Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Talus


Related Terms

  • Osteochondral Fracture of the Talar Dome
  • Shepherd Fracture
  • Snowboarder’s Ankle
  • Talar Body Fracture
  • Talar Fracture
  • Talar Head Fracture
  • Talar Neck Fracture
  • Transchondral Fracture of the Talar Dome

Differential Diagnosis

Specialists

  • Emergency Medicine Physician
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Sports Medicine Physician

Factors Influencing Duration

The type and severity of the fracture, age of the individual, complications of the injury, ability to modify work activities, and rate of healing may affect disability periods.

Medical Codes

ICD-9-CM:
825.21 - Closed Fracture of Talus
825.31 - Open Fracture of Other Tarsal and Metatarsal Bones, Astragalus

Overview

© Reed Group
The human ankle is a complex joint that consists of three bones: the tibia, the fibula, and the talus. The three bones work in unison to provide the range of motion necessary for daily and recreational activities (e.g., running, jumping, walking). The range of motion of the ankle joint is unique, and medical scientists have not been able to successfully duplicate the joint with an implant.

Fractures of the talus are rare but are often associated with long-term disability. There are four main types of talar fractures. Neck and body fractures are the most common talar fracture and may be associated with subtalar dislocation. The vast majority of talar neck fractures are associated with sudden bracing actions of the foot, as when applying the brakes forcefully during a motor vehicle accident or in falls from a height (Crim). Lateral process fractures (snowboarder's fracture, snowboarder's ankle) occur primarily as a result of snowboarding accidents when the foot is dorsiflexed and inverted. These fractures are frequently confused with an ankle sprain. Posterior process fractures (Shepherd’s fractures) are caused by damage to the posterior process of the talus by either sudden extension of the foot so that the forefoot is depressed relative to the heel (plantar flexion) or by repetitive motion (especially in athletes or dancers). Talar dome fractures are caused by small cartilaginous avulsions or body chips at the site of tibial articulation and are commonly associated with ankle inversion injuries.

Incidence and Prevalence: The incidence of ankle injuries is 1 to 10 million per year, and 15% of these injuries are ankle fractures (Iskyan). Talus fractures make up 3% to 5% of all foot and ankle fractures, with 50% involving the talar neck (Crim).

Source: Medical Disability Advisor



Causation and Known Risk Factors

The risk of talus fractures is increased among young athletes and individuals who experience a motor vehicle accident or a fall from a height. Individuals who snowboard have 17 times more risk of a lateral process talus fracture than non-snowboarders (Chan).

Men are twice as likely to sustain an ankle fracture as women, but women older than 50 years of age have a higher incidence of ankle fracture (Iskyan).

Source: Medical Disability Advisor



Diagnosis

History: A complete medical history is obtained, including prior fractures or orthopedic surgery, underlying medical conditions (especially bone disease, neoplasia, arthritis), medications taken, allergies, and occupation. A description of the mechanism of injury, including the magnitude, location, and direction of impact, is helpful. Individuals may report a traumatic event such as a motor vehicle accident, fall, or jump from a height. Individuals usually complain of swelling, stiffness, and pain with ankle motion and weight bearing. The individual will usually relate a history of twisting the ankle or foot, jumping and landing on the foot, or jamming the foot and ankle. The history is specific to the type (location) of the talar injury.

Physical exam: Findings on examination and associated injuries are specific to the type (location) of the talar injury. There may be significant soft tissue trauma, including open wounds of the ankle. Careful observation and examination of the entire foot and ankle are crucial in the detection of associated injuries. Deformity, swelling (edema), and bruising (ecchymosis) may be noted on observation. The exam may reveal bony tenderness to gentle touch (palpation) and an inability to bear weight. Limitations of active and passive range of motion should be noted. A thorough neurovascular examination is essential.

Tests: Although standard 3-view ankle x-rays may reveal the fracture, many talar fractures are subtle and easily missed. Specific views such as a Broden view may be ordered, depending on the type (location) of the talar injury. Some fractures of the talus may be difficult to detect on x-ray. Although a CT scan may show occult fractures, MRI scan is the imaging study of choice if the diagnosis of a fracture is in question.

Source: Medical Disability Advisor



Treatment

Treatment varies with the location and type of talar fracture. Talar head fractures that are nondisplaced are treated by immobilization with below-the-knee casting or a fracture brace for 6 to 10 weeks. Displaced talar head fractures require open reduction, internal fixation (ORIF).

Nondisplaced neck and body fractures are treated with a short leg cast or fracture brace and no weight bearing for 6 to 10 weeks. If the fracture exceeds the criteria for nonoperative management, surgery may be necessary. Displaced neck and body fractures usually require ORIF.

Treatment of lateral process fractures depends on the size of the fragment and the degree of displacement. Nondisplaced fractures should be immobilized with a cast or fracture brace, and weight bearing should be avoided. Displaced lateral process fractures usually require ORIF.

Initial therapy for talar dome fractures includes immobilization without weight bearing, followed by arthroscopic débridement, subchondral drilling, synovectomy, and bone graft, depending on the severity of the injury.

Posterior process (Shepherd) fractures are treated by immobilization with either partial or full weight bearing.

Source: Medical Disability Advisor



Prognosis

Most talar fractures eventually heal, but the recovery may be slowed dramatically by complications. Accurate reduction is important because any misalignment in the bones and joints can produce arthritis when movement and activity resume.

Talar head fractures generally have a low incidence of osteoarthritis of the talonavicular joint.

Talar neck and body fractures are usually treated with ORIF and have a high incidence of avascular necrosis and osteoarthritis of the ankle and subtalar joint.

Both nondisplaced lateral talar process fractures treated with below-the-knee casting or bracing and displaced lateral talar process fractures treated with ORIF yield a high proportion of individuals with residual subtalar joint pain.

Long-term follow-up of talar dome fractures shows that despite the type of treatment, most individuals will have chronic ankle pain and swelling.

Posterior process (Shepherd) fractures treated with immobilization and partial or full weight bearing generally have a good outcome, with the possibility of some residual pain and stiffness.

Source: Medical Disability Advisor



Rehabilitation

The goals of rehabilitation following a fracture of the talus are to decrease pain and to return the individual to full function with a painless mobile ankle. The duration of treatment is related to associated soft tissue involvement and type of fracture.

The main focus of rehabilitation should emphasize restoring full range of motion, strength, proprioception, and endurance while maintaining independence in all activities of daily living. While the resumption of pre-injury status is the goal, the type and location of the fracture on the talus will affect the speed and success of rehabilitation. Protocols for rehabilitation must take into account the stability of the fracture, as well as the type of fracture management (operative, nonoperative), and must be guided by the treating physician.

In order to decrease pain, local cold application may be beneficial. Edema, a common problem, may be controlled using modalities such as cold packs (Salter) and compressive wrapping. To prevent complications of inactivity, individuals should be encouraged to continue functional activities that do not compromise the status of the fracture.

Non-displaced fractures may progress to weight bearing after 4 to 6 weeks (Easley). Because residual impairment is common with displaced fractures of the talus, these are usually surgically repaired (Easley). If the fracture required surgery, the treating physician will dictate the rehabilitation protocol.

When appropriate to return the individual to functional activities, gait training using appropriate assistive devices is indicated to promote independent ambulation. Therapists should instruct the individual to progress from walker to crutches to cane according to his or her ability and weight bearing status. If the ankle is splinted or casted, range of motion exercises of the adjacent joints may be beneficial unless contraindicated based on fracture stability. After splint or cast removal, range of motion, proprioceptive, and strengthening exercises should be started at the ankle and forefoot. Exercise intensity and difficulty should be progressed until full function is evident.

Bone healing may occur within 6 to 12 weeks; however, the bone strength and the ability of the bone to sustain a heavy load may take up to several years (Chapman). Once healing has occurred, the individual may resume activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The resumption of heavy work and sports should be guided by the treating physician.

Additional information may provide greater insight into the rehabilitation needs of these individuals (Fortin; Thordarson).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Talus
Physical TherapistUp to 16 visits within 8 weeks
Surgical
SpecialistFracture, Talus
Physical TherapistUp to 12 visits within 6 weeks
Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Avascular necrosis is a serious complication that develops when the blood supply to the talus is disrupted. Ninety percent of talar avascular necrosis occurs with talar neck fractures. Degenerative joint disease (arthritis) is another possible complication. Left untreated or undetected, talus fractures lead to nonunion and chronic pain. Untreated osteochondral fractures may develop loose bodies within the joint. The incidence of long-term complications increases with age (Iskyan).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Use of a cast, walking cast, ankle brace with crutches, cane, walker, or wheelchair will be necessary for a period of days to months. Therefore, work restrictions may include no prolonged standing (weight bearing), no walking, no kneeling, no climbing of stairs or ladders, no driving, and no operation of heavy equipment. Frequent rest periods to elevate or ice the ankle may be necessary.

Safety issues concerning work in a confined space or on uneven or slick surfaces should be considered.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Has diagnosis of fractured talus been confirmed by imaging study (x-ray, CT, MRI)?
  • Has individual experienced any complications related to the fracture or treatment?
  • Does individual have any underlying conditions that may affect recovery?

Regarding treatment:

  • What type of fracture occurred (displaced, nondisplaced, lateral process, posterior process, or Shepherd fracture)?
  • Where was fracture located (talar head, neck, body, or dome)?
  • Did the fracture require ORIF?
  • Did treatment include casting or a fracture brace?
  • Has arthroscopic procedure been performed? What interventions were required?
  • Is individual participating in physical therapy?
  • Is individual compliant with weight-bearing restrictions?

Regarding prognosis:

  • Has recovery been affected by complications or residual pain?
  • To what extent is function impaired? What else can be done?
  • Is individual following prescribed rehabilitative therapy

Source: Medical Disability Advisor



References

Cited

Chan, G. M., and D. Yoshida. "Fracture of the Lateral Process of the Talus Associated with Snowboarding." Annals of Emergency Medicine 41 6 (2003): 854-858. MD Consult. 1 Jun. 2003. Elsevier, Inc. 5 Dec. 2008 <http://home.mdconsult.com/das/journal/view/42015338-12/N/13418711?sid=289246352&source=MI>.

Chapman, Michael W. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2001.

Crim, Julia. "Talus, Fractures." eMedicine. Eds. Amilcare Gentili, et al. 30 Dec. 2008. Medscape. 18 Mar. 2009 <http://emedicine.medscape.com/article/396568-overview>.

Fortin, P. T., and J. E. Balazsy. "Talus Fractures: Evaluation and Treatment." Journal of the American Academy of Orthopaedic Surgeons 9 2 (2001): 114-127. National Center for Biotechnology Information. National Library of Medicine. 5 Dec. 2008 <PMID: 11281635>.

Rahul, Banerjee, et al. "Chapter 61 - Foot Injuries." Skeletal Trauma. Eds. Bruce D. Browner, et al. 4 ed. Saunders, 2008.

Salter, Robert, ed. Textbook of Disorders and Injuries of the Musculoskeletal System. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 1999.

Thordarson, David B. "Talar Body Fractures." Orthopedic Clinics of North America 32 1 (2001): 65-77. National Center for Biotechnology Information. National Library of Medicine. 5 Dec. 2009 <PMID: 11465134>.

Source: Medical Disability Advisor






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