May 31, 2001 -- Advances in automobile safety are obvious: Air bags and seat belts have saved many lives in automobile accidents. But foot safety is being neglected. New research shows foot and ankle injuries as a result of car crashes are on the rise.
"We have been seeing more survivable accidents because of improvements in safety, but we are running into an increase in the number of serious leg, foot, and ankle injuries," says Paul A. Eisenstein, publisher of TheCarConnection.com, an online magazine that follows the automotive industry.
Before seat belts and airbags, fewer passengers were surviving accidents, so "minor" injuries were not much of an issue. Now, says Eisenstein, "We may see a serious crush of the legs, yet the passengers survive."
That's why improvements in the floor panels of cars may be necessary, German researchers report in the May issue of the Journal of Orthopaedic Trauma.
Lead researcher Martinus Richter, MD, of the trauma department at Hannover Medical School in Germany, and colleagues looked at automobile accident reports and medical records from more than 15,500 car accidents occurring from 1973 to 1996.
More than 260 front seat occupants -- including drivers and passengers -- sustained foot and ankle fractures as a result of the accidents. Half of these injuries occurred during head-on collisions and 34% occurred in accidents with multiple collisions.
Foot fractures are mostly caused when the foot compartment crumples during frontal collisions, the German researcher report. "A further increase of foot compartment stability would be essential for prevention of these injuries," they write. This holds true for both light and heavy automobiles.
To that end, many car manufacturers are taking steps to develop technology that's gentler on the feet, Eisenstein tells WebMD. For example, some companies are developing hardware that crumples better in an accident.
"Currently what happens is that the whole area gets crushed up in an accident because the hardware can't absorb the impact," Eisenstein says.
"Some companies are designing the engine so that in an accident instead of penetrating into the passenger [compartment], it may penetrate downward so it doesn't go into the feet," he says. "Manufacturers have been making crushable or deformable pedals that will be more absorbent of the force."
U.S. podiatrist Sutpal Singh, DPM, of Apple Valley and Barstow, Calif., says he sees accident-related foot, ankle, and leg injuries at least a couple times a year.
Though the German researchers conclude that the actual structure of the automobile's foot compartment is not stable enough to protect feet in an accident, Singh has a different impression of what causes the injury. Here's how it can happen, he says:
"You are driving straight ahead and slam on the breaks, and all the pressure is on your foot because your leg and knee are extended," he says. "Your foot is on the ground and the impact of the front of the car and the end of the other car compresses on your foot and ankle, potentially resulting in a compression fracture or a dislocation," he says.
"Imagine taking your fist and hitting against the wall. That's what you are doing essentially," he says.
"Once they have a severe ankle fracture, they usually have pain for quite a long time," Singh tells WebMD. "If the cartilage is damaged, they will develop arthritis, but if it's a minor fracture, then they usually do pretty well."
Cary M. Golub, DPM, a podiatrist in private practice in Long Beach, N.Y., agrees with Singh. "Injury to the foot is caused when you try to brace yourself by pressing your foot into the brake as impact occurs, " he says. "It can occur to a passenger when their foot compresses against the floor as they brace themselves in an accident."
In the new study, foot and ankle injuries among drivers and front seat passengers were similar. Richter writes, "the pedals, steering wheel, or asymmetric design of the dashboard do not influence the injury incidence, mechanism, or severity." Rather the abrupt change in velocity and "the extent of foot compartment [damage] correlated with the [extent of injury]."
"These injuries are sudden and painful and can result in dislocation between two parts of the foot and may need surgery," Golub says.
"Ankle fractures are very common because as you are bracing yourself, the retrograde force of the foot against the pedal or brake causes impact at the ankle joints," he says.
But "these are often unconscious motions and may be necessary evils just as seat belts can cause burns around the chest strap but are necessary to prevent further trauma."
According to Ronald D. Jensen, DPM, a podiatrist practicing in Modesto, Calif., treatment depends on the severity of the injury. "The simplest form of ligament damage may require an ankle brace and crutches depending on the damage. If a fracture occurs, we may need to use pins to stabilize the bones followed by a cast. However, if bone is exposed, it's a medical emergency that requires surgery," he says.
Often injuries to the foot or ankle get overlooked after an accident, he adds.
"They get overlooked because other injuries are more serious," Jensen tells WebMD. But "you shouldn't accept your foot being sore as a result of an accident and not have it evaluated. Follow-up when symptoms become apparent."