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

Abstract

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.

Keywords: Lauge–Hansen; adhesion; checkrein deformity; flexor hallucis longus; malleolar fracture.

Figure 1

X-ray (A, anteroposterior view and B, lateral view) and 3D reconstruction of a CT scan (C) of a primary left ankle injury. Radiographic evaluation confirmed the diagnosis of a Lauge–Hansen PER stage IV malleolar fracture.

Figure 2

X-ray of the left foot and ankle 32 months after the primary operation. No dislocation of the IP and MP joints (A,B) and synostosis formation at the fracture site or interosseous membrane (D) was observed. Syndesmotic screws (C) were removed at postoperative 10 weeks after primary operation.

Figure 3

Macroscopic appearance of the checkrein deformity of the left hallux and second toe 32 months after the primary operation. (A) The deformity was exaggerated with ankle dorsiflexion. (B) The deformity was ameliorated with ankle plantar flexion.

Figure 4

The asterisk indicated the presence of FHL tendon in the malleolar canal by the dynamic ultrasound.

Figure 5

Incisions of the exploration operation and FHL tenolysis. (A) The glide of the FHL tendon was observed within the malleolar canal through posteromedial incision. (B) The FHL muscle belly was attached to the fibula in the deep posterior compartment.

Figure 6

Macroscopic appearance of the left foot after surgical correction. Independent of the ankle position, dorsiflexion (A), plantar flexion (B), neutral (C), and the range of motion of the hallux and second toe was restored.