, a fracture associated with a nail bed injury is probably an open fracture, needs some sort of debridement. So this is just my case from earlier, talking about nail bed injuries, so I figured I'd go over what I would typically do, which is wash it out, and then repair the nail bed with some chromic sutures, and replace the nail and keep the nail bed splinted open. Next on the list is turf toe, which is a hyperextension injury of the hallux metatarsophalangeal joint, and it's a tear of the plantar plate structure, so if you look at, you know, I have that yellow star there, and those stars correlate to the stars on those anatomical drawings on the right, which denote the plantar plate structures. When you look at epidemiological studies of this, college athletes, four and a half to six athletes per team per year, according to Waldrop et al. in 2013, and then they also discussed, they also did a survey of NFL athletes, and they said 50 to 80 percent of athletes have had this injury in their career, so fairly common when you talk about high-level athletes. So as far as a workup goes, these are people that have a painful dorsal flexion of their first metatarsophalangeal joint, they can have this traumatic bunion appearance, so they had a normal toe, they had this injury, and now their toe goes into a bunion, as seen in the patient on the bottom left picture, and then the x-rays can show retraction of the sesamoids. I'll draw your attention to the picture on the top right, with those yellow boxes. The right foot has a normal station appearance of the sesamoids, and the left foot, you can see that those sesamoids have retracted. Even more so, bottom right pictures denote that retraction of the sesamoids. Once again, the treatment for this, though, is generally non-operative, in a post-op shoe, some people use a carbon fiber insert, or a Morton shank insert, carbon fiber inserts, the one on the left here, the one on the right is the Morton extension shank, I tend to pull up Amazon in the clinic and show patients where to buy it, so these are screenshots from Amazon. As far as grading it and staging it, I attached this table on the right from McQuarrie-Ettall in 2010, which shows some varying degrees of treatment, simplifying it down, 1s and 2s, non-operative 3s can be operative, or long-term non-operative, but it's controversial. Moving on to sesamoid injuries themselves, these are either called meteorolateral sesamoids, or the tibia and fibular sesamoids, named for their corresponding meteorolateral position on the toe, the flexor hallucis brevis tendon is the tendon that passes through these bones to give it mechanical advantage, and then there's an entity called a bipartate sesamoid, which is seen here on the right of the tibial sesamoid, and similar things may happen in the patella, this is just the foot equivalent. Yes, these can get fractured, once again the treatment initially is generally non-operative, short boot, post-op shoe, trying to limit that toe motion, because that's what causes the pain. You can get custom orthotics with excavation under the sesamoid to offload that, and if they have continued pain and they're considering operative intervention, there are techniques out there that describe vascularized bone grafting, or bone grafting and RAF, or some people do an isolated sesamoid excision, but these are pictures or x-rays of what an acute fracture of a sesamoid would look like. Moving on to Liz Frank, injuries, dislocations, so the midfoot is a very important structure and these joints are a very important structure for conferring the stability of the arches of the foot, because this is the crux of the transfer of force between the calf to the forefoot. Minimal to no motion typically occurs at these joints, and that allows the foot to have a rigid lever arm to allow for push-off, but when a Liz Frank injury happens, it can destabilize that arch and leads to motion at these joints, which is pathologic, and it predictably leads to chronic foot pain and arch collapse. So I have these pictures here on the right-hand side, kind of showing some cartoons between the relationship of all the bones in the midfoot. So going from left to right here, going from first metatarsal to fifth metatarsal, these are some of the ligaments involved in the stability of the foot. If you notice, the fourth and fifth metatarsal have inner metatarsal ligaments going between the fourth and fifth, the third and fourth ones do as well. Second and third one does, but the second and first metatarsal does not. That's because the second metatarsal attaches to the medial cuneiform here via the Liz Frank ligament. And if you also notice, the second metatarsal is recessed back behind the articulation of the first tarsal metatarsal and third tarsal metatarsal, because it acts as a keystone in the transverse arch. So that's this picture over here on the right side, kind of a cut. This is kind of a cut through the midfoot-forefoot junction right here, and you can see that the second metatarsal is recessed in comparison to the medial cuneiform. So when a Liz Frank injury happens, which is a rupture of this ligament, and then dislocations of some of the tarsal metatarsal joints, this whole arch tends to be compromised. So the typical mechanism of this is a plantarflex position with an axial load. This is another cartoon here describing and demonstrating some of these injuries that happen, dislocation of essentially the forefoot from the midfoot that happens with these injuries. You get this classic plantar medial echemosis, and these are some stress examinations that you can do or that can be done to further delineate where these fracture, the stability of this fracture. What we're looking at here is this space between the second metatarsal base and the medial cuneiform. Here you can see, well, maybe it's possibly a little wide, I can't really tell. This examiner is doing a forced abduction maneuver that shows that that space is wide and this second TMT joint is subluxed. So workup for this, as I showed earlier, x-rays, AP oblique lateral stress x-rays, either weight bearing or the manual forced abduction. CT scans can be warranted, sometimes MRIs, depending on how subtle these injuries are. In terms of treatments for them, this is a classification by Dr. Nunley talking about the different varying stages of this injury. Breaking it down, stage one is non-operative, stage twos and threes are operative. For a non-operative treatment, give it a splint for a week or two to allow for soft tissue rest, then a short boot or a cast for six weeks. Stage two or three, we're looking at either open reduction internal fixation versus a primary fusion of the joints involved. And so here is some pictures of a patient of mine who had a kneeing injury and he had this pretty visible gap between his base of his second metatarsal and his medial cuneiform seen on this AP view. Nothing really on the oblique or the lateral really jumped out. So I got a CT scan to further delineate where the sublux, if any of the other joints were subluxed at. And he had some combination in his third TMT joint and his first TMT joint wasn't fully reduced either. So he decided to go for a 1-2-3 TMT fusion. Moving on to metatarsal fractures, according to Rockwood and Green, 35% of all foot fractures are in the metatarsals. And in general, when it comes to treating these, the goal is to maintain a normal metatarsal parabola in both the AP and transverse plane. And that can be seen in those pictures from the OT on the right. Starting with the first metatarsal, the first metatarsal, most of these fractures are generally operative, mainly because there's minimal ligamentous attachments to the other metatarsals to brace it. It's also a very load-bearing metatarsal. So any dorsal plantar displacement is not well-tolerated and tends to shift the normal weight-bearing aspect of the foot. Shifting is not well-tolerated because it leads to transverse metatarsalgia. Rotation is not well-tolerated because it can lead to a bunion. Initial treatment is typically in a short leg splint or a short boot, and then followed by operative intervention if there's displacement. These are just some pictures from an article showing one author's method of treating these with a mini-fragment plate. When it comes to lesser metatarsals, metatarsals 2 through 4, there's not really consensus on treatment in the literature. There's some authors that say that 10 degrees of angulation, either the dorsal plantar plane, less than that and less than 3 to 5 millimeters of shortening is okay for non-operative treatment. This is because there's lots of ligamentous attachments between the metatarsals in the distal and proximal ends that give it that internal brace to prevent shortening and angulation. But once again, what's not tolerated is angulation of the toes, distal toes meaning hammer toes, or angulation of the metatarsals themselves in the dorsal plantar plane because they can lead to metatarsalgia and plantar keratosis or a big callus under these metatarsals if they're too dorsal or too plantar. Moving on to the special fifth metatarsal fractures, I've kind of broken it down into four different areas that can cause issues, or four different areas of the fifth metatarsal and they're all kind of treated a little bit differently. Starting with, as I said, this is kind of controversial. I do a PubMed search for all the articles in the last five years about fifth metatarsal fractures and I did, I applied last five years English human studies, there's 150 results of people investigating fifth metatarsal fractures over the last five years, so it continues to be controversial on how to manage these. Starting with the dancer's fracture though, this is a shaft fracture, spiral distal third of a shaft fracture. If you're not familiar with orthopedics, there's eponyms for everything. Eponyms is just a name of a fracture that was given to something or someone, so a dancer's fracture is something that commonly occurs in professional dancers. It's typically a twisting type injury. The treatment for these is typically non-operative in a post-operative shoe. The study by Morgan et al had a series of patients were treated non-operatively regardless of how much the fracture was displaced. All the fractures went on to heal and they all had very good post-operative outcome scores. Moving on to the base of the fifth metatarsal fractures. So this area of the fifth metatarsal can have a vascular watershed area that makes it difficult for some areas of this fracture to heal. If you break this thing down into three zones, zone one fractures, which is this one right here, are proximal to the articulation of the fourth and fifth metatarsals. Zone two fractures are in this articulation between the fourth and fifth metatarsal. Zone three injuries are typically distal to that articulation. Zone one injuries are typically an avulsion fracture from a twisting injury. Zone two fractures are the same thing, but they're in this vascular watershed area, whereas zone three fractures tend to be stress fractures. So starting distal and working proximal, zone three injuries, stress fractures, they can be associated with foot deformity. So some people with a higher arched foot, this picture on the left here is a guy with a classic cavus deformity, high arched foot, varus heel. They're going to have a lot of lateral forefoot driven pain. They can have a stress fracture on that side. I want to pull your attention to the picture on the right, which is a patient with a subtle cavus deformity, not as obvious, but they still have what they call a peekaboo heel deformity where their heel is just in slight varus. These people also tend to have a little bit more lateral border of the foot overload. Other things to look out for is the female athlete triad. You get our young high school marathon runners that have low energy bioavailability because they're burning off so many calories and not eating or intaking the same amount of calories in a daily basis. They tend to have amenorrhea and going along with that osteoporosis, something to look out for. And also patients with low vitamin D, those can all be a factor in the formation of these stress fractures. Initial treatment, the short leg splint or a tall boot. So you need a tall boot to immobilize the peroneal brevis because that's going to pull on that fifth metatarsal. However, these are generally operative, an ORF and plates and screws versus an intramedullary screw. This is a patient of mine who had a football player, cavus deformity, had pain in his foot in this area about three weeks before this injury actually happened and then felt it pop. We discussed waiting it out or doing surgery and he decided to go with the surgical route. So I tend to treat these with a solid screw in the shaft of the fifth metatarsal. Moving on to type two injuries or true Jones type fractures. This is in that vascular watershed. Treatment continues to be a bit controversial, operative indications, athlete because it minimizes the risk of refracture. There's been studies that show it has a quicker return to play, polytrauma, people that have other injuries to other areas of their body to improve their mobilization or chronic fractures that are a non-union typically are operated on. In terms of choosing non-operative outcomes, there are varying ranges of rates of healing between 76 and 100 percent. In terms of their immobilization method, a tall boot is recommended because it has a quicker time to walk than a post-op shoot. These are just some pictures from an article about treatment of a Jones fracture with an IM screw. And then pseudo-Jones fractures, tuberosity, and avulsion fractures. These are typically treated non-operatively because they have a very good healing potential. There have been studies that show that they had a large cohort of non-operatively treated zone 1 fractures that had a clinical union, meaning they didn't have any pain. Granted, the x-ray wasn't fully filled in with bone by eight weeks. What to do about it in the long term if they remain painful is controversial. Some people advocate an open reduction internal fixation and reattaching that bone, whereas other people say remove the bone fragment and advance the peroneal brevis tendon. And this is a patient of mine who had a type 1 Jones fracture. He was treated non-operatively and after eight weeks he didn't have any pain, so he started doing sport-specific drills. And he's been doing well. Here is just a snapshot slide if anyone wants to take a picture of it to just say, oh, this is what's coming in my clinic. This is how I need to mobilize them. I have a lot of urgent carers in my community that tend to put a lot of things in short boots when a tall boot's a little bit more appropriate, and I do a lot of education on that. So I figured this slide would be helpful. And here are my references. Thanks for your attention. Sorry for running a little over. That was great. Thank you so much. I think we'll just do, I don't see any questions right now, so we'll just do questions at the end then after. Okay, great. Dr. Senquist, are you ready to go? All set. Okay, let me introduce you. Dr. Derek Senquist is a fellowship-trained orthopedic trauma surgeon, undergrad from Dartmouth College and medical degree from Harvard, stayed for residency at the Harvard Combined Orthopedic Residency Program, and went on to complete his fellowship at Tampa General Hospital under the Dr. Roy Sanders. Dr. Derek enjoys all facets of orthopedic trauma, care with particular interest in upper and lower extremity fractures, pelvic, acetabular fractures, and hip arthroplasty. Thank you so much for being here. Thanks for having me. I'm just going to get my slideshow going here. It's funny that you say the Roy Sanders. Indeed, I didn't write that intro. He's a good guy. All right, can you see my screen okay? All right, awesome. Well, thanks so much for having me. It's really fun to be here as part of this AOFS and OTA combined talk, and I look forward to some discussion afterwards, so I have no disclosures. The city goal of the webinar was to identify triage and manage common ambulatory fractures of the foot and ankle, so I interpreted ambulatory fractures as the ones that may wander into the office of urgent care, but my sister's a PA in urgent care, and so I think she's probably better at reducing shoulder dislocations than most of our residents. Deformed ones certainly come in there, so I had our allied health providers in mind in putting this together. I'm going to talk in some broad strokes about ankle fractures first, and then we'll get into a little bit more detail. So these are going to walk into your office, obviously injuries to both sides of the ankle, unstable ankle fracture, put them in a splint, refer them for surgery, deformity, get them reduced. We're going to be planning for surgery. Let's talk about some other stuff here. We're going to talk a little bit more about triaging and managing these ones that are a little more subtle, maybe a little more difficult. Which ones can go home? Which ones are stable? How soon do they need to be seen again? Like that one on the left there, that's not deformed. What are you going to do with that? You're going to stress it. I'll try and get into a little bit, stir the pot a little bit about opinions on that. So a quick outline ankle fractures. We'll talk about the Weber classification, I think, allow you Hansen classifications a little beyond the scope of the talk. I got to try to get to calcaneus fractures and some talus fractures too. And then which ones should walk out of clinic? Then we'll talk about some more subtle diagnoses in the areas of calcaneus and talus fractures. And maybe my foot and ankle qualities can give me a hard time as I get into the weeds on some things that are definitely not in my wheelhouse. So bimodular ankle fracture, obvious bony injury to both sides, lateral tailor shift, unstable ankle fracture. Do not pass go, do not collect $200. This one is not subtle. You're going to put in a splint, get the talus under the tibia and refer for surgery, like we said before. Here, there's no medial side and bony injury, but obviously again, not subtle. You know, this needs surgery. The talus is way lateral and the medial torso space is extremely wide. So unstable ankle fracture, reduced splint, non-weight bearing, refer for surgery. When you're looking at fibula fractures, we can group these by the Weber classification, trying to keep it simple. So we'll talk about broad strokes here. Type A is below the level of syndesmosis. Type B is at the level of syndesmosis. Type C is above the level of syndesmosis. Type C often has an associated syndesmonic injury. Type B, about 50% of the time, type A, it's more rare to have a syndesmonic injury. So here's the first case, 52-year-old male stepped on a rock and drive while he was walking backwards and then rolled his ankle. So you get these x-rays, you've got a little avulsion fracture of the fibula there. Weber A, right? So we put him in an air cast boot, tall air cast boot, weight bearing is tolerated, essentially treated like an ankle sprain. We'll hear a little bit more about rehab for these maybe from our PT colleagues later. But the mechanism for these with just an isolated, again, we're talking isolated fibula fractures here, at the level of the Weber A, ankle eversion, typically low energy, turn my ankle, swelling and tenderness at the tip, avulsion fracture, weight bearing is tolerated in a tall air cast boot, treated like an ankle sprain, non-operative management. At three weeks, he's doing fine. Bring him back, make sure there's no displacement, anything else that has showed up since he went away, and then get him into some ankle sprain rehab. And for me, the return to sport, I tell people usually along the same timeline as a bad ankle sprain, sometimes a little bit longer, more protracted recovery. Here's another case, real world scenario may come into your clinic, right? You got an isolated fibula fracture, but it's high this time. We're talking Weber C, 18-year-old male, football injury against the clinic in a splint with these x-rays. He was seen at an outside ED, now he's seeing you in the office. So here you're looking at this, you're like, wow, the talus is pretty well located under the tibia there. But note the loss of tib-fib overlap, a concern for a synesthematic injury. Make sure you talk to mom, she has the pictures on her phone of the outside hospital x-rays, lateral tailor shift, obviously clear, medial sided injury, need surgery. So the take home here, Weber C, high association with syndesmotic injuries, and you can see here the clear syndesmotic injury there on the injury films. But if they show up to you later, they're already reduced, you don't have a high index of suspicion. He gets surgery, obviously, longer contract, he's a big lineman type guy, comparison films. Make sure you get the injury films, get a good history, see if they needed a reduction. If the fibular fracture is proximal to the syndesmosis, it's safest to triage with non-weight bearing in a splint, you refer to your surgeon, you talk to your attending. The direct blow may not have a syndesmotic injury, so it's not always true that a fibular fracture at this level is associated with a syndesmotic injury, but you should have a high level of suspicion. And remember, the tail has to be maintained in the tibia while they're waiting for surgery. So higher energy injuries, sometimes sports injuries, may have deformity or swelling, but may be more subtle. Majority have deltoid and syndesmotic injuries. Again, we're talking medial bony side, bony injury, and typically going for surgery. So here's the one that I want to spend a little time on, and maybe stir the pot a little bit. So 18-year-old male, everted his foot during gymnastics, penultimately pass, get the lateral view, you see this oblique fibular fracture, the level of syndesmosis, whether it be ankle fracture, whether it be fibular fracture. What next? Is it stable or unstable? How do you decide? How do you manage it in the short term? There's many different protocols for this. Even in my residency, it changed during the time I was there from a protocol of getting that initial x-ray and weight bearing all of them and bringing them back to clinic to now gravity stress view. So what's the deal? We're talking, is this stable or unstable? So we get a gravity stress view. Is this really helpful? Right? We're looking for medial clear space widening, a lateral shift to the tail as well. Maybe it looks a little wide on the medial side. It's a little more wide than the superior clear space. I did obtain a CT here to make sure there's no post-term alleles or other surprises given his young age. I'll be curious if the other faculty do this for these, but if you're ever uncertain, you're never wrong to splint them and make them non-weight bearing in the short term and speak to someone else about how they might manage or get some advice, but it's a conversation with the patient with him. In this case, ultimately we decided to reshare decision-making on weight bearing as tolerated and follow up. And, you know, at one week he's been walking on it now and it's all air cast boot, putting full weight on it, you know, using crutches for longer distances, but he's really been weight bearing around the house, even without the boot, it's not shifted. You know, another conversation with the patient, maybe it was a little bit shorter, a little bit more displaced than the lateral view, but no medial clear space. Shared decision to continue with non-op management. He's actually saw him today, he's now six weeks out and it still looks good. So just to make sure I'm not crazy, you know, here's a, here are some slides from the OTA resident core curriculum, same case, 29-year-old female with a right oblique distal fibula fracture, subtle medial clear space widening on the gravity stress view, but nothing again under her weight bearing films or her initial presentation x-rays. And then she's managed non-operatively with success and no long-term medial clear space widening, no shift. Again, I say long-term and this is, this is her follow-up x-rays and healing. So we'll get into that a little bit. So where's this coming from? Well, there's some more recent evidence now people have been trying to challenging paradigm of stress views again. And here's, here's a study from JOT in 2024, just this last year, 69 patients with Weber B fibula fractures. 38 of them, 55% had medial clear space widening on the gravity stress view, but not on their weight bearing x-rays. And some people have called this an SCR4A injury, but just remember they have presentation x-rays with no medial clear space widening, weight bearing x-rays with no medial clear space widening, gravity stress views are positive. What do you do? All 38 were followed prospectively weight-bearing tolerated and then were converted to ORF, no difference. And finally, OFAS scores. And then out of JBJS prospective study in 2023, similar, exact, nearly exact same study design, 151 patients with Weber B and medial clear space less than seven on static x-rays. Every patient got a weight, bilateral weight bearing x-rays and gravity stress view, and they grouped them into two groups. So one group with normal weight bearing x-rays and normal gravity stress. And the other one with normal weight bearing x-rays and abnormal gravity stress and followed them all prospectively. And they compared them and only 2% had to go on to ORF based on weight bearing x-rays. And if they had used the gravity stress view to determine who needed surgery, they would have operated on 42%. So at two years, no difference in functional scores. However, so I just share all that, but I, you gotta be really careful with this, right? And I'm going to show you an example of when this can be applied incorrectly. So here's a patient, 30 year old male, semi pro football player. He was injured in a game in North Carolina, flew back, seen in the emergency department by a resident. This is his x-ray that was obtained in the emergency department. You can see there's an orthoplast splint on there, probably from the outside hospital. The x-rays were interpreted as, okay, static films. I don't see any medial clear space widening. I'm going to take off your splint, give you a tall air cast boot and tell you you can weight bear as tall or not. So it goes back to my clinic at a week. He says, doc, I couldn't walk on it because it hurt too much. And it also swelled up more and I had new blisters. And one thing you notice right away on this x-ray is the symptomatic widening, the lack of overlap there. Then the APA view looked like this. So he doesn't even need a stress view anymore, right? So probably would have been seen on that initial encounter if he, if it had been taken out of x-rays or if they'd gotten x-rays out of the splint before he left. The problem with this is that his soft tissues were hurting. So now he's been trying to walk around on this unstable ankle fracture and his soft tissues look like this. And then we have to wait four weeks to fix it. And it's a really painful experience to fix it for him and for me. He's doing okay at three months. We had to really wait for that postural lateral skin to calm down. So there's a fantastic commentary perspective article on this, this article on JBJS. And I think it's important to be thoughtful about this. We still don't know the answer. You know, the question was, is the degree of stability implied by the well-lined weight bearing radiograph or that initial x-ray of your Weber B fibular fracture that's not displaced? You know, is that enough to imply that there's stability for all the way to healing? And in these prospective studies, they said, yes, it does, but there are really important caveats, right? One is time. We don't know. We have two-year data now, sure, on that prospective study, but we don't know what that means for the 18-year-old with 20, 30, 40-year data. Does that, we know that weight-bearing x-rays cause the, because of the saddle shape of the talus, that they can cause reduction of the most, I mean, reduction of the mortis, you know, but maybe that there's some micro instability that's implied by the positive gravity stress view that may lead to arthrosis down that way, down the line that we're not appreciating that. So we don't know. It's important to have that conversation with the patient. Then generalizability in this nice study in JBJS, they had all these Norwegian people who were really compliant and all did great weight-bearing x-rays, but that's probably not reality. And then of course, if you have altered sensation, this can never be applied and you should never be using it for neuropathic patients. And I would add soft tissues, degree of trauma, and don't forget that lateral view on that x-ray I showed, he was clearly subluxated on the lateral view and not concentric at the, at the get-go. So that kind of takes you out of this protocol if you're thinking about using it. So what went wrong, again, these were not injury films, no x-rays out of the splint, the joint's not concentric on the lateral view. If you're uncertain or no injury films are available, get a stress view and then consider soft tissues in the mechanism as a clue. So displaced unstable, obviously needs surgery, right? That shifted one I showed you with no bony injury on the medial side, but clearly wide medial clear space, tail is shifted laterally, needs surgery. Stable weight-bearing x-ray but abnormal stress views. Remember those, remember your caveats. I would say one size does not fit all. Have a conversation with your colleagues about how to approach these, how are people doing it, what's their protocol, do they stress them all, or do they weight-bear stress and come back in a week? And for younger patients, be really thoughtful, have a thorough conversation about what these studies do and do not truly show. All right, and then just to tick through a few more of the ankle injuries, we'll go from ankle to calc, to the tail, that's working from proximal to the distal. You know, masonry of injuries, similar idea, this is a gravity stress view, showing positive gravity stress, don't forget about that, excuse me, manual stress, don't forget about that high fibula fracture when you see patients come in with ankle pain after a twisting injury, make sure you're squeezing the proximal calf and consider tib-fib films, and then isolated posterior malleolus fracture, never forget that lateral view. Posterior malleolus fractures in isolation are extremely rare, sign of a more complex injury until proven otherwise, so they may have a high fibula fracture, deltoid revulsion, syndesmotic injury. So, tib-fib x-ray, low threshold for CT scan if you're seeing just that isolated posterior malleolus clinic, and then lastly, don't miss a flex sign, so off the lateral aspect of the distal fibula, indicating a superior perineal retinacular avulsion, resulting in perineal tendon instability, and the mechanism is oftentimes forceful dorsiflexion with simultaneous contraction of the perineal muscles, and an important one to not miss. All right, so moving on to calcaneus fractures, same idea, you know, you see this, this is in clinic, put them in a bulky Jones, right, non-weight-bearing crutches, and get them off to surgery, but the more subtle ones that I've always struggled with, especially as a resident, when I would see these patients in the ED, and they would be like, you know, oh, they've got that little fleck off there, and what is this, a midfoot sprain, I don't know if they're okay, can I let them weight-bear? This is a great MSK imaging review in American Journal of Radiology from 2015, a lot of nice examples of some calcaneus, different avulsion fractures and diagnoses you may see in clinic, so we'll go through some of these. Avulsion fractures about the calcaneus of current reproducible locations, and some can be subtle and easy to miss. You know, here's a 43-year-old man who fell off a horse and experienced pain and bruising in the back of his ankle, this is, this one is not so subtle, but then this one is a lot more subtle, so here's a little tiny fleck, and he may have some dorsal, plantar flexion weakness, but he may be intact, so being really careful not to miss an avulsion off of the Achilles tendon, splint non-weight-bearing, in my opinion, for a surgeon who treats Achilles tendon ruptures. Calcaneus fracture anterior process, I tend to have these in my clinic, and they're really easy to miss, and they're commonly diagnosed as ankle sprains, so they're often best seen in the lateral view, but an oblique view can be helpful, I have a slide about that in a second, with a really nice example, and a CT scan if you're equivocal, or if you have something that's just not adding up with someone who's coming in saying, I sprained my ankle, or they seem to have an ankle sprain, we're going to go through, at the end, a differential diagnosis of ankle sprains, and really important not to miss some of these things, so for the anterior process, two, two common mechanisms, one is an avulsion of the bifurcate ligament, which is a Y-shaped ligament with the calcaneo-navicular and calcaneo-cuboid limbs, this first one is a football player with trauma, and you can see, we'll show you in a second where the bifurcate ligament is attaching, the compressive fracture tends to occur by impaction of the anterior process from the cuboid and talus during eversion and dorsiflexion, and the avulsion fracture is caused by the tension on the bifurcate ligament during forceful inversion and plantar flexion of the foot, so you could get a type 1, which is the small or sometimes non-displaced injury fracture there, and then type 2, which is often minimally displaced, no cc joint involvement, and type 3, common or large with involvement of the cc joint. There's a, sorry, here's my example that I wanted to show you of the oblique view right here, this is a 25 year old man who fell skiing, you can see it pretty well on the lateral view, but also this is the nice oblique view where you may be able to identify that a little bit better, so the treatment is typically non-surgical management, including six weeks of protective weight-bearing past mobilization when it's a small fragment, surgery for larger displaced fragments, especially involving greater than 24% of the cc joint, but I'll tell you, I've definitely had a few young active patients who walked it off in an air cast boot with ankle sprain treatment and did fine, I'd love to hear from the faculty about how they're treating these, because, you know, clearly large displaced ones that involve a large amount of the cc joint should be fixed, but the smaller avulsions, I've found that patients do pretty well with non-operative management and immediate weight-bearing in a tall air cast boot. Calcaneocuboid ligament avulsion, so another part of the bifurcate ligament, best seen on the front frontal and oblique foot x-rays, sometimes not seen on the ankle x-ray, often linear in nature adjacent to the anterior process and distinguished from a stress fracture of the lateral aspect of the cuboid. This is a 21 year old male who inverted his foot and had pain laterally. It begs the question, you know, should we be getting foot x-rays on every ankle sprain? I'd be interested in hearing from the faculty on that too. Maybe not, but I have a low threshold. I, you know, you're going to change my management, this person is going to be managed non-operatively, but you want to make sure we're not missing something else. Maybe, and then I tend to get ad foot x-rays if they have entertainingness, excessive swelling, pain, or bruising, and a low threshold for a CT scan, if I'm concerned. I'm not CT scanning all my ankle sprains, but I'm talking about symptoms that don't add up, so they're not tender just over the ATFL, they don't have the typical symptoms. And again, this is about trying to not miss subtle diagnoses. Calcaneicuboid ligament avulsion, just another view here, and then EDB avulsion, which this is a 32 year old female tennis player who inverted her foot and had dorsolateral bruising, and you can see that on the ankle x-ray, the rotator fragment of the bone there was tissue swelling, and in the foot radiograph showing that it's located near the anterior calcaneal body, treated like an ankle sprain, so I would treat this with a tolerFS boot and weight-bearing is tolerated. Lastly, talus fractures, you know, don't miss fractures of the head, neck, or the talus. The treatment for those is casting and non-weight-bearing for displaced fractures, non-displaced fractures, and surgery for displaced fractures. We're going to skim past that because we're talking about a little more subtle diagnoses, but you know, this one, you're not, you're not, you're going to not miss that. That's obvious need surgery. I've also fractures of the head and neck. So here's dorsal capsular evulsion treated like an ankle sprain in the absence of significant injuries, um, maybe associated with injuries to the show part joint, um, such as the CC ligament evulsion or the anterior process of calcaneus fracture. So look out for those in combination with these dorsal capsular evulsions. And then their treatment is an initial, um, immobilization and aircast boot for, for symptomatic for comfort and then early weight gradual functional rehabilitation. And, um, I would get them some PT, uh, for ankle sprain type rehab, um, lateral process of the tail is fractured. So this is a 50 year old male had a contract on ankle fracture dislocation, which was a really distracting injury and he complained of pain and we nearly missed this subtle lateral process fracture. So you can see it on the lateral view there. Um, conservative treatment is possible depending on the size, displacement and level of combination of the fracture. But, um, for smaller fragments and those with minimal or no displacement, you can treat them with, um, protective weight bearing and early motion, but definitely I would, I would immobilize and do non-weight bearing for at least six weeks and then progress their weight bearing after that, if they're larger or displaced fragments, they can involve a large part of the subtalar joint and cause arthrosis. So they definitely should be fixed often with mini frag screws or plus or minus a plate. I don't fix a lot of these. So again, please, um, hopefully we can have a good discussion about it. Um, afterwards. And then, um, like I said, minimum non-weight bearing six weeks in an early range of motion and gradual resumption of weight bearing if they're being managed non-operatively. This is what he looked like and you can see it involving the subtalar joint there. And then here's another example of a 30 year old snowboarder. As you know, these are called the snowboarder's fracture involving more of the subtalar joint in the coronal plane. And lastly, posterior process of the, uh, of the talus fractures. Um, I just have an example of the, um, this is the only one I could find. I haven't treated many of them non-operatively. This was not subtle, but, uh, but he had this posterior process of the talus fracture that clearly involves a subtalar joint as well. You can see if you miss something that was isolated like this, how it would have the potential for arthrosis of the subtalar joint, um, we've got, uh, mini frag screws and a larger cannulated screw from PA and then the rest of his fracture was addressed. So again, ankle sprain, uh, differential diagnosis. We covered a lot of these, uh, sort of quickly and I'll wrap up. Um, but you can see there, the impulsion of the EDB, the, uh, anterior process of calcaneus, the fracture of the lateral process of the talus, um, perineal tendon rupture or SPR avulsion, um, cystic my injury. So these are often sites of, uh, foot fractures that can mimic an ankle, mimic an ankle sprain, and you can see the ones there in the calc and the. The tail is some of which we covered. So have a, have a list in your head of your differential diagnosis to make sure one of my partners, um, art in Asia always brings up this article and it's a nice list to have sort of in your back pocket of, um, when you're getting consulted on these in the, in the hospital, or if you're in clinic, when you, you're seeing these patients. So thanks so much for having me. That's all I've got. Thanks, Dr. Stankiewicz. That was a really wonderful talk. I, I really appreciated your thoughtful comments on what Weber bees and. Uh, being in practice for a while. I know that that's gone through a lot of changes through the years and it continues to be something that you really have to think about, um, we'll, we'll have time for questions, hopefully at the end. Um, our, our next speaker here is Ashley McCown. She's a board certified clinical specialist in orthopedic, uh, physical therapy, and she works at the university of Rochester. Um, she is, um, the practice committee chair for the Academy of Orthopedic physical therapies, foot and ankle specialty group. Um, she's a certified coach for the road runners of America, and she has a special interest in working with masters athletes. She was, uh, speak to us today about the rehabilitation of ambulatory fractures. Um, thank you. Thank you so much. I appreciate that. I can, everybody see my regular view or we see in the presenter view on here. Uh, that looks good. Okay. No presenter view. Wonderful. All right. So just my title slide today, I'll be talking about PT rehabilitation of ambulatory fractures. So again, a little bit about myself and, um, how I got into this crazy world of physical therapy. I, uh, had a couple of injuries myself as a high school athlete and ended up going to the university of Buffalo in their DPT program. So I graduated from school there in 2014. I worked for a couple of years and I learned very quickly that I didn't have the knowledge that I wanted to be able to treat my patients with the best care when it came to orthopedic practice. So I went ahead and studied for the orthopedic specialty exam. Um, and then. As I mentioned in my bio, I've been, as part of that, I've been practicing as well with the facet group, which has been great learning experience for me. And I've been able to bring back some of those, um, educational topics that I've learned with my participation there into what I do full time. Um, managing a clinic where we see primarily sports and orthopedic patients. Um, more recently than not, these little feet have taken up most of my time. I'm getting my firsthand experience of learning all about foot and how it develops right from the newborn stages. So just a little bit more about the U of R U of R is the only level one trauma center in the finger lakes region. So it's kind of a unique opportunity for us as physical therapists, because we get to see a vast variety of ankle fractures. Um, we get a lot of referrals, not only from our trauma docs, but we also get, um, referrals from our orthopedic docs as well. We're ranked the number one hospital in the Rochester region for orthopedics. And then we see the highest number of fracture repairs of any hospital in the States. So when I was putting together this presentation, there was a lot of different things. I thought, man, I could talk a lot about one specific fracture. I could break it up as, you know, some of the other physicians have on this call. I decided that I was just going to take more of a broad stroke because generally with, um, fractures in the physical therapy world, we're treating them all generally the same, but we all have to have an understanding of, um, biomechanics where the fracture is, and a lot of that comes down to effective communication between physicians and ancillary professionals like physical therapists. Um, but there are a lot of fractures in the U S 7.9 million fractures in the year, 5 to 20% of those have impaired healing. And I like to think that this is where we can really come in and help out with making sure that we're doing everything that we can to reduce the incident of having male unions, non-unions or, uh, delayed unions. And then of course we're relying on more of our physician faculty to do our four hours, the recognizing the fracture, retaining it, or reducing it, making sure that that reduction is retained. And then lastly, some of the other things that we're doing is we're making sure that that reduction is retained and then lastly, sending you them off to rehab. So I broke down our general rehabilitation goals into four subcategories as well. So as a PT is, you know, our job is to try to promote healing as much as possible. Um, reducing pain is an obvious one. A lot of these folks come in with an awful lot of pain, and sometimes it's just having a conversation with them on pain management, and that can really go a long way. Um, we're also working to restore mobility, which goes hand in hand really with promoting, uh, healing, but I'm going to break these down a little bit more here in upcoming slides. And then generally, um, before they're discharged from our care, we really like to ensure that we're doing everything that we can to enhance their quality of life, which really looks at more than just the fracture that they're coming in to see us with. So how do we promote healing? So one of the first things that we like to do for promoting healing is to get them moving early, so there's lots of different ways that we can get them moving. We can look more locally at the area that we're treating. So take, for example, a Weber fracture. If I had somebody coming into the clinic, I'd want to make sure that I was doing anything I could to ensure that they were not getting stiff in the forefoot and the great toe, I would be making sure that their knee was mobile. If there was anything that maybe I could address in the hip and core, you know, we're really looking at the whole body so that when we do get into later stages of rehab where we might have a little less restriction on us from a fracture healing standpoint, we kind of already have a really good understanding of where this individual is and what type of exercise program might benefit them in the long run. So more globally thinking, you know, individuals that come in to see us, we have very high level athletes. We also have very a variety of ages. We'll put it that way from young to old. So some folks that don't have growth plates that are totally fused yet, some that are old and may have suffered from a fall, and this is how they ended up with their fracture. So a lot of different assistive device training and experience with assistive devices. So sometimes that really is a lot of our early stage rehabilitation is just making sure that they're safe with their emulation and then also providing them with that distal and proximal exercise program. Some folks come to us that, you know, they've been told that they're going to be non-weight bearing for four to six weeks, let's say, and there's somebody who's a gym rat and they're going to be doing something somehow. So it's always nice to be able to provide them with the safe exercises. And then some folks have never really exercised at all. And we know that generally they're going to have to have a good exercise routine to get stronger and to recover from their injury. And it's just kind of nice to plant the seed early with them to get them on a good exercise program. And that's where, you know, the tailored patient education comes in as well. We're educating them on normal bone healing timeframes. Also giving them an appropriate home exercise program, whether it's exercises, avoidance of, you know, the bad things that we don't want, or even just general home setup, you know, tips and tricks for how to get around the house a little bit safer. And then, of course, following the weight bearing restrictions per the MD guidelines, whatever is on the referral. And then just knowing that, you know, with Wolf's Law, you're going to remodel the bone in an appropriate way when you are actually loading it. So we want to make sure that we're loading it as much as we can within reason. And then, of course, smoking cessation is always something that's in our toolbox for those folks that may have a higher risk for delayed union if they're smoking. OK, so then reducing pain. So just a review of the price protocol with our patients. So protection, rest, ice, compression and elevation. In the clinic, we have a game ready machine, which is a vaso-pneumatic machine that circulates ice cold water and provides compression. We have foot and ankle sleeves. We have longer knee sleeves that sometimes I'll use with my, you know, midshaft fibula fractures. So those come in really handy in those early stages. Also pain neuroscience education, you know, that really just allows patients to understand their condition and motivate them to become active participants in the management program. You know, it really helps to just basically demystify the biological and psychological aspects that will help empower patients to manage their condition more effectively and foster a sense of control, which is going to be really important for their their consistency with their program and their long term outcomes. And then, of course, promote active recovery in any way that we can. So number three, restoring mobility. So, again, this really goes hand in hand with promoting healing. But locally, you know, at the injury site, we really want to think about optimizing biomechanics. So typically I'm performing some sort of joint mobilization as needed as early as six to eight weeks after a fracture. And I'm usually in communication with the physicians in regards to this. And I want to know exactly how the how the fracture is healing before I do any high grade joint mobilization. Oftentimes it's just a grade one mobilization to encourage a little bit of movement at the joint. So, you know, unfortunately, after the mobilization period that's required for fractures like a Weber fracture or foot and ankle, midfoot, they get really, really stiff, really, really quick. And, you know, the benefit of having them in that offloading boot is obviously outweighing the risk of them getting stiff. But it takes quite a lot of effort to get their mobility back. So the earlier we can do mobility, not only self-directed, but also PT assisted can really go a long way. So I'm also encouraging my patients to do a lot of soft tissue work, whether it's foam rolling or just manual work. And also if it's a postoperative situation, oftentimes folks have a lot of sensitivity to their scars. It can be really debilitating for them to even wear socks or to, you know, allow me to do the manual interventions that we want to do if they have that hypersensitivity. So oftentimes part of my home exercise program for some of those early stages are just desensitization strategies for the scar. And then globally, again, stepping away from the fracture site a little bit and thinking about the larger scale things that we can do from a PT standpoint is to just encourage them to do both active and dynamic stretching to facilitate return to whatever function they may need. A lot of dorsiflexion stretching would be, you know, our primary goal initially, and then we turn that into a more dynamic function based on what our patient's goals may be, whether they're, again, returning to sport, returning to work, or maybe they're just looking to walk with less pain. And then, of course, strengthening goes hand in hand with the stretching and balance also is very, very important for these folks because, again, you've been immobilized for a while. Your neuromuscular control is going to be really poor when you get out of that boot. And, you know, doing what you can to not only get them back to where they were prior, but maybe even progress them if it was, you know, a case where it was an older individual may have had a fall with the resulting fracture that can be hugely beneficial as well in the older population. And then lastly, just that long term quality of life and what we can do to optimize this, so making sure that before they're discharged from our care, they're not only, you know, our normal expectations or goals would be something as simple as, you know, restore normal range of motion, reduce symptoms to minimal, make sure that their strength is within normal limits for participation in day to day. But we also want to make sure that their long term goals are achieved and their risk reduction strategies for future injuries are also addressed. So, you know, an individual that has flat feet, for example, may have had flat feet forever if they come in to see me and they've had some sort of ankle fracture. I will be working hard with both feet, knowing that, you know, I don't expect them to walk out without flat feet, but teaching them the strategies that they may need for some more neuromuscular control to prevent a re-injury can be really helpful. Also, oftentimes, especially with foot fractures, I'll have folks that want to walk on the lateral side of their foot, which from an anatomical standpoint, it makes sense. You want to weight bear on the side of your foot that is most rigid anatomically, which would be riding the lateral border of the foot. Unfortunately, if you've had, you know, a fifth metatarsal stress fracture or any sort of injury to the lateral ankle, that's going to end up overloading that side of the foot. So oftentimes it's a matter of educating them on engagement of some of the muscles that help control pronation, control supination and, you know, giving them the tools that they need to prevent overloading a joint unnecessarily. Okay, so I just wanted to touch a little bit, too, on like what an ideal plan of care would look like and what a realistic plan may be. So, you know, in an ideal world, a patient has a fracture. That fracture is immediately addressed by the physician, whether it is not operatively managed or if there was an RAF situation required. MD would place a referral to PT. PT would see them the next day and say, you know, we're going to do this, we're going to do this. MD would see them the next day, in my opinion, or the same day, just later that day, and would develop an appropriate plan of care. And then from there on out, the PT and the MD would communicate seamlessly regarding that patient status. As my time in practice as a clinician, but even more so as of late in my role as a senior PT at the place that I work, I'm recognizing that there's a lot of barriers to patient care. And sometimes a more realistic view of these folks when they get sent to physical therapy is they have some real hurdles that they're up against. And that ideal plan of care doesn't always go the way that's planned. So some folks, this is their first pain experience and they really they don't know much about dealing with pain and they don't know much about how to get around their home safely. So I've been surprised to see what we take for granted. I would say as physical therapists, something as simple as encouraging a patient to use ice can really go a long way. And some athletes know this and they've been doing it before they get to see us. And some really are surprised that that's that's an option for them for a pain management opportunity. So, you know, using that piece of our clinical brain to be able to give them those little pieces of advice can be seem like not a huge deal, but could really go a long way in the long run. And then that kind of, you know, boils in with the poor health literacy. You know, some some folks just really don't have much experience with activity, with exercise. So getting them in early and really being able to understand where they're coming from and understand their background with, you know, their past medical history, knowing what their their goals, their hobbies, their demands at work are can be hugely beneficial for us to know early on so that we can develop a plan of care that not only is going to be, you know, our idea of ideal, but also realistic for them to to carry out. And that boils right into with transportation barriers. Some of our patients will get the referral from a physician and then they need medical transport. And unfortunately, that leads to some delayed starts of care, which obviously hinders their progress a little bit. And it ends up with a longer a longer plan of care required for them to get back to what they need. And then the fun insurance challenges that we're all up against in the world of medicine that can also be a factor for limiting how many physical therapy visits that an individual an individual may get. You know, I always tell my my physician colleagues that as soon as you see a patient, I don't care if they're in a splint. I want to see them because I can start working on core and hip stability exercises in a non-weight bearing position from day one as long as they can tolerate it. Right. But there is that hurdle of, well, you may only have 10 insurance visits for a calendar year. So that's another barrier that some some patients may be up against as well. So I thought that was kind of important to mention on this call because it's it's really nice to have good communication between physician and physical therapist when you're treating these folks, which leads me to my teamwork is the dream work spiel. So early referral not only is an early referral helpful for us, but, you know, at least where I'm currently employed, we have a lot of other resources that we could suggest. So as an example, if we were to have a stress fracture patient, I've dealt with this a lot in the past because I work with a lot of runners. You may get a stress fracture and then you have a suspicion that there might be some sort of eating disorder and they're not going to tell you on the first day in most cases. Right. They might not tell you the second day. And as a physician seeing them once every four to six weeks, they may never feel comfortable enough to say it to you. And some will. But you really build quite a good rapport with folks when you're seeing them once a week for six months in some cases. So oftentimes they're opening up to you in ways and you're able to assist them with getting some referrals from you that may be appropriate for them, whether it's a referral for a nutrition consult, referral for sports psychology, all of the things that can help them, you know, not only heal better biologically, but also to heal better mentally. So like I said, my spiel is to try to get them in as soon as possible. And then I did put a couple of case examples on here and I didn't go into much detail because I figured we might be able to build some conversation on some of the other presentations today as well. But, you know, currently on my caseload, I have a variety of fractures. So I see a lot of conservatively treated fractures. I see less, but still a good number of operative management. And then I see a very good chunk of stress fractures. And I won't get into stress fractures too much unless somebody really wants to chat about it, because I feel like that could be a presentation in and of itself. But I really wanted to highlight here the fifth metatarsal base fracture that I have right now. This is actually a 25 year old woman. It was kind of a unique mechanism of injury. She was sitting on a call. She works from home. She was sitting kind of in like a tailor set. She went to go stand up and her foot was numb from sitting on it and she fractured her foot. And I mean, 25 years old, it's like, wow, that's kind of unique for me. I never had anything quite like that. But I put these dates down because this is sort of how, you know, how in an ideal world the plan of care would go. So she went to urgent care on October 7th of this year. She was seen by an ortho specialist on the 10th. They put her in a boot for a couple of weeks and then she was referred to PT on the 24th and we were able to get her in on the 30th. So she's actually doing exceptionally well now. At this point, she's she's pretty much doing everything that she wants with the exception of running. And, you know, for return to run and return to sports, we do actually have some criteria that we use in our clinic for all foot and ankle injuries. So not necessarily just with fractures, but it carries over across the spectrum. So I'll be taking her through that return to run progression here at our next visit because she's doing exceptionally well and her fracture has been shown to be completely healed through x-ray so that's reassuring. On the operative side, I have kind of a unique situation as well and I think this case example really provides a good example of how early intervention can really make a huge difference. So when I got back from maternity leave, I had these two folks on my caseload almost like back to back and one of which was the five week there. So I evaluated her on, or excuse me, this was the gentleman. So this was like a 69 year old male that was referred or was seen by ortho in September and then I saw him in November. So again, it's still a pretty good chunk of time but he had a trimalleolar fracture. So between, you know, having the surgery, recovering from that, and then being referred and seen by PT, that's a pretty like standard plan of care. He is actually discharged from my care at this point. He still has some range of motion restrictions but unfortunately he had a comorbidity of a ACL tear on the same side that he is now going to be having addressed now that he has been cleared from his ortho doc for his foot. But he reported hardly any symptom, any functional limitations due to his foot. Now, yes, I'm sure a lot of that was overshadowed by the knee being his new major factor. He felt very stable, his pain was minimal on his ankle, so he is pretty happy. The second case there was essentially the same and, you know, no two patients are identical but trimalleolar fracture was a woman who had the fracture in the ORIF on the 17th of July but I didn't see her in physical therapy for four months. And I just saw her earlier this week and she is very stiff still. I've been working with her now for about six weeks, right? So we've been doing a lot of joint mobilizations, a lot of mobility work to restore even just sagittal plane movement for her. So dorsiflexion, plantar flexion is pretty poor. It was a work-related injury so there were the complications of it being a workman's comp case and everything had to be approved and I think that that held up the triage a little bit of this patient case and, you know, to no favor of anybody unfortunately. But she's a bus driver and she had just mentioned to me like two weeks ago that she hadn't drove yet. She was fearful of driving, not necessarily that she couldn't do it if she had to, certainly not for work but even her own personal vehicle. She was fearful of getting behind the wheel and that again just reminded me of the importance that that early intervention that we can have as physical therapists talking about with some of that pain, neuroscience education and providing them with the tools that they need to get over that as much as, you know, would be reasonable. So and then of course my stress fracture spiel here, like I said, we see a lot of these. I've seen a lot of tibial stress fractures. I would say it was probably the bulk of my stress fracture caseload but with these folks we have a very close relationship as part of the RUN team at the U of R working with some of our non-op sports med doctors and we've developed a bone risk injury stratification to allow for us to have constant communication between physician and PT as far as, you know, where is this patient. Some of the things that we take into consideration are from the physician side. They're giving us a scale of MRI severity. Also we're taking into consideration the location of the stress fracture when we're deeming it a high, medium or low risk patient. We're looking at their BMI and oftentimes a lot of this is we're looking for the lower end as part of our high risk and an individual that's been clinically diagnosed with any sort of eating disorder automatically goes in our high risk category. So we have a pretty standardized way that we treat all of our stress fracture patients depending upon those certain factors. Quite frankly it's usually a four week arrest period before we're seeing them but we are lucky enough to have access to an AlterG treadmill so we work up to that. Essentially we do four weeks of low impact training and then we kind of report back to the physician to let them know how they're tolerating that before we get the clearance for for overground running and some of these limb symmetry index tests that we do. And then I guess we'll have questions for the end and then there are my references. Thanks so much. Thanks so much Ashley that was great. Allie you about ready? Yes ma'am. Great. Alexandra Janis, Allie is a Nevada native who graduated from the Orvis School of Nursing at UNR in 2008 with her undergrad again in 2011 with a master's as a family nurse practitioner and more recently with her doctorate in 2023. For the last 13 years she has worked in a variety of inpatient and outpatient spine and orthopedic surgery roles. Recently she has opened an orthopedic walk-in clinic for the Great Basin Orthopedics here in Reno Nevada. Thank you so much. Thank you for having me. All right so good evening. Thanks for joining us. I started walk-in clinic practice for a orthopedic group here in town. Today we'll be discussing operational considerations, strategic planning, and challenges of an orthopedic walk-in. I have nothing to disclose. The objectives of this presentation aim to analyze target market and population needs, design an efficient and patient-centered care system, evaluate revenue opportunities and financial sustainability, build a team with the expertise to deliver quality care, plan effective outreach to attract and retain patients, and identify and address possible obstacles to success. Collectively these objectives aim to create sustainable and effective health care service model. Industry outlook. Orthopedic complaints account for nearly 60 percent of patient visits. Physician and APP shortages and lack of access to outpatient care increases demand on emergency rooms. Additionally about 7.7 percent of the population is uninsured and the population is aging leading to increased ER visits and lack of timely location appropriate care. Therefore orthopedic urgent care agencies can bridge the gap between lack of PCP availability and busy ER centers. A similar orthopedic clinic to mine documented about two times the growth in five years demonstrating that current markets are prime for such practices and now can be found nationwide. I thought I'd give you a little personal data. So this is actually a look at what my last three months have looked like and I actually joined a practice that had never had any APPs of any kind really. So I was kind of there first and I opened a walk-in clinic for them. So in the last three months I saw 535 new patient visits. I saw 649 established or follow-up patients and this could be patients from even the emergency room, established patients with new injuries. So they vary in code from 212s to 214s and then about 11 percent were no-charge or post-op visits because I do help the surgeons in the practice with some of their post-op care. So I average about 25 to 30 patients a day and as we all know their urgent care is feast or famine so someday I see eight and the max I've seen is 50 which was a big day but average about 25 to 30 and I work four days a week. So this is my typical payer mix for my area and location. So I see about 19 percent Medicare and then 15 percent Blue Cross and the rest tend to be other private payers. Another big payer is a mix of small private insurances, Medicaid population. We actually do quite a bit of Medicaid at our practice and then we do have cash pay options through HealthMe which really kind of bridges that gap between outpatient primary care but also ERs. So typical services rendered include extended operational hours to early morning, evening, weekend, and holidays. We treat acute and chronic complaints of the shoulder, above hip, hand, knee, foot, and ankle. Treatment of spine conditions is inevitable but pain management and concussions are controversial. Many spine conditions masquerade as upper and lower extremity complaints so it's important that staff are trained to recognize red flags in common presentations and treat accordingly. If the practice does not include spine or physiatry care or have physicians that treat like conditions it is important to create relationships within the community. In my practice I do not have a spine team therefore I have close relationships with Sierra Neurosurgery local group in Reno who accommodate my patients quickly if needed. Casting, DME, and injections all require skilled staff and substantial overhead costs to maintain supplies. In a new practice like mine items like highly individualized braces of the hand and foot are not mandatory as they are used so rarely and can be sent out to an orthopedic supply company. It is very important to make sure that you keep a variety of the most used equipment and ensure that stock is current. Imaging. Imaging is typically performed in-house and same day. Other services like same-day MRI or ultrasound guided injections can also be offered and advertised. However, I recommend using caution advertising for same-day MRI because patients will assume they can walk straight off the street into the scanner without a visit for any sort of reason. Staffing considerations. The front desk serves as our front line and triage. They get the best and the worst of our patients. It's important that they are timely, efficient, and trained to speak with our patients under stress. As a result of determining whether or not that patient is appropriate for my clinic I have instituted two different questionnaires that our front desk can hand to our patients for high energy and fall. These were based off of questions that our level one trauma center uses in order to stage and triage their own patients. I made that in order to reflect what I would and would not see. It's used to escalate care if needed. In the event that a patient flagged positive for any red flag that patient is brought back immediately for interview by either myself or my medical assistant to determine if the walk-in is an appropriate care site. If the ER is recommended the provider should document the conversation and that transport was offered to the patient. Medical assistants and nurses are used in a variety of different states. My girlfriend has a nurse whereas I here in mostly Nevada we use medical assistants for most of our room discharge, order entry, DME placement, wound care, and scribing at times. I've seen different facilities use these people in a role of ways as well as cross-training them to do multiple tasks but I recommend that you do not let this person get stretched too thin because they get burnt out quite easily. Nurse practitioners and PAs can provide expert care when they have deferred diffuse orthopedic knowledge and can be highly skilled at injections, aspirations, reductions, splinting, and casting. All APPs must be able to treat a population across the lifespan so I recommend using caution when hiring nurse practitioners to ensure that they're either family trained or dual certified for either adult and pediatrics. Further staffing considerations is x-ray and we all know this experience matters. There is nothing like having a skilled x-ray tech to help you especially when things are busy. They must be fast yet kind with positioning. It's also very helpful when they know alternative views if standard views are just not achievable. For instance, trying to get an axillary lateral with proximal humerus fracture or shoulder dislocation is nearly impossible but they could consider a Valpo type angle as an alternative. Casting and DME techs usually have a higher rate therefore a higher overhead given their additional training. APPs also should be proficient in placing their own splints and casts to ensure their quality however but I cannot underestimate how helpful they are during reductions. Now physicians and surgeons are the backbone of the walk-in. They should perform chart and x-ray reviews, provide on-call support, encourage regular education, and show an active interest in role. When this is accomplished I feel like the staff is better supported and they stay for longer. So, some operational considerations. Website clarity decreases patient confusion and decreases inappropriate patient visits. This is an example of my initial page. Then the patient is diverted to a scheduling option and able to choose from a list of conditions that I will see. I've included many resources at the end with examples of websites nationwide. Some are very comprehensive with detailed algorithms for helping patients decide if the walk-in or the ER is the right choice while others are fairly simple. When considering your own website you may want to consider listing other conditions that are hard stops which may include second opinions. I feel like nurse practitioners and PAs can perform second opinions but I personally feel like maybe that should come from a surgeon's perspective so that one is a bit controversial. Worker's comp, so work comp being able to fill out a C4 on their initial visit usually comes with a very detailed contract and is limited to certain pairs. Nail care like nail removal and then rib and chest trauma. I personally do not see ribs as chest x-rays are rather complex x-rays. Also, there's no physician in my practice that also interprets chest x-rays. However, I do not limit my nurse practitioners and PAs so if they feel confident in getting their own chest x-rays, feel confident to do so, I would not tell them that they could not do that. I personally just don't given liability. Hours of operation and staffing considerations. As service hours extend, it's important that labor laws are enforced. Do you consider cross-training your staff so that they can cross-cover lunch hours or do you just close? Do you have firm stop times where you stop taking patients so that you are not keeping the staff late? Do you consider staggering shifts in order to address these types of issues? These are all issues that need to be addressed when you're doing a walk-in. I will tell you that it seems like every patient comes in right at the buzzer when I'm trying to close and so how will you address that moving forward so that you avoid burnout and overtime? And I will say that while we all play a role in health care, ER and urgent care centers offer services and treatments that differ from a standard clinic. Patients usually present the worst pain of their lives. Anxiety is high and wait times can feel daunting. As a result, APP turnover is high. Physician support is important to demonstrate solidarity within the company, ensure adequate training, and understand and relate to site-specific stressors. One option to reduce the potential hierarchy that sometimes forms is to cross-train all APPs to fill gaps in the walk-in, clinic, or OR as needed. This ensures regular interactions with the clinic staff and education and sets the bar high for APPs across the board while providing opportunities for professional growth. I know this one is a bit of a hot-button topic which is imaging interpretation. It's been a commonly expressed concern amongst APPs. Without adequate training, company liability will increase. There are a few solutions which include regular retraining and educational seminars. This can be very casual, a check-in with a surgeon to review skills and discuss challenges or potential cases. Additionally, in another facility that I spent some time at and looked into, they actually have a physician that comes in the next day and is responsible for reviewing that urgent care's x-rays and just doing a very quick overview of the plan of care, looking at the x-rays and being like, yay or nay, or recommending follow-up to that APP if something was missed or maybe plan of care should have been altered. That physician does receive a small stipend for reviewing those x-rays from the day prior. Another option is to send all x-rays to radiologists to read. However, many billing questions will come up and reimbursement will go down. This would also serve as just a backup to the APP's original interpretation as we all know that those tests have the potential to take hours or days for a read. Other urgent care challenges include following up on imaging labs and aspirations. At times, I see 25 patients a day, up to 50 a day, but I teach all my new hires that once I order those tests, those tests belong to me until they are referred to the corresponding provider. So, I have encouraged all of my staff to develop protocols on how they're going to follow up on their patients and really make sure that they are not missing their big urgent tests. Chest x-ray interpretation does come with high liability. Again, I have gotten a couple chest x-rays in my lifetime, but those are the ones that I will send off to radiology for a second read and then therefore not get paid for that interpretation. Rib versus T-spine is always sometimes difficult to know. So, I usually start with the T-spine x-ray, and if it's not clear that it's truly thoracic and it could be related, sometimes I'll request that that patient goes to a general urgent care where a radiologist can read a chest x-ray for me and provide an opinion, just to make sure that I am not missing something more global. Also, what you'll see is abuse of the walk-in urgent care clinics for non-urgent or chronic conditions with time. So, the patients are going to love it. They get good care there, and we have good staff with good training. Why would they come and see their physician partner for their injection when we can do the same thing for them on a Saturday? So, this is the other thing that I saw at some of the websites is that the urgent cares will not see chronic pain more than six weeks. So, that's another option if you're really seeing abuse with chronic conditions and you cannot prioritize your acute injuries. Pain management, also very controversial. I usually say refer to your state laws and regulations, but most of them say you have to be able to establish a relationship with your patient. That is somewhat difficult to do in an urgent care because many times we treat you, and then we get you to a physician or surgeon that could potentially manage that for you. So, again, there are exceptions to every rule. In my clinic, I also see follow-up patients with post-op care, and sometimes those do require pain medications, also for fractures. I think that that is very appropriate, but usually do not do longer than a few days to seven days. Setting realistic patient expectations. So, this could mean that the patient is there. They have two hours to see you, and they want to be seen for bilateral shoulders, hips, knees, feet, and ankle. And so, I just don't think that that is appropriate for an urgent care. So, usually I do limit it to two body parts and say, what's hurting you the most and how can I help you? The only caveat I will say to that is if the patient does have an injury, has a fall, legitimately injures all of these body parts, many times we are going to have to be responsible for that. So, I do set the stage for follow-up and continued care. Many times we are, you know, putting them in braces or doing some preliminary stressing. We are making sure that everything, blood is flowing, all the red flags have been addressed, and then we are having that patient follow up with another team member in a few days to a week or two, whatever is appropriate. Surgeon expectations. So, did the urgent care provider do the right thing, even if it wasn't what you would have done? So, I came from a busy practice of roughly 30 surgeons with 30 nurse practitioners, and I got 60 different opinions in a day about an injury. And I will say that we did talk about just Weber B fractures today that have multiple different ways to manage it. And so, treating that patient based on an individual basis, but also the provider from the urgent care on an individual basis to see like, gosh, did they somewhat do the right thing? And also reminding yourself that hindsight's 20-20. Again, we see them when they have 10 out of 10 pain. Everything is a big deal. Everything is hurting. And in three days after we've calmed it down with anti-inflammatories and splinted it, the diagnosis is way more clear. So, I just encourage surgeons to say, gosh, did we miss it or did we not? And did we do somewhat of the appropriate thing? Again, being careful of advertising first thing day MRI. And it's really important to train our staff to recognize red flags and when it's appropriate to send to the ER. All of our new providers are so much more careful. They also have a higher rate of sending to the ER versus ordering extra tests. And I think that's a degree of normal until they get more comfortable and that will improve with time. But really reinforcing red flags and when to be mindful is important. So, expansion. So, I have a feeling that almost everybody has experienced an orthopedic walk-in. So, how do you set yourself apart from the general consensus? And I say, analyze your competitors. See what they're doing. See where they are not. And that's where you build and start a new clinic. Can you expand injuries or introduce specialized services? I think we're going to see a lot more with like weight-bearing MRI and CT or fluoroguided versus ultrasound-guided injections. I also think about just optimizing scheduling, leveraging your EHR to help you for patient tracking, branding. So, utilize website searching and also getting involved in local sports. I also think we're going to see a lot of bundled care services coming out with insurances, where you get just a radius traction, you get $3 in order to treat that. So I think we are going to be really kind of forced into some bundled payments. And so that's maybe a way to think about outpatient, ambulatory, orthopedic care, and how we can reduce costs moving forward. Here's all those websites that I went through at some point and what they look like, my resources. Thank you. Thanks so much, everyone. What a well-rounded panel we have. Let's see. We've got a couple of questions. Rich, do you mind if I just go through these real quick? It looks like we just have two on the Q&A. Oh, Ali, this one is for you. And it looks like you just answered that. Are we able to see your triage or screening questions used by the front desk, or maybe where did you get that? And I can actually type that in. OK. So what I ended up using is our level one trauma center has a red, yellow, green triage system for that nurse that comes in. And so I can kind of pull that up here. I'll talk and try and find it. So what that looks like is in the case that you fall from greater than 8 feet, that escalates your care. If you, let me show you. OK. I just found this here. So share my screen. This one. So this is very basic because it's to be filled out by the patient. And so did you fall? How far was it? Did you hit your head? Do you have any dizziness? Are there concussion symptoms? Are you on a blood thinner? Which one? Because if you're on a blood thinner and you hit your head, you need a CT scan. And I can't do that in my orthopedic clinic. Do you have chest pain, shortness of breath, difficulty coughing, seizing? Do you have any rectal bleeding? So this kind of, or spine pain, new or incontinent since the time of your injury. So ruling out red flags, again, quadroquina syndrome. So if they do flag positive for any of these, that questionnaire, my front desk just continues to check in as normal. They don't say, oh, we can't see you. They just bring that questionnaire to myself. I usually bring that patient back and I'm like, well, did you really hit your head? Or are you just, is this your baseline or something? And do a little bit better history with them. If they are truly flagging positive for any of these symptoms, I usually do a hard stop there. And I say, with respect, ma'am, you need a higher level of care. May I get you a ride to the ambulance? And then they either say yes or no. And then I get them out of my office. I also have one for motor vehicle accidents. So same thing, like if, were you wearing a seatbelt? Did your airbags deploy? Did the windshield break? Or was it a motorcycle? Those are also escalated. Just like our trauma designation at our hospital. Correct. Right. EMTs use that as well, right? Like in the field, whether to go to a local hospital or a trauma center, at least that's what we do in our area here. OK, this one is for Ashley. Someone is wondering if you ever use a lymphatic approach to manage edema in the subacute stage. Yeah, so I guess I'll start off by saying I don't have my lymphedema certification necessarily. There is a subspecialty physical therapy field that you could do a lymphatic certification. So I don't know it to that degree. However, with more of the acute and subacute, I do like to use that GameReady device a lot, which, like I said, it's a vaso-pneumatic machine. So it pumps ice-cold water through a sleeve. The sleeve compresses. And usually, I'll have folks on there for somewhere between 15 and 20 minutes to reduce that swelling. And I think a lot of it is making sure that the patients are compliant with something that they can do at home as well. So of course, they're not going to have the fancy machine, but I'll always encourage the price protocol. The other thing that I like to look at, especially with my foot and ankle patients, is day one during the evaluation, I'm always taking a figure of eight measurement with a tape measure. That's something that I do every visit to ensure that their swelling is stable or reducing. I use that as a way to keep my really gung-ho athletes from overdoing it on their foot and ankle and coming back and seeing me and saying, oh, no, it feels great. It's a little swollen. My shoe doesn't fit right anymore. And so then we can take the figure of eight measurement, and then I have to go into my, the swelling is going to inhibit your muscles. Unfortunately, that muscle inhibition is going to prolong your recovery. So even though you may feel good, things aren't looking good, and we need to slow it down a little bit. I've also shown people just some retrograde massage and elevation, just very light massage to try to reduce the edema. So yeah, I think there's definitely a lot to be said about getting those early stage healing principles down. Rich, that was it for the Q&A that people typed in. Well, I have one or two questions, and the faculty can ask some questions also. But for Dr. Mueller, sometimes I see fifth toe fractures, and they're angulated. And usually it's somebody who stubs their toe walking around their house at night. But often, when you look at both feet, you can see the toe is angulated. Do you have any tips or tricks to reducing that in the office, and how often do those patients need to go to the OR? Well, that's a good question. I honestly haven't come across it yet, and maybe they've seen me and I haven't seen them. And as I said, I don't particularly like buddy taping or that kind of splinting, but I guess I've seen similar techniques for like postoperative bunion type surgeries, where you kind of put a tongue depressor on the border of the foot to kind of prevent the toe from, well, in a bunion, you kind of prevent it from crossing back over. But I guess with a, I'm guessing with a fifth toe, it comes in kind of angulated laterally. So I guess I would try to use that tongue depressor as a lateral buttress and keep it straight. I don't know if there's anything commercially available on the market. I suppose if it's interfering with shoe or ear, it wouldn't be that hard to pin it straight in the OR. And I would just talk to the patient about goals of care, if that's something they're interested in, make a shared decision. Yeah, I've had some of those fractures and I would like to hear what Dr. Stenquist thinks, but I've been able to close, reduce them. And sometimes that's enough for them. It can be quite difficult to pin those fractures in the OR, or at least in my hands, I find it difficult. They are. I don't know if Dr. Stenquist has any thoughts on that fracture, which will definitely come into the office. No, I'm with you. Usually it's non-operative. I don't have a lot to add on that one, but they can be really hard to reduce. Sure. Another question for Dr. Stenquist, with the Weber bees and some of these other injuries that we see, is there any role for casting any of these patients for a short amount of time, or do they all go into a boot? And is there any particular patient that if you're worried that it might not be the right path that you put in a cast instead of a boot? Oh, absolutely. In that study I showed on the JBGS 2023 article, the protocol involved initial x-rays, followed by three to seven days of casting, and then weight-bearing x-rays in clinic after that. So the thought was that with the casting, they would calm down the pain and make people more able to tolerate the weight-bearing x-rays in clinic, which I think is interesting. It's not something that we do at all. But I think there's definitely a role for that. The kid that I showed, the gymnast, who had the ankle fracture and had sort of shared decision-making, I offered him a cast for a short period of time. He didn't want it. He wanted to be able to shower. And that was sort of part of the shared decision-making that drove me to manage him just in an air cast, but it made the weight-bearings tolerated for his... You know, I knew the data that said it would most likely be okay, but we would follow him closely for the first few weeks and make sure he was in this place and then he's good to go. So I definitely... And then I've even managed... I've managed a 92-year-old with a trimel and a cast, and it's really painful, but they were not... Their skin was horrible, not a surgical candidate, and you're changing the cast every two to three weeks, and you're gently molding it yourself and then getting pre- and post-x-rays, and it's... I mean, if you can keep the tails under the tibia and get the fibula to heal at a reasonable length, you can manage anything in the cast, as long as the patient's not developing... There's in your... Check... Sorry, check them carefully, so... Yeah, I think casting sometimes can be very helpful, and especially if it's a patient you don't necessarily trust to be in their boot at all times. And anybody else can jump in for questions, but I'll ask another question or two, unless anybody has... I lost my audio there, so I apologize if you ask me a question. So, these injuries, the show parts injuries, where you have an injury to the tail and avicular joint and the calcaneocuboid joint, I've always found they take a long time to heal. Do you have any feelings on whether they are... They take longer to heal than a regular ankle sprain, and whether you'd change your plan at all with them? Yeah, absolutely. I actually, I have the same feeling. I think they're injuries to multiple joints. I think they're very painful. They're not a typical ankle sprain. We call it a foot sprain, but I think it's a complex injury that may be associated with an ankle sprain as well, like an injury to the ATFL or the CFL as well. And I, in general, if the patient has normal sensation, I still tend to manage them in a tall Aircast boot, but if I see that the patient is particularly sore or I'm worried at all about their sensation, or I just want to have another look at them in a week, I'll put them in a splint and make a knot weight bearing, and then we come back to the clinic and just see how they're doing. And those are the patients too, that sometimes you need to get a CT scan to rule out midfoot fractures or something else that you might be missing. I just worry that when there are certain patients who have excessive bruising or swelling or tenderness that just doesn't match their injury pattern, and I have a low threshold to get a CT on those patients too. There's a question in the chat box. I mean, this is about using aspirin for DVT prophylaxis for, we'll say non-surgical, and we'll also say non-Achilles, because I think the evidence is pretty clear that if there's an Achilles, we should be using aspirin for that, but we'll say non-surgical, non-Achilles, if someone's in a boot, do you guys use aspirin? Yes. Same. So the chest guidelines don't recommend it, but I absolutely do. And we have a trauma protocol at our place that we developed based somewhat on, there was a JBJS consensus article on this last year, I think, and the evidence is not convincing for it, but we err on the side of caution. Also the PREVENT-CLOT trial, that was all operative fractures, so I think it's a great question about non-operative fractures. We're doing 81 aspirin twice daily for four weeks with anything lower extremity, but I'd be interested to hear what other people do. I do the same thing. When we get up into the above the knee, we switch to Lobinox, but we do aspirin below the knee. Okay. All right, it looks like that's it. Are any of you guys using like a vitamin C protocol for anything you immobilize, similar to what's been done in the hand literature for immobilizing upper extremity fractures to help mitigate CRPS? I don't know, I don't think I'd be interested. We looked at that literature when we were, we had a real narcotic problem here in Nevada eight or nine years ago, and really got forced to start looking at multimodal pain management, and we pulled that literature from the hand folks, and they also used quite a bit of sort of gabapentin as a, you know, like a one-week preventative treatment. Preventative, post-operative, and so instead of doing the vitamin C, we just did the week of gabapentin. I don't know why, I don't have a great answer for that, to be honest with you, but we looked at that, and there's good evidence for it, and we just haven't adopted it here, but we saw a huge improvement by putting folks on gabapentin, or Lyrica. Lyrica's for- Just for a week? Yeah, we do it for a week, and then we tell patients, listen, if you start to get this rebound pain, we're really fast about refilling it. Our medical assistants know if they come, you know, if they call in with like, oh, I'm having all this extra pain, and they've just stopped their gabapentin, it's likely they just need it a little bit longer. I would say about 30% of our patients continue that gabapentin for another few weeks. What dose of gabapentin are you doing, and the frequency, if you don't mind me asking? Well, for sure, we start with 300 milligrams at night, and for our kids, we'll do 100 milligrams, although I've seen some slip by at 300, but I like to do 100 milligrams for the teenagers, but for our adults, we do 300 at night, and I would say overall tolerated pretty well. And do you do that for both operative and non-operatively treated things that you immobilize? No, great question. We probably should think about it, because we certainly see a lot of CRPS, even in the non-operative folks, so those ankles. I mean, if you're a girl and you're a teenager, you're gonna get some sort of hypersensitivity, it feels like for us, but I will say that all of our medical assistants are well-trained, and they have a very low threshold for just asking us for gabapentin for patients when they call in with a pain out of proportion situation, so we give it a lot around here. Do you have an age restriction, elderly-wise? We don't, we don't. I came from primary care, and when we first, you know, I was like, well, we play a little fast and loose with this gabapentin, but people do pretty well with it. I absolutely counsel them, though, right? Like, this is a far- Yes, yes, yes, for sure. You know, a depression risk for my teenagers, for sure, but yeah, it's worked pretty well for us. Okay, good. A question for Ashley. I had a question. Are you, on some of these patients with the avulsion fractures, whether it's an anterior process of a calcaneus fracture or one of these other sort of ankle sprain adjacent diagnoses where we have some fractures in the foot, but the patient is pretty quickly put into some functional rehabilitation, do you find that those patients recover more slowly than the real true ankle sprain patients? And when they are struggling, do you, like, what do you do next? I worry about some of those patients who are like, you know, I was playing basketball when I did this, and, you know, it's been three or four months and I can't play basketball, but I can do almost everything I want. I just can't get that last way back. I've had one or two of those, and I, you know, I don't know if I'm doing them a disservice. I've even gotten so far as to get an MRI, and there's nothing obvious there that was missed or needed surgery, but. Yeah. I'm sorry, Dr. Sinclair, was that a question for me or for Dr. Mueller? Yeah, just in general about, like, those patients that have these, like, ankle sprain adjacent diagnoses, but they're not, they've got fractures, do you find that they have a harder time recovering than patients with true ankle sprains? Or if you have someone who's struggling like that, what do you kind of, what do you do as next steps? Do you send them back to the surgeon or the sportsman doc, or, you know, do you try different approaches with them? Yeah, that's typically what I would do is if I'm not seeing success with our return to run screen. So just to kind of give you a little bit of a rundown for whether it's a fracture or an ankle sprain, we have criteria that we expect our folks to be able to pass before we will clear them for running. So essentially we're looking at their closed chain dorsiflexion range of motion to ensure that that's symmetrical between sides. We want to see at least seven center meters doing a knee to wall stretch to make sure that they've got the mobility in that ankle joint to be able to accept demands of running. We're also doing a limb symmetry index for their calf strength. So typically we're doing it with single leg heel raise and also looking at glute med for the hip. So we're making sure that they have adequate strength side to side, and then usually there's a component of agility, so we're doing like a little bit of vertical hopping. And then traditionally what I'll do is I'll have my folks start with a walk run progression. So if they're looking to get back into basketball, they've got to be able to run in order to play basketball. So they'll do the return to run progression. And I base that, you know, we have some protocols that we've developed as a run team and a foot and ankle team at the facility where I work. But quite frankly, I've gotten to the point where I just sort of use my personal judgment with how much run walking they should be doing because everybody's a little different. So I just take into consideration what their prior level was. And usually if they are struggling to get through that return to run progression, I'm messaging the doctor to say, hey, I know their long-term goal is basketball. We've got all of our criteria that we need, but for whatever reason, the impact of running is still not going so well. That's usually when I'm reaching back out because I wouldn't want to clear them for any of like the agility testing that we would do for a return to basketball until they've demonstrated that. So usually if there's some sort of malunion or nonunion, of course, you're going to catch that in an x-ray is my understanding. But sometimes if there's something else going on, like for example, I've had some folks in the past that have been referred to me for an ankle sprain and they end up having some sort of foot sprain as well. And those usually get caught somewhere in that phase. Usually they're able to pass that functional portion, but then when you start the impact, things go south quick. Awesome, thank you. Yeah, of course. Thank you. We have one other question in the chat. Any recommendations in the situation of a suspected lisp-frank injury with apparently normal x-rays, but without access to weight-bearing x-rays or a CT scan? Dr. Meehan. I guess my question would be, is this in their urgent care setting or a surgeon's office, if it's an urgent care and you're kind of suspecting it, just splint it and send it our way. And don't worry about it. If you're in the surgeon's office and you're trying to make a determination, you can do a stress exam or you do a forefoot abduction test or a forefoot abduction stress examination if you can't weight-bear them or don't have a CT. And that'll show some widening if it's truly a lisp-frank injury. But if you're at all suspicious and you're in an ER or urgent care setting and you don't have access to that, just splint them, make them not weight-bearing and send them our way and we'll take care of it. I think we likely have time for one other question. Anybody from the panel have a question? If not, I'll ask Ashley. What are you... Oh, go ahead, Dr. Sheldon. I wanted to know if you guys are doing gravity stress views or any stress views. I still like them and I still do them routinely and I'm more likely to take somebody to the OR with a gravity stress test, even if their weight-bearing x-ray is more normal appearing. Go ahead. It makes a great point about, there's still a lot of unknowns around that. I'm sorry, go ahead. I said, I usually do a gravity stress and if it's like overtly wide, I'd probably take them to the OR. But if it's subtle, I'll probably let them wait. I'll probably put them in a boot and let them weight-bear on it for a week, bring them back, get weight-bearing x-rays. And then if it's subtle, I'll take them to the OR. But if it's subtle, I'll probably put them in a boot and get weight-bearing x-rays. And if things are moved, well, writing's on the wall. It's an easy conversation to have with the patient. I'd like to thank all the speakers. They were really wonderful talks and we thank Dr. Stankiewicz for coming from OTA and being part of our webinar. Hopefully we can do some other joint webinars in the future. And thank you for tuning in today. Thanks everyone. Thanks everyone. Thank you.

ambulatory fractures

outpatient care

AOFAS

OTA

foot and ankle surgery

midfoot fractures

forefoot fractures

fifth metatarsal

ankle fractures

orthopedic trauma

rehabilitation

physical therapy

patient education

orthopedic clinics

interdisciplinary care