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Treating Checkrein Deformities After Trauma

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.

   We directed our initial attention to the lateral aspect of the lower leg and located the healed fibular fracture. Freeing the muscle from the healed fracture site provided a moderate degree of improvement in the deformity but some contracture persisted. Accordingly, we performed a release of the intramuscular portion of the flexor hallucis longus posteriorly, providing the desired release of the contracture.

In Conclusion

The flexor hallucis longus tendon arises from the inferior two-thirds of the posterior surface of the fibula and interosseous membrane. Lee and colleagues described two types of surgical repair for checkrein deformity, one with release of adhesions and Z-plasty lengthening at the musculotendinous junction above the ankle at the fracture site and the other technique involving lengthening of the flexor hallucis longus in the midfoot.6 The authors noted prolonged success with the latter procedures while the more proximally-based procedures had varying degrees of recurrence to the formation of new adhesions.

   In our particular case, the release of adhesions proximally at the location of the fracture callus did not allow for complete reduction of the deformity and more distal release was necessary. Although the gross appearance of the flexor hallucis longus muscle tissue was normal, contracture required the additional intramuscular release. We observed complete resolution of the deformity following this aspect of the procedure.

   Dr. Haddon is in private practice in Mesa, Ariz.

   Dr. Freed is in private practice in Mesa, Ariz.

   Dr. Johnson is a third-year resident at Maricopa Medical Center in Phoenix.


1. Kim SH, Lee KT, Smitt RW, Park YU. Checkrein deformity secondary to entrapment of FHL after talus fracture: a case report. Foot Ankle Int. 2010; 31(4):336-338.

2. Carr JB. Complications of calcaneus fractures: entrapment of the flexor hallucis longus: report of two cases. J Orthop Trauma. 1990; 4(2):166-168.

3. Sanhudo JAV, Lompa PA. Checkrein deformity – flexor hallucis tethering: two case reports. Foot Ankle Int. 2002; 23(9):799-800.

4. Fitoussi F, Ilharreborde B, Guerin F, Souchet P, Pennecot GF, Mazda K. Claw toes after tibial fracture in children. J Child Orthop. 2008; 3(5):339-343.

5. Rosenberg GA, Sferra JJ. Checkrein deformity – an unusual complication associated with a closed Salter Harris type II ankle fracture: a case report. Foot Ankle Int. 1999; 20(9):591-594.

6. Lee HS, Kim JS, Park SS, Lee DH, Park JM, Wapner KL. Treatment of checkrein deformity of the hallux. J Bone Joint Surg Br. 2008; 90(8):1055-1058.

Additional References

7. Carranza-Benzaco A, Gomez-Arroyo JA, Fernandez-Torres JJ. Hallux flexus deformity due to entrapment of the flexor hallucis longus tendon after an open fracture of the tibia and fibula. Foot Ankle Surg. 2000; 6(2):133-135.

8. Sammarco GJ, Miller EH. Partial rupture of the flexor hallucis longus tendon in classical ballet dancer. J Bone Joint Surg Am. 1979; 61(1):149-151.

9. Leitschuh PH, Zimmerman JP, Uhorchak JM, Arciero RA, Bowser L. Hallux flexion deformity secondary to entrapment of the flexor hallucis longus tendon after fibular fracture. Foot Ankle Int. 1995; 16(4):232-235.

10. Gould N. Stenosing tenosynovitis of the flexor hallucis tendon of the great toe. Foot Ankle. 1981; 2(1):46-48.

11. Clawson DK. Claw toes following tibial fracture. Clin Orthop Relat Res. 1974; 103:47-48.

12. Feeney MS, Williams RL, Stephens MM. Selective lengthening of the proximal flexor tendon in the management of acquired claw toes. J Bone Joint Surg Br. 2001; 83(3):335-338.

13. Tsai K, Wang C. Checkrein deformity following tibial fractures a report of five cases. J Orthop Surg Taiwan. 2001; 18(4):193-197.

14. Canale ST, Beaty JH. Campbell’s Operative Orthopaedics, 12th Edition, Ch. 54, Elsevier, Philadelphia, 2013, pp. 2617-2724.

Online Case Study
Todd Haddon, DPM, Lewis Freed, DPM, and Kate Johnson, DPM
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