Bad Tib-Fib Fracture = Hammer Toe During Ankle Dorsiflexion...

[LightRanger]

So I've been thinking about posting this up here, but hadn't gotten around to it.

Did my tib-fib back in late February, see discussion and x-rays here: [ame="http://www.tetongravity.com/forums/showthread.php?t=152976"]http://www.tetongravity.com/forums/showthread.php?t=152976[/ame]

My recovery is going pretty well for a serious fracture, or so says my ortho. Walking mostly without a limp, and that limp seems to be due to this condition I have.

When I flex my ankle so that my toes are moving toward my knee, my two biggest toes involuntarily curl downward (i.e. they sort of ball up). Ortho I've been seeing in SF says that its rare but happens occasionally. He said to try to stretch them opposite to the curl, but it hasn't really done much other than hurt from the force of my hand pushing on the bone in my big toe.

I have an appointment on August 3rd and my ortho ordered a film of my foot too, so I have it in hand when I see a podiatrist/another ortho. (I'm off this insurance on August 24, and probably going with Kaiser after that to see the orthos my mom works with as a Kaiser nurse.)

I'm guessing it's either from: (a) one of the four screws in the area (check the x-rays in the previous thread); (b) adhesions somewhere messing with the tendons; or (c) I tore something when I initially broke it (my boot/ski *was* at something like a 45 degree angle outward from normal, so there was some major twisting action that could have torn sometime). (There's definitely a bit of nerve damage too because a bit of my heel has a dull sensation, and so does most of my big toe.) I'm hopefully getting the screws pulled in September, so we'll see if that does the trick. I'm just hoping I don't have to get corrective surgery done on it.

Any thoughts? Anybody heard of this/had it happen to them? Input from Dr. Mark?

I'll post some pics in the next day or so.

[splat]

Try flexing them gently with the curl. One of the things they always comeback to in orthobionomy is to 'exaggerate what is', which pretty much means that rather force muscles against their will in the opposite direction, go ahead and take them in the direction they want to go...gently. A big part of the touch of this healing technique is to feel the muscles relax and then let them move in the other direction once they relax. Sometimes in baby steps.

[skiing-in-jackson]

(b) adhesions somewhere messing with the tendons; or

(c) I tore something when I initially broke it (my boot/ski *was* at something like a 45 degree angle outward from normal, so there was some major twisting action that could have torn sometime). (There's definitely a bit of nerve damage too because a bit of my heel has a dull sensation, and so does most of my big toe.)

You may be on to something here. In gait's swing cycle, your toes normally dorsiflect. How far do the two toes plantarflex (flex towards the floor or away from you)?

You may have injured the [ame="http://en.wikipedia.org/wiki/Tibialis_anterior_muscle"]tibialis anterior[/ame] or one of the primary dorisflectors in the anterior compartment of your leg.

Extensive physical therapy is common and sometimes people have to wear stuff like

There are piles of different types of splints and a MD/DPM can write a perscription for a C. Ped to fill for a more specialized splint. Dorsiflection is an important part of gait so you don't catch your toes on a carpet while barefoot.

[LightRanger]

Thanks guys.

Stephen, the tibialis anterior looks like it might be what's going on. The plantar flexion is basically as far as the toe can go when my ankle is flexed, but it only occurs at the Ext. Hallucis Longus joint in the big toe and the two corresponding joints in the second toe. The joint at the head of the metatarsals seems to work fine.

[Vinman]

Try doing a little of everything. Splat's suggestion is good. DO some active DF with active toe flexion as well as try stretching the Flexor Hallcis longus and flexor digitorums as well as the calf and achillies. If there are some adhesions binding the tendon working the muscle and tendon actively may free it up.

[sean890]

So SCUT, i remember reading about your injury, as i snapped my tibia in half days before.

I too am having issues with hammertoes in my smallest toes. I had compartment syndrome though, and they sliced my muscles nice, so the podiatrist thought that I was simply a matter of waiting for the muscle to regain strength and then it should be fine.

Best of luck dealing with that, keep us updated on how things are going

[ETP112]

Don't mean to necro the thread, but I've had this problem since I got hit by a car when I was 13, I'm sick and tired of my toes/foot being like this.

I would really love to hear from the OP and the other people with similar problems to see if they found a solution or what they tried, etc. I got surgery to try and fix it 7 years ago and it didn't work. Any info you guys can share would be amazing.

Thanks for your time,
Evan

[Orthoski]

With a tib-fib fracture people can most commonly get curly toe for a couple reasons:

1) Compartment syndrome: Spoken about previously, the injury can cause a build up of pressure in the leg compartments and ultimately some of the muscles die. Of the four compartments in the lower leg, the deep posterior one (the one right behind the tibia) is most prone to this. Among the muscles that live there are the long flexors to the big and lesser toes. As the muscle dies and scars its contracts and the tendons pull the toes into a flexed position.
2) Adhesion: The flexor muscles that live right against the tibia bone scar against the fracture/bone, limiting their ability to stretch (they're stuck).

The reason the toes flex as you lift up your foot is that, like the calf muscle, the muscles in the back of your leg need to stretch as you dorsiflex the foot (flex up). If the muscle is scarred or stuck, the tendons act like reins on a horse and pull the toes down. If the muscle is alive, sometime a release in the back of the leg can be used, but this is a sizable procedure and inherently unpredictable, esp. after if the injury happened a long time ago. If the muscle has died and scarred with compartment syndrome, then something in the foot such as a tendon release and pinning is indicated.

Best of luck.

[LightRanger]

Pinning the toes is non indicated. I had that done by a podiatrist who didn't know what he was looking at and my toes are fucked for life. Maybe after you had the below done, but not before.

@ETP112, I was repeatedly misdiagnosed by a ton of orthos and podiatrists, including the head of orthopedics at one of the best university hospitals in the country.

Ultimately what helped me the most (though it didn't completely go away) was a z-plasty of the flexor hallucis longus at the midfoot. That's the best method for fixing a Checkrein Deformity indicated by the literature as of when I had it done in December 2012. I haven't checked since.

Best of luck man. Unfortunately time is your/our enemy on this. I wish I'd had that same surgery done three years prior because I've had a whole host of biomechanical issues that came with it. In December 2009, when I got screws out, ortho went into the fracture site and tried to clean out adhesions, but that literally did nothing and only created a bunch of unnecessary scarring that bugs me now.

[Orthoski]

Pinning the toes is non indicated.

It's not indicated if that's the only thing you're doing. You can't just pin the toe straight and expect it to stay there, but you hit it on the head when you mentioned z-lengthening. Something needs to lengthen the musculotendinous unit, which is contracted. There are a myriad of ways to do this, either in the leg, the midfoot, or at the toe. Doing something in the midfoot works well except that in many cases, by the time you're doing the procedure, the toes themselves have permanent contractures in the joints from being bent for so long. In such a scenario, you not only have to lengthen the tendon, but also release the toe joints. The toes subsequently need to be temporarily pinned - the pins are pulled in clinic but they act to temporarily strut the toe straight after the release. To LightRanger's point, consider an finding an orthopedic surgeon who has experience dealing with these conditions, often someone with foot and ankle training.

[LightRanger]

^^^ Good advice.

[ETP112]

Thank you Lightranger and Orthoski for your input and insight. I have a lot to consider.

I had a procedure done for z-lengthening of the big toe tendon midfoot (I think this is what you were talking about lightranger?) around 6 or 7 years ago. after the procedure the toe looked pretty great, totally straightened out and I had the bunyon cut off the side of the joint that starts the big toe.

I don't know anything about "pinning" but certainly nothing of the sort was done, and after a few months my toe just slowly reverted back to the way it had been (hammered state) and in the many years since its just gotten worse. Definitely have Checkrein deformity of the big toe.

Orthoski so if I had this done and it reverted, you think I needed to have my toes pinned temporarily? I'm not a doctor at all but I couldn't understand how despite the fact that I had my tendon lengthened, something could have pulled it tight again the way it had been. The guy I went to to have the procedure was supposed to be a foot specialist, so much for that.

I really, truly appreciate you guys sharing your knowledge and experiences. I want more than anything to fix this somehow, but having tried z lengthening surgery and had it fail years ago has left me quite despondent about how to fix it.

Much love,
Evan

[Orthoski]

Even in the best of hands a procedure can have imperfect outcomes. Nonetheless, I honestly always have a little bit of pause when someone talks about "having the bunion cut off the side of the joint". A bunion (aka, hallux valgus) is a completely separate condition and deformity, and effectively reconstructing it is generally more involved than shaving down a bump (you have to actually realign the bones themselves that underlie the deformity).

My recommendation is find an orthopedic surgeon with subspecialty training in foot and ankle, if that isn't who treated you before. Having a big toe that's clawed is quite a difficult condition given how much force goes across the big toe when with every step. But there are things that can be done depending on your exam. For example, if your toe is bent in the middle (which is often the case), the flexor hallucis longus (FHL) whose muscle belly is in the back of your leg is the major contributor. If lengthening it didn't work, you can instead release the big toe's middle joint and then transfer the tendon through drill holes to the bone closer to the base of the big toe so the FHL no longer bends the toe down in the middle (and you don't just cut the FHL because then the extensor that pulls the toe up can then act unopposed causing your toe to rise up). There are things that can be done, and I would leave it to your treating surgeon to decide - maybe not to make you perfect after all these years, but better. That being said, see someone that specializes in these kind of things.

Best of luck.