Lateral Malleolus Fractures: Recovery Challenges and Solutions

Closed fracture of the left fibula with lateral malleolus displacement (with internal fixation implant)?

Hello, Doctor.
On December 18, 2023, I fell off my bike while riding down a slope, and my left foot was crushed under the bike (I was wearing protective gear).
At the moment of the injury, I experienced a severe twisting sensation, as if my foot had twisted half a turn.
I was startled and instinctively turned my body back, which made it feel somewhat normal.
Later, I went to the hospital for an examination and was diagnosed with a closed fracture with dislocation of the left fibula at the lateral malleolus, which seemed more like a sprain.
I subsequently underwent surgery to implant a titanium alloy fixation from the ankle to the fibula, approximately 20 centimeters long.

After the surgery, I followed medical advice and was hospitalized for about four days.
After being discharged, I continued with simple rehabilitation at home.
For the first three months, although the surgical site only occasionally ached and did not significantly affect me, the pain in the sole and dorsum of my foot frequently woke me up at night, causing me to wake up 5-6 times, severely affecting my sleep quality.
Even when I was at rest, the pain was intense enough to bring me to tears.
During these three months, the sole of my foot became abnormally sensitive; even a light touch would cause extreme discomfort.
I searched online for similar experiences but found none.
Eventually, with the help of a physical therapist and traditional Chinese medicine massage, the pain and joint mobility gradually improved.
However, I have since hit a plateau.

It has now been six months, and I am unable to spread my big toe outward.
There is little sensation on the dorsum of my ring finger, and I cannot control the middle joints of my index, middle, and ring fingers to grip steadily, which has made walking very difficult.
Although I can bear weight now, I am unsure if the fracture and sprain have worsened the slight valgus angle of my big toe, which has been measured at approximately 22 degrees.
My pelvis and shoulders are also not level.

Currently, my biggest concern is that although I have been practicing walking with crutches since 6-8 weeks post-surgery, and by 12-14 weeks I could walk slowly without crutches, I have returned to work and often need to drive a manual transmission car or lift heavy objects.
Now, six months later, I can bear weight and walk, appearing somewhat normal despite the pain.
However, the inner side of my foot still shows significant atrophy and depression.
My previously flat feet now appear to have developed a slight arch, and the plantar fascia feels very tight, making walking uncomfortable.
Even when walking on flat surfaces, I feel the bones in my foot making contact with the ground, which is very uncomfortable.
The metatarsals, big toe, and heel all hurt to the point that I am afraid to walk barefoot.
The toes at the extremities are numb and painful.

I would like to ask the doctor if there is a chance for recovery from these conditions I am currently facing.
How can I improve the issues I am experiencing? Should I consider seeing a neurosurgeon or explore acupuncture and other examinations in traditional Chinese medicine? Thank you for your patience in reading this.

KK, 20~29 year old female. Ask Date: 2023/06/13

Dr. You Dianqi reply Orthopedics

Hello, it is recommended to schedule a follow-up appointment with your physician to discuss the subsequent rehabilitation progress.
Thank you.

Reply Date: 2023/06/13

More Info

Lateral malleolus fractures, particularly those resulting from traumatic events like falls or accidents, can lead to a complex recovery process. Your experience, as described, highlights several common challenges faced by individuals recovering from such injuries.
First, it’s important to understand the nature of your injury. A lateral malleolus fracture involves the fibula near the ankle, and in your case, it was accompanied by significant trauma and displacement. Surgical intervention, such as the insertion of a titanium plate for stabilization, is often necessary to ensure proper alignment and healing of the bone. Post-surgery, the focus typically shifts to rehabilitation, which can be a lengthy and sometimes painful process.

From your description, it seems you have been proactive in your recovery, adhering to rehabilitation protocols and seeking assistance from physical therapists and other practitioners. However, persistent pain, sensitivity, and functional limitations, such as difficulty with toe movement and altered gait, are not uncommon after such injuries.

Recovery Challenges
1. Pain Management: Chronic pain, especially at night, can significantly affect your quality of life. This pain may stem from several factors, including nerve irritation, inflammation, or even issues related to the surgical site. It’s crucial to communicate this ongoing pain to your healthcare provider, as they may need to adjust your pain management plan.

2. Sensitivity and Swelling: The heightened sensitivity in your foot could be due to nerve involvement or changes in the soft tissue surrounding the fracture site. This can lead to discomfort even with light touch. Regular physical therapy can help desensitize the area over time.

3. Range of Motion and Strength: The inability to move your big toe outward or the lack of sensation in certain areas can indicate issues with nerve function or muscle control. This can be exacerbated by immobilization during the healing phase. Engaging in targeted exercises, as prescribed by your therapist, can help improve strength and coordination.

4. Foot Structure Changes: The development of a foot arch and changes in foot structure, such as increased hallux valgus (bunion), can occur post-injury. These changes may affect your gait and lead to further discomfort. Custom orthotics or supportive footwear may be beneficial in managing these structural changes.

Recommendations for Improvement
1. Continued Rehabilitation: It’s essential to maintain a consistent rehabilitation program. Focus on exercises that enhance flexibility, strength, and proprioception. Your physical therapist can provide a tailored program that addresses your specific needs.

2. Pain Management Strategies: If you are experiencing significant pain, consider discussing alternative pain management options with your physician. This could include medications, physical modalities (like ultrasound or electrical stimulation), or even acupuncture, which some patients find beneficial.

3. Neurological Assessment: Given the sensory changes you’ve described, it may be worthwhile to consult a neurologist. They can assess for any nerve damage or dysfunction that may be contributing to your symptoms.

4. Footwear and Orthotics: Investing in supportive footwear and possibly custom orthotics can help alleviate some of the discomfort you’re experiencing while walking. Proper arch support and cushioning can make a significant difference.

5. Gradual Return to Activity: As you continue to recover, gradually increase your activity level. Listen to your body and avoid pushing through pain, as this can lead to setbacks.

6. Follow-Up Care: Regular follow-up appointments with your orthopedic surgeon are crucial to monitor your healing progress and make necessary adjustments to your treatment plan.

In conclusion, while the recovery from a lateral malleolus fracture can be challenging, many individuals do experience significant improvements over time with appropriate care and rehabilitation. It’s essential to remain patient and proactive in your recovery efforts, and don’t hesitate to seek further evaluations if your symptoms persist or worsen. Your commitment to rehabilitation and self-care will play a vital role in your overall recovery journey.

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