Checkrein deformity--an unusual complication associated with a closed Salter-Harris Type II ankle fracture: a case report

Endoscopic Release of the Flexor Hallucis Longus Tendon at Posterior Ankle for Management of Checkrein Deformity of the Great Toe, Second Toe, and Third Toe

Checkrein deformity is rare and involves entrapment or fixed tethering of the flexor hallucis longus (FHL) in the posterior foot, just proximal to the flexor retinaculum of the ankle, and causes the "constant length phenomenon" of FHL. The clinical presentation is a dynamic flexion deformity of the great toe characterized by flexion contracture of the interphalangeal joint with mild extension contracture of the metatarsophalangeal joint, causing difficulty in walking since in the stance phase of gait, the hallux is forced into plantar flexion and impinges onto the ground. Because the FHL tendon has some interconnection to the tendons of the flexor digitorum longus at the master knot of Henry, deformities of the second and third toes are sometimes seen. There is no standard surgical treatment for checkrein deformity. Surgical release of the FHL muscle or release/lengthening of the FHL tendon has been proposed. The purpose of this Technical Note is to report the endoscopic release of the FHL tendon at the posterior ankle for management of checkrein deformity of the great toe, second toe, and third toe.

Management of Checkrein Deformity

Checkrein deformity is characterized by the dynamic status of the hallux, in which flexion deformity is aggravated by ankle dorsiflexion and relieved by ankle plantarflexion. In most cases, a checkrein deformity occurs secondary to trauma or following surgery. It has been suggested that the flexor hallucis longus tendon tethers or entraps scar tissue or fracture sites. Improvement with conservative treatment is difficult once the deformity has already become entrenched, and surgical management is usually required in severe cases. Various surgical options are available for the correction of checkrein deformities. It includes a simple release of adhesion at the fracture site; lengthening of the flexor hallucis longus by Z-plasty at the fracture site combined with the release of adhesion; lengthening of the flexor hallucis longus by Z-plasty at the midfoot, retromalleolar, or tarsal tunnel area; and flexor hallucis longus tenotomy with interphalangeal arthrodesis for recurrent cases. This review aimed to summarize the overall etiology, relevant anatomy, diagnosis, and treatment of checkrein deformities described in the literature.

Application of ultrasound in preoperative localization diagnosis of checkrein deformity: A retrospective case series

BACKGROUND

Checkrein deformity, is a rare claw toe dynamic deformity of the hallux or great toe. This study investigated the use of diagnostic ultrasound in positioning the accurate injury location causing checkrein deformity and its clinical significance for etiological diagnosis and selection of surgical methods.

METHODS

This retrospective study included patients with confirmed checkrein deformities (according to typical symptoms) at the Department of Traumatic Orthopedics of Tianjin Hospital (Tianjin, China) from March 2017 to July 2021.

RESULTS

A total of 11 patients (8 males and 3 females) with a mean age of 36.7 ± 16.8 (range 19-61) were included in this study. The injuries included six cases of tibia and fibula fracture, one case of single tibia fracture, and one case of single fibula fracture. Four patients were treated with steel plate internal fixation, three patients with intramedullary nailing, and one patient with external fixation. Three patients reported no history of any high-energy trauma or surgery. The ultrasound results showed that seven patients suffered from flexor hallucis longus (FHL) lesions, two patients suffered from flexor digitorum longus (FDL) lesions, and two patients suffered from FHL and FDL lesions. The patients underwent different surgeries tailored to their specific lesions. Toe flexion deformity was completely corrected after operation in all patients. The function of the toes was recovered to varying extent.

CONCLUSION

The results of this study demonstrates that the checkrein deformities can be confirmed by ultrasound. It could be used to determine the adhesions before the operation, acting as guidance while establishing the surgical planning.

Posttraumatic checkrein deformity following isolated Lauge-Hansen pronation external rotation stage IV malleolar fracture-a case report and literature review

The checkrein deformity is characterized by flexion contracture of the interphalangeal joint and extension contracture of the metatarsophalangeal joint. It is a rare condition occurring after lower extremity trauma, especially a malleolar fracture. Little is known about the possible cause and therapeutic strategy. This unique case presents a 20-year-old male patient with a diagnosis of the checkrein deformity secondary to open reduction and internal fixation of a Lauge-Hansen pronation external rotation stage IV malleolar fracture. After performing a detailed physical examination, radiographic evaluation, and ultrasonography, open exploration was performed to remove the hardware and correct the deformity with sole tenolysis of the flexor hallucis longus (FHL). In the 4-month follow-up, no recurrence of the checkrein deformity was observed. This deformity was caused by FHL adhesion. Interosseous membrane injury and fibular fracture together with local hematomas increases the risk of FHL adhesion. Open exploration and tenolysis of the FHL are feasible options to correct the checkrein deformity.

Rupture of the Tibialis Posterior Tendon With Associated Bimalleolar Ankle Fracture

The acute traumatic rupture of the tibialis posterior tendon in association with closed ankle fractures is rare and often under-recognised. If recognised early, outcomes can be excellent. There are 28 known cases in the literature, and we report two further cases associated with bimalleolar ankle fracture dislocation. A 49-year-old presented with valgus deformity at the ankle joint and global tenderness following a work injury as a mechanic. A plain radiograph showed a displaced oblique comminuted fracture of the lateral malleolus with valgus angulation at a syndesmosis, with significant talar shift. The patient underwent open reduction and internal fixation with a seven-hole, one-third tubular plate and screws. A 35-year-old involved in a motorcycle collision with a car presented with swollen left ankle and valgus deformity. Plain radiographs revealed bimalleolar fracture subluxation. Closed reduction was unsuccessful and hence direct medial approach demonstrated a complete rupture of the posterior tendon. The medial malleolus was fixed using lag screws and washers. The tendon was repaired using the modified Kessler technique in both cases. The tibialis posterior plays a significant role in foot and ankle biomechanics due to its broad tendinous insertion. Acute traumatic rupture is rare, as it is protected due to its deep-seated anatomic location within the deep posterior compartment of the leg. Preoperative diagnosis of this injury is challenging and hence this diagnosis is often made intraoperatively. In both cases, there was a retraction of the proximal end beyond incision margins, and this can make tendon rupture difficult to identify intraoperatively as well. Upon identification, assessment of the tendon for degenerative changes was key to deciding upon suitability for primary repair. Despite its rarity, a high index of suspicion should be maintained in fracture dislocation of the ankle joint, especially when the mechanism is known to be pronation-external rotation.

Retro-Malleolar Z-Plasty of Flexor Hallucis Longus Tendon in Post-Traumatic Checkrein Deformity: A Case Series and Literature Review

Checkrein deformity (CD) is a dynamic deformity of the hallux characterized by flexion contracture of the interphalangeal (IF) joint and extension contracture of the metatarsophalangeal (MTP) joint, worsened by ankle dorsiflexion. It is due to post-traumatic or ischemic retraction of the long hallux flexor tendon (FHL) following soft tissue trauma, leg fractures, ankle fractures and, more rarely, calcaneal or talar fractures. Diagnosis is essentially clinical, associated with imaging, to rule out unrecognized causes and evaluate fracture healing process. Few cases are reported in literature without univocal treatment. Background and Objectives: To analyze clinical and functional outcomes in patients with CD treated with release and retro-malleolar Z-plasty lengthening of FHL tendon. Materials and Methods: Patients diagnosed with CD treated with retro-malleolar (at tarsal tunnel) Z-plasty lengthening of the FHL tendon between January 2016 and August 2020 were included. Clinical and functional outcomes were collected on admission and post-surgery and analysed retrospectively. Patients with a minimum follow-up of 18 months were included. Results: A total of 14 patients, with mean age of 37.4 years old, with CD diagnosis were included in the study. All patients were suffering from post-traumatic CD and the mean time from trauma to onset of deformity was of 7 months (range 1−12). At a mean follow-up of 31.8 months (range 18−48) we found a significant improvement (p < 0.05) in terms of pain relief (VAS), function (AOFAS score) and ROM of the IP and MTP hallux joints. No recurrence, loss of strength, nerve injury or tarsal tunnel syndrome were observed. No patient required revision surgery. Conclusions: In this case series the retro-malleolar FHL tendon Z-plasty proved to be a suitable option for CD correction, allowing a good clinical and functional recovery.

Closed Pantalar Dislocation With Checkrein Deformity: A Unique Case Report and Literature Review

Closed pantalar dislocations are a rare variant of an uncommon injury. Pantalar dislocations are typically caused by high-energy trauma resulting in an open injury with associated fracture of the articulating bones. Given its obscurity, the literature on closed pantalar dislocations is scarce, and no standard treatment protocol has been accepted. This case report chronicles the treatment and outcome of a 29-year-old man who presented with a checkrein deformity of all digits after a closed pantalar dislocation with 6-month follow-up. A comprehensive literature review found 28 articles representing 39 patients with closed pantalar dislocations without talar neck or body fractures. Roughly equal numbers of closed and open reduction techniques were performed with avascular necrosis occurring in 7 of 36 patients. Although outcome measures and follow-up were variable, what can be considered a suitable outcome was seen in approximately 83% of patients, with only 3 of 35 requiring a secondary operation. Long-term studies with well-defined outcome measures are needed to adequately predict the prognosis of this rare injury and efficacy of treatment protocols.

Treatment and outcomes of distal tibia salter harris II fractures

BACKGROUND

Distal Salter-Harris (SH) II fractures of the tibia are common injuries in the pediatric population. The purpose of this study is to evaluate our treatment and outcomes of SH II fractures of the distal tibia.

METHODS

The study was approved by the medical school's institutional review board (IRB). Fifty-one distal tibia SH type II fractures were treated from 2003 to 2017. We performed a retrospective review of all patients. Patients with displacement less than 3 mm, on x-ray, were treated with a cast. Patients with displacement greater than or equal to 3 mm displacement were initially treated with closed reduction in the emergency department with conscious sedation. Patients were also categorized based on the mechanism of injury and complications were noted. Patients were followed for an average of 4 months (range, 4 weeks-28 months).

RESULTS

Fifty-one patients, 28 females and 23 males, were included in the study, with a mean age of 9.4 years (range, 13 months-13 years) at presentation. The most common mechanism of injury was participation in sports (43%). Out of the 51 patients, 45 were minimally displaced and treated with cast. Six displaced fractures were treated with closed reduction. The mean displacement in the closed reduction group at presentation was 5.7 (range, 3- 8.8) mm. Five out of 6 patients had reduction to less than 3 mm. The overall complication rate was 1 out of 51 patients, 2%. When examining displaced fractures, the complication rate was 1 out of 6 patients, 17%.

CONCLUSION

Most SH II fractures of the distal tibia are minimally displaced and do not need a reduction. 6/51 cases (12%) in the current study were displaced and were indicated for a reduction. Displacement greater than or equal to 3 mm can be treated with closed reduction followed by a cast; if closed reduction fails, open reduction is indicated. Displaced fractures have a small risk of growth arrest.

Checkrein Deformity of the Great toe Managed by Midfoot Flexor Hallucis Longus Z-Plasty: A Case Report

Introduction:

Checkrein deformities are rare and involve entrapment or fixed tethering of the flexor hallucis longus (FHL) tendon.

Case Report:

We present the case of a 25-year-old male who presented with complaint of clawing of his great toe. A history of previous open reduction internal fixation for distal tibia fracture was described 3 years back. Exploration of FHL tendons was performed at the level of the midfoot. Correction was achieved after z-plasty of FHL tendon. This case highlights another late complication of distal tibial fracture which should be actively looked for in patients with this injury. We describe the ease of surgical correction through an operative field free of scar tissue as compared to classical method of operating near fracture site and releasing adhesions of muscle belly.

Conclusion:

We suggest that exploration at the midfoot should be the primary surgical intervention in similar cases of checkrein deformity.

Endoscopic Adhesiolysis of Flexor Hallucis Longus Muscle

Adhesion of the flexor hallucis longus (FHL) muscle to the distal tibia can occur after distal tibial fracture, distal fibular fracture, low tibial osteotomy, soft-tissue injury at the posterior ankle, subclinical compartment syndrome of the distal deep posterior compartment of the leg, or Volkmann contracture after deep posterior compartment syndrome of the leg. The purpose of this Technical Note is to report the endoscopic approach of FHL muscle adhesiolysis. It is indicated in patients with symptomatic adhesion of the FHL muscle and contraindicated if there is entrapment of the FHL muscle or tendon in the fracture callus or if there is extensive fibrosis and contracture of the FHL muscle as a result of Volkmann contracture after deep posterior compartment syndrome of the leg.

Z-plasty of the flexor hallucis longus tendon at tarsal tunnel for checkrein deformity

PURPOSES

To review the outcome of Z-plasty of the flexor hallucis longus (FHL) tendon at the tarsal tunnel for checkrein deformity in 8 patients.

METHODS

Records of 6 males and 2 females aged 14 to 67 (mean, 39.5) years who underwent Z-plasty (lengthening) of the FHL tendon at the tarsal tunnel for checkrein deformity in the first and second toes by a single surgeon were reviewed. All patients had undergone 3 months of conservative treatment. The mean time from injury to surgical treatment was 8.4 (range, 5-12) months. All patients had associated injuries including distal tibiofibular fracture (n=6), distal fibular fracture (n=1), and crush injury aroundthe ankle (n=1); they were treated with intramedullary nailing (n=6), long leg splinting (n=1), and short leg splinting (n=1).

RESULTS

After a mean follow-up of 3.4 (range, 1-7) years, the FHL tendon was lengthened by a mean of 1.7 (range, 1.6-1.8) cm, and the mean American Orthopedic Foot and Ankle Society hallux score increased from 59 (range, 52-67) to 89 (range, 80-90). No patient had recurrence, nerve injury, or tarsal tunnel syndrome, although one patient had sensory disturbance of the posterior tibial nerve in the forefoot, which resolved spontaneously at week 2.

CONCLUSION

Z-plasty of the FHL tendon at the tarsal tunnel is a viable option for correction of checkrein deformity.

Acute Tibialis Posterior Tendon Rupture With Pronation-Type Ankle Fractures

Tibialis posterior tendon rupture in the setting of pronation-type ankle fractures can lead to long-term debility as a result of chronic tendon dysfunction. This rare injury pattern presents a diagnostic challenge because thorough preoperative examination of the function of the tendon is limited by pain, swelling, and inherent instability of the fracture. As such, a high index of suspicion is necessary in ankle fractures with radiographs showing a medial malleolus fracture with an associated suprasyndesmotic fibula fracture. This report describes 3 cases of tibialis posterior tendon rupture associated with pronation-type ankle fractures treated acutely with open reduction and internal fixation and primary tendon repair. Additionally, common features of this injury pattern are discussed based on the current literature. In accordance with this report, the typical mechanism of injury is high energy and includes forced pronation, external rotation, and dorsiflexion of the ankle, which places maximal stress on the tibialis posterior tendon. Rupture most commonly occurs in a relatively hypovascular area of the tendon located at the posteromedial extent of the medial malleolus fracture. In the operative treatment of pronation-type ankle fractures, direct inspection of the tibialis posterior tendon allows for timely diagnosis and treatment of associated ruptures. [Orthopedics.2016; 39(5):e970-e975.].

Flexor digitorum brevis tendon transfer to the flexor digitorum longus tendon according to Valtin in posttraumatic flexible claw toe deformity due to extrinsic toe flexor shortening

Claw toe deformity after posterior leg compartment syndrome is rare but incapacitating. When the mechanism is flexor digitorum longus (FDL) shortening due to ischemic contracture of the muscle after posterior leg syndrome, a good treatment option is the Valtin procedure in which the flexor digitorum brevis (FDB) is transferred to the FDL after FDL tenotomy. The Valtin procedure reduces the deformity by lengthening and reactivating the FDL. Here, we report the outcomes of FDB to FDL transfer according to Valtin in 10 patients with posttraumatic claw toe deformity treated a mean of 34 months after the injury. Toe flexion was restored in all 10 patients, with no claw toe deformity even during dorsiflexion of the ankle.

Adhesion of flexor hallucis longus at the site of a tibial-shaft fracture--a cause of a checkrein deformity

Post-traumatic adhesion of toe flexors at the tibial fracture site resulted in checkrein deformity is rare and only a few case reports or case series were reported in the English literature. Major differential diagnosis includes deep compartment syndrome or adhesion of the muscle due to various causes. We are not able to conclude what is the best treatment option. Open exploration and adhesiolysis at the adhesion site together with tendon lengthening at the distal tibial level is a feasible surgical option with satisfactory result.

A case of check-rein deformities of the great and lesser toes treated through exploration at the midfoot

We present the case of a twenty-two year old man who presented to the orthopaedic clinic complaining of clawing of his great toe. Further examination revealed clawing of the lesser toes and surgical scarring to the fibula and tibia. A history of previous operative fixation for lower limb trauma was described. Exploration of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) tendons was performed at the level of the midfoot. A full correction was achieved after release of the inter-tendinous connection between FHL and FDL tendons and z-plasty of the FHL tendon. This case highlights another possible complication of tibial fracture which should be actively looked for in patients with this injury. We describe and illustrate the ease of surgical correction through an operative field free of scar tissue which has the ability to possibly prevent unnecessary tendon z-plasty. We suggest that exploration at the midfoot should be the primary surgical intervention in similar cases of check-rein deformity.

Endoscopic adhesiolysis of the flexor hallucis longus muscle

Flexor hallucis longus muscle can adhere to the distal tibia after tibial fracture. The patient may complain of deep posteromedial ankle pain, checkrein deformity of the hallux, hallux flexus or development of hallux rigidus. Surgical treatment of release of the FHL muscle or lengthening of the FHL tendon has been proposed. We described an endoscopic approach of release of the FHL muscle from the distal tibia with the advantage of minimal soft tissue dissection.

LEVEL OF EVIDENCE

Therapeutic Level V: Expert Opinion/Technique.

Entrapment of the Flexor Hallucis Longus Tendon by Direct Impalement in the Osseofibrous Tunnel Under the Sustentaculum Tali: An Extremely Rare Complication of a Calcaneal Fracture: A Case Report

CASE

This article presents a case of entrapment of the flexor hallucis longus tendon in the osseofibrous tunnel under the sustentaculum tali due to a bone fragment from a calcaneal fracture. Despite good visualization with computed tomography, we did not recognize this complication preoperatively. Limited motion of the hallux was the key to recognition of this rare pathogenic situation.

CONCLUSION

We emphasize the importance of careful physical examination of the forefoot when there is a hindfoot injury.

Dynamic positional deformity of the hallux

The present study reports a case with concomitant tethering of the flexor tendon and extensor tendon of the hallux after closed tibiofibular shaft fractures. We have obtained good clinical results using tenotomy of the flexor hallucis longus tendon and Z-plasty lengthening of the extensor hallucis longus tendon. Because few studies have described the clinical results and operative methods for this type of combined deformity, we report a case with dynamic positional deformity of the hallux.

Surgical correction of checkrein deformity after malunited distal tibia fracture: a case report

Checkrein deformities are rare and involve entrapment or tethering of the flexor hallucis longus and, occasionally, flexor digitorum longus tendons. The deformity has typically been secondary to traumatic fractures of the talus, calcaneus, or deep posterior compartment syndrome resulting from fractures of the tibia and fibula and most fractures of the ankle. These result in flexion contractures at the interphalangeal joint of the hallux. Because of the rarity of this deformity, no single surgical technique has been defined as the standard. Previous interventions have included release of adhesions with or without Z-plasty lengthening of the involved tendons. The present study reports a case of checkrein deformity secondary to a malunited distal tibia fracture, with flexion deformities to digits 1 through 3. The patient underwent successful surgical correction with flexor tenotomies to the affected digits with interphalangeal arthrodesis to the hallux.

Checkrein deformity due to extensor hallucis longus hypotrophy treated with extensor digitorum longus tendon transfer

Checkrein deformity is a relatively rare condition caused by hypotrophy or adhesion of a tendon after a lower leg injury. The occurrence of this condition due to the dysfunction of the extensor hallucis longus (EHL) is extremely rare. Only a few related case reports have been published, and Z-lengthening of the EHL tendon was performed for almost all patients. We report a case of checkrein deformity due to EHL hypotrophy. The patient was involved in a traffic accident 7 years ago. He sustained left tibial and fibular closed diaphyseal fractures and underwent minimally invasive plate osteosynthesis. He continued to have left great toe symptoms characterized by dorsiflexion of the great toe during ankle plantarflexion. The EHL had become an insufficient power source because of considerable hypotrophy. Therefore, a tendon transfer using the extensor digitorum longus to the second toe was performed as a primary treatment.

Tibialis posterior entrapment: case report

Level of Evidence: V, Expert Opinion

Claw toes after tibial fracture in children

PURPOSE

The development of claw toe deformity following fracture of the tibia in children has not been described in our review of the literature. We report on the management of the acquired claw toe deformity after tibia fracture in five children.

METHODS

We report on five patients, between 5 and 15 years of age, who developed clawing of the hallux following a fracture of the tibia. In two patients, the lesser toes were involved. On examination, when the ankle was passively plantar flexed, a flexion contracture of the interphalangeal joint of the hallux became fully flexible. When the ankle was dorsiflexed, the clawing became more obvious and fixed. A magnetic resonance imaging (MRI) study in two cases demonstrated fibrosis under or just proximal to the tarsal tunnel.

RESULTS

The contractures were relieved by performing a tenolysis proximal to the medial malleolus. The operative findings demonstrated that the etiology could be possibly associated with a localized subclinical compartment syndrome.

CONCLUSIONS

We described five patients with a claw toe deformity following a tibia fracture associated with adhesions of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles to the surrounding structures under or just proximal to the flexor retinaculum. It is the authors' opinion that this condition may be related to a subclinical compartment syndrome localized in the distal part of the deep posterior compartment. Soft-tissue release without tendon lengthening allowed recovery in all patients.

Treatment of checkrein deformity of the hallux

We studied 11 patients with checkrein deformities of the hallux who underwent surgical treatment. Six had lengthening of the flexor hallucis longus tendon by Z-plasty in the midfoot, and five underwent release of adhesions and lengthening of the tendon by Z-plasty at the musculotendinous junction at the fracture site.

All six patients who underwent Z-plasty at the midfoot showed complete correction of the deformity without recurrence. Of the five who had release of adhesions and Z-plasty of the tendon at the fracture site, two showed partial and one showed complete recurrence.

Rupture du tendon du tibial postérieur lors des fractures de la cheville

We report three cases of complete traumatic tibialis posterior tendon rupture which occurred after ankle fracture. Diagnosis was established at surgery. Repair of the non-degenerative tendon was achieved during the procedure for osteosynthesis of the malleolar fracture. Fractures healed a few months after surgery. The posterior tibialis muscle tendon functioned plantar arch was normal, except in one patient with multiple injuries who died in intensive care thirteen days after the accident. Although exceptional, injury of the tibialis posterior tendon should not be overlooked after ankle fracture. These injuries become apparent only at surgery for the malleolar fracture since pain hinders clinical examination. Primary suture best guarantees a good functional outcome. Residual pain, deficit in active inversion of the foot, modified medial longitudinal arch, or progression to planovalgus are retrospective diagnostic signs.

Disorders of the hallucal interphalangeal joint

Most clinical presentations of the hallux concern the metatarsophalangeal joint; however, interphalangeal joint (IPJ) pathology also may be clinically significant. This article reviews conditions that commonly affect the hallucal IPJ and the appropriate treatment.

Checkrein deformity--flexor hallucis tethering: two case reports

The authors present two cases of checkrein deformity, a tethering of the flexor hallucis longus (FHL) tendon, following ankle surgery. The first case was treated by tenolysis and tendon lengthening posterior to the ankle. The second case was treated by lengthening of the FHL at the midfoot, a more simple procedure which produced a better outcome and faster recovery. The authors recommend this latter treatment should be considered to treat this problem.