Treating Checkrein Deformities After Trauma

Todd Haddon, DPM, Lewis Freed, DPM, and Kate Johnson, DPM

These authors detail the treatment of a 23-year-old patient who presented with a big toe that would not straighten three and a half years after a car accident.

A checkrein deformity occurs due to a tethering or scar contracture around a tendon, which affects the tendon’s normal function. In the lower extremity, it is not uncommon to have an injury to the flexor hallucis longus tendon after lower leg trauma.

   The trauma typically involves the distal third of the leg and although authors typically describe the checkrein deformity with tibial fractures, the deformity has also occurred in conjunction with calcaneal, talar and fibular fractures.1,2 A checkrein deformity has also occurred after compartment syndrome and following the harvest of a fibular bone graft.3,4 A checkrein deformity can result from direct entrapment of the tendon within fracture callus and scar tissue located at the fracture site, or be due to damage and contracture of the muscle tissue itself.

   Patients often present with a flexion contracture of the hallux interphalangeal joint and extension contracture of the metatarsophalangeal joint. Dorsiflexion at the ankle causes the contractures to increase while plantarflexion lessens or resolves the contractures. A review of the literature indicates that the onset of the deformity may occur within 1.5 to nine months after injury.2,5

   Surgical treatment of these deformities can vary and often includes release of adhesions with debridement of fracture callus and tendon lengthening at the fracture site versus tendon lengthening distally.2

A Closer Look At The Patient Presentation

A 23-year-old male presented to our clinic with complaints of difficulty walking due to a big toe that would not straighten. Three and a half years earlier, he had been involved in a motor vehicle accident. Surgeons used an intramedullary nail in the treatment of the patient’s right tibial and fibular fractures. They did not surgically reduce the fibula.

   When the patient presented to us, we noted a flexion contracture at the level of the hallux interphalangeal joint and to a lesser extent at the metatarsophalangeal joint. This deformity increased significantly with dorsiflexion of the ankle and resolved with plantarflexion.

   After initial radiographic examination, we obtained magnetic resonance imaging to assess the viability of the flexor hallucis muscle and the location of entrapment. The flexor hallucis longus tendon was tethered proximally to bone at the healed fibular fracture site. No flexor hallucis muscle atrophy was visible.

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