Date: Wed, 12 Feb 2003 09:15:58 +0500
Subject: 1st toe drop
Hello All,
Some time ago there was a discussion about postop/postraumatic drop of the 1st toe of the foot. If somebody keeps the messages in his/her database pls forward some to me. Or hint what does cause the drop and what literature on the subject can be found online.
THX in advance.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Wed, 12 Feb 2003 18:03:39 +0000
From: Chris Oliver
J Bone Joint Surg Br 1999 May;81(3):481-4
Dropped hallux after the intramedullary nailing of tibial fractures.
Robinson CM, O'Donnell J, Will E, Keating JF.
Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, UK.
We made a prospective study of 208 patients with tibial fractures treated by reamed intramedullary nailing. Of these, 11 (5.3%) developed dysfunction of the peroneal nerve with no evidence of a compartment syndrome. The patients with this complication were significantly younger (mean age 25.6 years) and most had closed fractures of the forced-varus type with relatively minor soft-tissue damage. The fibula was intact in three, fractured in the distal or middle third in seven, with only one fracture in the proximal third. Eight of the 11 patients showed a 'dropped hallux' syndrome, with weakness of extensor hallucis longus and numbness in the first web space, but no clinical involvement of extensor digitorum longus or tibialis anterior. This was confirmed by nerve- conduction studies in three of the eight patients. There was good recovery of muscle function within three to four months in all cases, but after one year three patients still had some residual tightness of extensor hallucis longus, and two some numbness in the first web space. No patient required further treatment.
Date: Thu, 13 Feb 2003 11:07:13 -0500
From: David Goetz
It is possible to damage the motor branch to the EHL with the drill bit for the proximal locking screw of the tibial rod. We have had one such case confirmed: loss of isolated motor loss to the EHL without other weakness or numbness. A brief contracture of the EHL was seen intraoperative at the time of the drill "plunge" into the anterior compartment.
David R. Goetz MD
Medical Director, Orthopaedic Trauma
Date: Thu, 13 Feb 2003 17:30:31 -0500
From: Michael Tucker
The circumstance of 'dropped hallux' does occur occasionally after tibial IM nailing. I have experienced this 2-3 times in my career without obvious explanation. This subject was covered reasonably well in the following article
JBJS (British) 81(3):481-484
Dropped Hallux After Intramedullary Nailing of Tibial Fractures
Should be available online. Hope this helps.
Mike Tucker
Michael C. Tucker, MD
Director, Orthopaedic Trauma Service
Assistant Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Medical College of Georgia
Date: Fri, 14 Feb 2003 19:14:15 EST
From: Tadabq
As previously observed on this website, it seems to me that patients who have trouble with big toe extention (and perhaps dorsiflexion of the ankle) get a diagnosis of "peroneal palsy" in the US whereas the same patient is diagnosed with "dropped hallux" in England. So to some degree, it's a difference in terminology and I'm not sure which one is more correct or precise. Oftimes the ankle dorsiflexion returns but the patient is left with weakness or inability to fully extend the big toe.
That problem overshadows the issue of trying to distinguish the specific cause of various maladies of the anterior compartment. Is it specifically the EHL vs a more generalized peroneal nerve distribution motor weakness versus a myriad of other etiologies (anterior compartment syndrome, individual muscle compartment syndrome, direct muscle injury, individual nerve branch injury, more proximal nerve injury (common peroneal or sciatic,...)
Tom DeCoster
Date: Sat, 15 Feb 2003 10:06:53 +0500
From: Alexander Chelnokov
Hello Tom,
TAC> That problem overshadows the issue of trying to distinguish the specific nerve branch injury, more proximal nerve injury (common peroneal or sciatic,...)
Recently the dropped hallux (not entire foot) has occured in our patient after iliosacral screw insertion.
Best regards,
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Mon, 3 Mar 2003 12:40:52 -0700
From: Thomas A. DeCoster
Have you been able to identify the deficit any more precisely? Is this 0/5 of the EHL on physical exam. What is the motor exam to the other toe extensors and the rest of the foot. What is the sensation testing? Have you performed electrodiagnostic tests like EMG/NCV? Partial or complete denervation?
I'd have to review the neuroanatomy to see if we know which neural elements (L5, S1, S2 nerve roots, lumbo-sacral plexus, sacral plexus) provide which peripheral motor function (EHL). With neuro deficit after SI injury and IS screw placement, the level of injury seems likely to be around the sacrum. Direct injury to a nerve from an implant or instrument, indirect injury from stretch or compression, or exacerbation of original trauma injury (hematoma, etc) are all possible. It's sometimes hard to distinguish a new nerve deficit from a previously unrecognized or incompletely described nerve deficit. Some will improve with time and we never know the exact etiology. Others persist. TD