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Crush Injuries to the Forefoot

John Kwon Foot and Ankle Surgeon at the Mass General HospitalJohn Kwon, MD is an orthopaedic surgeon at the Massachusetts General Hospital, Boston and a member of the Foot & Ankle Service, as well as the Partners Orthopaedic Trauma Service. Dr. Kwon specializes in foot & ankle fractures, sports injuries and correction of foot & ankle deformities.

Effect of a Steel Toe Cap

Crush injuries to the foot are a common workplace injury, causing significant morbidity, disability and lost wages. A report by the Bureau of Labor Statistics estimated that more than 60% of workplace injuries involve the musculoskeletal system, and 10% of these are foot and ankle injuries (1).

Regulatory bodies like the Occupational Safety and Health Administration (OSHA) were developed to protect the work force and to establish guidelines to improve work conditions and safety standards. Since OSHA’s inception in 1971, occupational injury and illness rates have declined 40% while the American work force has nearly doubled. However, while the total number of days lost from work due to occupational injuries has declined, the percentage of foot and ankle injuries has remained relatively constant.

Although steel toe capped boots are commonly accepted as a protective measure, there are no published data about the protection afforded by a steel toe. There is a common belief that a significant crush injury sustained while wearing steel toe capped boots results in amputations of the toes and that not wearing them may be safer. This belief is so pervasive that a popular television show, Myth Busters, investigated this (2). We studied the influence of the steel toe cap on injury pattern after a crush injury to the forefoot (3).

Five paired cadaver lower extremities were used for the study. The feet were measured and fitted into a corresponding size 9 work boot. Five pairs had a steel toe cap (ANSI Z-41 & ATSM 2315 compliant), while five corresponding pairs did not. One foot from each matched pair was fitted into a steel toe capped boot while the other foot was fitted into the regular work boot.
We constructed a custom jig to provide a reproducible crushing mechanism with a total weight of 150 lbs.

Each specimen was placed with the boom centered on the proximal edge of the steel toe cap. The boom was raised 3 feet and released to crush the cadaveric foot. X-rays were obtained to assess for fracture location and comminution. Stress fluoroscopy was performed to assess for any ligamentous Lisfranc injury.

Figure 1: X-ray of cadaver extremity in steel toe capped work boot.
X-ray of foot in steel toe capped work boot Trauma Rounds Crush Injuries to the Foot

Overall, the feet in the regular work boots averaged 8.2 fractures per foot while those protected in the steel toe boot averaged 3.6 fractures per foot. The steel toe boot had fewer metatarsal and toe fractures and less comminution to the bone. There were no bony nor ligamentous Lisfranc injuries. There were no traumatic amputations nor open fractures produced. Previous studies have shown that 4.4% of all occupational related injuries involve the foot and toes. This represents over 3 billion dollars in total cost, including lost wages and productivity, medical costs and administrative expenses (4).

OSHA has recommended the use of safety shoes in certain occupations, which must meet the American National Standards Institute (ANSI) minimum compression and impact performance standards. ANSI has established testing and performance criteria for footwear safety and has standardized the impact and compression resistance characteristics of steel toe capped boots. The ANSI testing consists of a steel weight weighing 50 lbs (±0.5 lbs) dropped from a height of 3 feet (5,6).

Figure 2: X-ray of a cadaveric forefoot after crush impact in a regular work boot (top) and in a steel toe capped work boot (bottom).
Crush Injuries of the Foot - Effect of Steel Toe Boots posted in Trauma Rounds by Arun Shanbhag

Crush Injuries of the Foot - Effect of Steel Toe Boots posted in Trauma Rounds by Arun Shanbhag

Figure 3: Steel toe cap after crush impact (left) compared to an uncrushed steel toe cap (right).

Crush Injuries of the Foot - Effect of Steel Toe Boots posted in Trauma Rounds by Arun Shanbhag

In our study we tripled this weight to ensure the creation of fractures in our non-protected specimens and to elucidate the protective nature of the steel cap. Even when tripling the weight used by the ANSI protocol we found no toe amputations nor complete failures of the steel toe cap.

Although steel toe capped boots are commonly accepted as a protective measure, there are no published data about how protection afforded by a steel toe influences foot fracture epidemiology. This study demonstrated that the steel toe protects the foot from crush injuries, limiting the number and severity of forefoot fractures. However, the steel toe cap does not fully protect the forefoot from injury and in addition to the use of safety shoes, strict adherence to workplace safety standards may limit the severity of crush injuries to the foot.

I would like to acknowledge my fellow myth busters: John T. Campbell, MD, Mark S. Myerson, MD and Cliff L. Jeng, MD.

1. Bureau of Labor Statistics. Care and demographic characteristics for work-related injury and illness involving days away from work. Washington, DC: Bureau of Labor Statistics, US Department of Labor; 1992 – 1999.
2. MythBusters, Episode 42, Discovery Channel: November 9, 2005
3. Kwon JY, Campbell JT, Myerson MS, Jeng CL, Effect of a steel toe cap on forefoot injury pattern in a cadaveric model. Foot and Ankle Int. 2011 Apr; 32(4):443-7.
4. Campbell, JT: Foot and ankle fractures in the industrial setting. Foot Ankle Clin. 7(2):323 – 50, 2002.
5. Bureau of Labor Statistics. Labor force statistics from the current population survey. Washington, DC: Bureau of Labor Statistics. US Department of Labor; 2001.
6. Bureau of Labor Statistics. Lost worktime injuries and illnesses: characteristics and resulting time away from work, 1999. Washington, DC: Bureau of Labor Statistics, US Department of Labor; 1999.

16 Responses

  1. […] John Kwon on Crush Injuries of Forefoot […]

  2. […] this simple study, researchers demonstrated that steel toe capped work boots can prevent serious injury to the […]

  3. I have an 18 year old son that sustained a crushed forefoot last week. We have heard such variation on what to do. Help!?
    Surgery or wait. He had steel toed boots, but the injury is major of the great toe, crushed at the joint, and the fractured necks of second and third metatarsals some say clean it up now, and some say wait and do it later. Some say they wouldn’t touch it, there is nothing to put it together with.
    We are at day 12 and need to make a decision!
    Input welcome, we are totally unsure.

  4. As an experienced safety director, from a metal fabrication shop my inquiry would be at what point do the steel toes become unsafe in terms of too much weight being dropped on them causing amputation etc. The experiment was limited to only 150 pounds. In our shop, if something falls, the equation would have “tons” involved. An awesome experiment would be to determine at what force would the steel collapse and trap foot to where Doctors could not save it or it proves to cause more damage than what it is protecting.

    • Here is a reply to your comment by Dr John Kwon:
      “Thank you for the interesting comment. We tripled the previous ANSI standard and were unable to cause a significant deformity of the steel toe cap to cause amputation. However, I would assume tons of weight could cause complete deformation of the steel toe cap and traumatic amputation. However, clinically the outcome would likely be the same as this amount of weight dropped on unprotected toes would lead to such a significant bony and soft tissue injury that the toes, if not amputated at the time of the accident, would likely be unsalvagable and require surgical amputation.”

      • That makes perfect sense, I have decided to continue Steel Toe usage in our shop. Thanks for your reply and all the time you have invested in this topic.

      • A strongman recently dropped a 160kg/350lb spherical stone on his foot from a height of 5ft, impact point was middle metatarsal heads, with probably a 5cm diameter area of impact all said and done. He got an infection which complicated the healing process, but his foot is fine 6months later. I imagine there is some issues with normal range on his digits but nothing that impedes his daily tasks. He is set to resume lifting shortly. I imagine a toe cap in this instance would have resulted in no toes for this man, but that’s only guessing. There is room for more research here (not that I’ve looked for any more.)

  5. […] 2011 study of steel toe and regular work boots clearly demonstrated the advantages of steel toe. Non-protected samples experienced an average of 8.2 fractures per foot, while the steel toe […]

  6. While I only work with my fathers water treatement company part time while not in college, I have been wearing steel toe boots while working after almost crushing my foot with a water tank weighing several hundred pounds. I honestly believe as long as you’re not a complete doofus and don’t blatently stick your foot/steel toed shoe under a moving car, steamroller, or other object of extreme weight, you’ll be safe. If someone wants to make too big of a deal about not wearing them while working, then hell, wear flip-flops for all I care. I’m no doctor, but I know they’re protecting my little piggies.

    • Wearing appropriate footwear is extremely important. One thing you must know when selecting the right steel toe boots is how to read the impact rating. It informs you of the amount of pounds of impact the shoes will protect against e.g. the minimum impact rating is I/50 rated pair of boots can withstand an impact of 50 pounds, I/75 – 75 pounds, etc.

  7. its nice to see data on steel toe shoes, what’s missing is the data on metatarsals in general are they using the same parameters using this type of safety tool? or is there darker secrets not being revealed here for adding metatarsals to the safety plans?

  8. I drive a forklift on a shipping and receiving dock of a very fast paced trucking firm in the mid-west. I’ve seen many of my co-workers enter our work place without them wearing protective footwear, and I’ve expressed my concern to them about their safety to no avail. They choose to ignore the fact that each of these forklifts weigh in excess of 4.000 lbs and if one of these machines should run over their foot or if freight should fall on them, they will literally not have a leg to stand on… Not with the company or it’s workers comp carrier… Sooo many stupid people, and not enough concern over their own safety… Still shaking my head in disbelief……………

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