Steel toe capped boots are commonly worn for foot protection in industrial settings. However, there is little data on how steel toes affect injury patterns. This study examined crush injuries to cadaver feet with and without steel toes, finding that steel toes reduced the number and severity of fractures compared to regular boots, but did not fully prevent injury.

1. P A R T N E R S O R T H O P A E D I C
Trauma Rounds
Case Reports from the Mass General Hospital and Brigham & Women’s Hospital
A Quarterly Case Study Volume 3, Spring 2012
Crush Injuries to the Forefoot
John Y. Kwon, MD Each specimen
was placed with
Effect of a Steel Toe Cap the boom centered
Crush injuries to the foot are a common work- on the proximal
place injury, causing significant morbidity, dis- edge of the steel
ability and lost wages. A report by the Bureau toe cap. The
of Labor Statistics estimated that more than 60% boom was raised
of workplace injuries involve the musculoskeletal system, and 3 feet and released
10% of these are foot and ankle injuries.1 to crush the ca-
daveric foot. X-
Regulatory bodies like the Occupational Safety and Health rays were ob-
Administration (OSHA) were developed to protect the work tained to assess
force and to establish guidelines to improve work conditions for fracture loca-
and safety standards. Since OSHA’s inception in 1971, occupa- tion and commi-
tional injury and illness rates have declined 40% while the nution. Stress
American work force has nearly doubled. However, while the fluoroscopy was
total number of days lost from work due to occupational inju- performed to as-
ries has declined, the percentage of foot and ankle injuries has sess for any liga-
remained relatively constant. mentous Lisfranc Figure 1: X-ray of cadaver extremity in steel toe
capped work boot.
Although steel toe capped boots are commonly accepted as a injury.
protective measure, there are no published data about the pro- Results
tection afforded by a steel toe. There is a common belief that a Overall, the feet in the regular work boots averaged 8.2 frac-
significant crush injury sustained while wearing steel toe tures per foot while those protected in the steel toe boot aver-
capped boots results in amputations of the toes and that not aged 3.6 fractures per foot. The steel toe boot had fewer meta-
wearing them may be safer. This belief is so pervasive that a tarsal and toe fractures and less comminution to the bone.
popular television show, Myth Busters, investigated this.2 We There were no bony nor ligamentous Lisfranc injuries. There
studied the influence of the steel toe cap on injury pattern after were no traumatic amputations nor open fractures produced.
a crush injury to the forefoot.3 Previous studies have shown that 4.4% of all occupational related
Methods injuries involve the foot and toes. This represents over 3 billion
Five paired cadaver lower extremities were used for the study. dollars in total cost, including lost wages and productivity, medical
The feet were measured and fitted into a corresponding size 9 costs and administrative expenses.
4
work boot. Five pairs had a steel toe cap (ANSI Z-41 & ATSM OSHA has recommended the use of safety shoes in certain occupa-
2315 compliant), while five corresponding pairs did not. One tions, which must meet the American National Standards Institute
foot from each matched pair was fitted into a steel toe capped (ANSI) minimum compression and impact performance stan-
boot while the other foot was fitted into the regular work boot. dards. ANSI has established testing and performance criteria for
footwear safety and has standardized the impact and compression
We constructed a custom jig to provide a reproducible crushing resistance characteristics of steel toe capped boots. The ANSI test-
mechanism with a total weight of 150 lbs.
Trauma Rounds, Volume 3, Spring 2012
1

2. P A R T N E R S O R T H O P A E D I C T R A U M A R O U N D S
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 pro-
tective 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.
Acknowledgements
I would like to acknowledge my fellow myth busters: John T.
Figure 2: X-ray of a cadaveric forefoot after crush impact in a regular
work boot (left) and in a steel toe capped work boot (right). Campbell, MD, Mark S. Myerson, MD and Cliff L. Jeng, MD.
Dr. John Kwon (Jkwon@partners.org) is an orthopaedic surgeon at the Massa-
ing consists of a steel weight weighing 50 lbs (±0.5 lbs) dropped chusetts General Hospital, Boston and a member of the Foot & Ankle Service, as
from a height of 3 feet. 5, 6 well as the Partners Orthopaedic Trauma Service. Dr. Kwon specializes in foot
& ankle fractures, sports injuries and correction of foot & ankle deformities.
Conclusions
Bibliography
In our study we tripled this weight to ensure the creation of frac- 1. Bureau of Labor Statistics. Care and demographic characteristics for work-related
tures in our non-protected specimens and to elucidate the protec- injury and illness involving days away from work. Washington, DC: Bureau of
tive nature of the steel cap. Even when tripling the weight used by 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 sur-
vey. 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.
In Memoriam
Figure 3: Steel toe cap after crush impact (left) compared to an
uncrushed steel toe cap (right). Edward "Teddy" Kim
September 3, 1984 - April 6, 2012
We are saddened to report the passing of our friend and former col-
league, Teddy Kim, who recently passed away after a yearlong battle
AchesAndJoints.org/Trauma with leukemia. Teddy worked with us as a research assistant during his
junior and senior years at Boston College. He will be missed.
Jesse Jupiter, MD — 617-726-5100 Please share your comments online, or by email:
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Mark Vrahas, MD — 617-726-2943 jjupiter@partners.org Yawkey Center for Outpatient Care, Suite 3C
Partners Chief of Orthopaedic Trauma 55 Fruit Street, Boston, MA 02114
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Mitchel B Harris, MD — 617-732-5385
MGH Hand & Upper Extremity Service Editor in Chief
dring@partners.org
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bearp@partners.org
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Editor, Publisher
John Kwon, MD — 617-643-5701 Arun Shanbhag, PhD, MBA
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BWH Orthopedic Trauma www.MassGeneral.org/ortho
jkwon@partners.org
mjweaver@partners.org www.BrighamAndWomens.org/orthopedics
2
Trauma Rounds, Volume 3, Spring 2012