"Dropped Toe"

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Hi Guys

Im looking for some thoughts on a patient i seen today with the orthopaedic surgeon. This 30 yr old gentleman had been in a car crash and subsequently fractured his proximal femur. He presented into clinic after the cast had been removed with a dropped hallux! When i heard the orthoapedic surgeon call me over for a dropped toe i started laughing until i actually saw it.

The patient has an inability to dorsiflex his big toe at all with a total loss of power in the EHL. After having a think i thought he could have damaged his peroneal nerve and have referred him for nerve conduction study.

The weird thing is that he is still able to fully dorsiflex his foot and the damage seems to be isolated to just the EHL. i found an article which describes this problem as well:

Compression Peroneal Nerve Palsy causing Isolated Extensor Hallucis Longus
Dysfunction.Chad D. Moorman, DPM,1 and Jane Pontious DPM, JFAS,Volume 48, Issue 4,Pages 466-468, July 2009

Big Question is - How would you manage this problem?
Splint? what type and how?
Orthotic? Morton extension?

Any help hugely appreciated

Matthew

 

Hi Matthew,

I would suggest a modified cluffy wedge is one option

Basicially orthotic of your design with a wedge which will keep the toe in a dorsiflexed position. This will help to with windlass etc. but can cause so 1st mtpj inflammation which might lead to a limited range of motion in the future.

Another option is to just consider that as the heel lift the toe will dorsiflex and therefore you have windlass.
By the patient wearing shoes there is no need to worry about the toe drop as shoe will stop it, but consider the loss of function of the EHL has on the MTJ and STJ joint and build an orthotic to help with that.

hope that helps

 

If the only deficit is loss of EHL then just have them wear shoes. The function of the EHL is to prevent tripping over your big toe in gait. Many years back my sister had a boyfriend who had an external fixitor for bad tibial fracture. They skewered his EHL muscle. The only problem that he had was trying to do martial arts barefoot. He kept tripping over his toe and get plantar flexion sprains. He had not trouble in shoes.

Thinking in terms of moments. The loss is dorsiflexion moment of the hallux. So, you need some mechanism to keep the dorsiflexed in swing. When the anterior muscle dorsiflexes the ankle when wearing a shoe, the shoe will dorsiflex the toe.

In the car crash there was no damage to EHL muscle or tendon? I agree that neurological is one thing to check. However, if it is still a short time after the injury a ruptured tendon might be able to be repaired.

Cheers,

Eric

 

Proximal Femur???
I doubt a fracture of the proximal end of the femur would give a localized paralysis of the EHL and nothing else.

Unless you mean the distal femur.


Odd.

Steve

 

Many thanks steve for pointing out my mistake. i did mean distal femur. I have enclosed a pic for you to look at. There is no problem with this guy in shoes as obviously the shoe stops the drop toe, but like you mentioned eric, he is a keen martial arts guy so is struggling barefoot.

 

Well that kind of changes things. Maybe try a boxing type shoe(soft ,flexiable )which you might have to re-enforce under the 1st MTP joint. From memory there is a martial arts shoe can´t remember the name maybe look into that ?

 

Did your Patient have ORIF?

I'd at least run a NCS and EMG to see what the damage is. AN MRI may help.
Depending on the injury, which was severe enough to Fx his Femur, he may have primary injury to the nerve or perhaps a compression or entrapment.

Depending on the degree of nerve injury and the cause, it may resolve itself.

Good luck

Steve

 

Steve,
What's "ORIF"? oh, and an "NCS".

May well be something obvious, but nothing's springing to mind midway through firday afternoon fatigue.
cheers,
Charlie

 

open reduction internal fixation
Nerve Conduction Study

 

Matt,

Along with your nerve conduction studies, you might want to refer to your local radiology department to rule out trauma to the tendon (or muscle) - US scan or MR (as Eric has previously mentioned). If you're in an MSK clinic, do you have access to ultrasound imaging? Get someone to have a look at it for you. It might respond to a fairly simple repair if it is a localised tendon pathology, but I'm sure the ortho you work with would have thought of this? Is it total loss of muscle power or just severely diminished? Any sign of muscle contraction at anterior group on passive extension in clinic? Do you have a nerve stimulator? Might be worth trying a stimulator as you would if you were giving a common peroneal block - this would potentially rule out nerve pathology related to distal femur fracture? Or just wait for the NCS?

You still working in the Manchester area?

Lee

 

Hi Matthew,

Any chance you could upload a copy of this on here? If not could you email me a copy please?

Thanks

Ian

 

I have attached the interesting article for you ian

 

Thanks Matthew. Spooky that I read this thread last week and then see my first ever case this morning. The beauty of Podiatry Arena.

My chap was referred to me by the Neurologist, so has previously had his EMG/NCS all done. He is a 59 year old chap who fell in June 2008 and hit the lateral aspect of his right knee on the corner of a table. He noticed an immediate foot dop and an inability to dorsiflex it at all.

However present day and he reports the foot itself has improved significantly (he could quite easily dorsiflex his foot today against my resistance with almost symmetrical power when compared to L side). However the right hallux is still 'dropped' and he is unable to lift it - and certainly on testing suggestive of EHL dysfunction/deficit. Naturally it's only a tripping hazard when barefoot (and luckily for me he is not into his martial arts).

However, he is quite keen on his golf, and reports a pain in his R1st MTPJ/IPJ at the end of his front swing (R handed golfer so pain when R foot in internally rotated/pronated position). I'm keeping my thought processes simple at the moment and suspecting an increased GRF sub hallux, so will probably try to offload it temporarily and send him out to hit a bucket of balls and see how he feels before considering something more permanent.

Is this something your chap reported at all?

Ian

 

My patient doesnt actually complain of any pain at all, its just when he does pilates and martial arts he experiences "tripping up" and a difficulty in doing certain movements.

As michael suggested before he is ok in shoes as they act as a splint when he walks its barefoot.

With this in mind me and a colleague are going to toy about with some soft cast stuff. This is the new thing for offloading diabetic pressure areas but the stuff can be made into any kind of splint device, so im going to try a version of the foot up splint...but as you can guess.. i will call it the toe up splint TM!! if it works ill upload the photo, but i think seeing this stuff is good enough to write up a case study on?

Matt

 

Matthew,

I have seen a patient with a different cause who suffered dorsal trauma which severed the FHL tendon.

This muscle is functionally a swing phase muscle and also decelates ankle plantarflexion at heel strike. Its absence functionally reduces the pretibial muscles ability to generate as much "power" when the heel strikes the ground.

As a dorsiflexor and invertor this could cause excessive sub-talar pronation at foot flat and demand more from tib ant specifically.

All this in mind, its highly likely your patients biggest difficulty will be putting a shoe on as his hallux may plantaflex uncontrollably.

Theoretically his biggest risk is from reduced 1st MTP dorsiflexion ROM and an increasingly pronating foot. My biggest concern would be acquiring deformity....

I would probably give him a supinated foot orthosis and may consider something similar to a Cluffy wedge.

I would also consider night splinting him in 1st MTP dorsiflexion to protect him ROM.

Good luck, not the easiest thing to desal with, hopefully the nerve conduction studies will confirm your diagnosis.

Best wishes

Simon

 

Hi simon thanks for taking the time to respond. A few things:

1.suffered dorsal trauma which severed the FHL tendon- did you mean the EHL as
the extensors are the Ant group muscles?

2. What is a cluffy wedge - i have already provided him with an orthotic to increase the supination moment around the stj.

3. Theoretically his biggest risk is from reduced 1st MTP dorsiflexion ROM - its too late as this gentleman actually already has an underlying hallux rigidus. the best we could hope for was to get the hallux to neutral.

4.I would also consider night splinting him in 1st MTP dorsiflexion to protect him ROM - what splint? are we talking about an adjustable type night splint?

 

http://www.cluffy.com/cons_wedge_cons.html

There the home page for you. As I mention in my 1st post a modified cluffy wedge might be an option, but with hallux rigidus it is not.

 

Matthew,

My apologies, it was a typo, i meant EHL not FHL.

A cluffy wedge is a sagittal toe wedge to dorsiflex the toe

As for the night splint i would custom make one with a small hinge, ideally a dorsiflexion sprung joint could be sourced. A USA company called Ultraflex Systems makes such joints. I think there website is ultraflexsystems.com

Best wishes

Simon

 

Normal walking will force dorsiflexion of the MPJ. If he isn't walking much then you might consider a splint. I've always felt that contractures develop when the range of motion is not used. Walking will attempt to use that motion and generally dorsiflex the MPJ past parallel with the floor. What more does he need if he does not have EHL function?

Cheers,
Eric

 

Just wondering has the patient simply tried taping / strapping the toe for the activities he is having problems with? (this appears to be unshod activities??)

 

Hi Matthew:

Just revisiting this thread - lots of suggestions as far as treatments, however, have you decided on a diagnosis yet? "Dropped toe" isn't good enough.

Sounds as though you have given up on treating the underlying pathology and have decided to deal with the consequences.

Did we ever get the results of the NCS or EMG?

Steve

 

Sorry ive not replied, my new baby boy has taken up the majority of my time recently and the nagging wife!

There is an oblique fracture through the proximal
shaft of the fibula with very mild lateral displacement of
the distal fracture fragments. No further evidence of bony
injury can be identified. NCS identified injury to a branch of the peroneal nerve which supplies only the EHL- quite rare said the neurologist. He doesnt think he will regain full function, but he has not really come across this so he actually said he isnt sure.

we are currently looking at some sort of splint for this guy to wear bare foot when he does martial arts, pilates etc... we are experimenting on ourselves to come up with something which works well and is not huge!

Anyone now of any splints designed for hallux valgus etc..which could be diversified!

 

Review of Drop Hallux: Assessment and Surgical Repair.
Kihm CA, Camasta CA
J Foot Ankle Surg. 2017 Jan - Feb;56(1):103-107. doi: 10.1053/j.jfas.2016.08.001.