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I have a 32 female patient with mild osteoporosis due to long term prednisolone use present with acute heel pain yesterday. She is a nurse with many allied health friends (oh joy) that arrived with x-rays and in an oversized cam-walker. She has a very high pain tolerence threshold and a past history of fractures due to bone density. She has asthma and many allergies, all of which are being managed well.

She had been getting dressed when she felt something snap in her left foot 7 days ago and since could not put her heel to the ground and had been toe walking since. On palpation she had no pain through ROM of the STJ or on plantar fascia ROM however was extremely painful on palp in the area of the medial calc tuberocity. The x-ray report was NAD however when we looked at it, it appeared as it there is a hairline fracture that is non-displaced, about 3mm in length at the medial tub of the calc.

At the moment I have got her into a more appropriate sized Cam Walker with the plan to continue this for the next 6 weeks however she has just rung me to tell me she got no sleep in the cam walker and can she just use an ankle brace a night. She is able to walk normal with minimal pain in the walker.

I am unsure with the management of fractures, especially in this part of the foot and if this is appropriate for night.

She is not working at the moment as she is nursing her palliative father so she needs to be alert and mobile so putting her in a cast or telling her to get used to it at night just isn't appropriate.

Would an afo at night help or just the splint or does this require further referral/managment? Any advice?

__________________
Cheers,
Cylie.... in a permanent state of confusion

Cylie:

I would suggest that you put her in the cam walker brace only while weightbearing. She doesn't need to wear it while lying down or sleeping. You may want to get either a three-phase bone scan, a CT scan or MRI scan to rule out calcaneal stress fracture. A woman at this age would probably need 6-8 weeks to heal the fracture and may need foot orthoses to help return to normal weightbearing activities sooner.

Hope this helps.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Thanks Kevin,

I have given her a referral for a MRI (sorry, should have added that in) and got a LOOK from her about the need for it. I unwilling agreed that she would ring and book it after 6 weeks if we had minimal improvement after immobilization. I will increase her wear time to 8 weeks though after your advice.

She already has orthoses that have been every effective in shock aborption and she is very compliant with excellent shoe choices. Her latest pair are about 6 months old. This has been her first foot fracture. The past have been stress fractures in her spine and a few finger fractures.

Let this be a lesson to all those osteoporitic patients.....sit down to put your underwear on!!!

__________________
Cheers,
Cylie.... in a permanent state of confusion

Cylie:

I would not necessarily have a woman like this wear the brace for a full 8 weeks. The longer she is in the brace, the weaker her leg will get and the more osteoporosis she will develop in that foot and leg. Only keep her in the brace as long as it is necessary until she can walk comfortably in her shoes and orthoses.

In addition, this woman sounds like she needs a referral to her general practitioner for bone density evaluation (DEXA scan) and possible treatment of her osteoporosis. They may suggest use of one of the anti-osteoporotic medicines such as Actonel, Boniva, and Fosamax. These medicines have, in my patients, been quite effective at reducing their risk for further pathologic fractures to their skeleton.

Hope this helps.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Thanks for that Kevin, I did wonder about that.

She is on a range of med's including fosamax to reduce her osteoporosis and it is being well managed by her specialist. This includes yearly bone density studies. She has very brittle asthma and is regularly in hospital despite doing everything right. Irony is that she is a asthma educator. Prednisalone side affects are nasty but it keeps her alive.

Appreciate your help.

__________________
Cheers,
Cylie.... in a permanent state of confusion