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Forum Name: Bone trauma and fractures

Question: Fractured toe 4 months ago, still not healed


 ugh - Sun Oct 07, 2007 2:33 pm

Hello,

I'm a 39-year-old healthy male. About four months ago, I was walking past a brick structure and hit it with my bare foot. The toe next to my little toe was obviously broken, as it was twisted upward and toward my little toe. I went to a walk-in clinic that day, where the doctor x-rayed, set, buddy-taped, and x-rayed it again, then gave me the usual 4-6 week diagnosis. She did not say anything about joints being involved, and to the best of my knowledge it was only a broken phalange.

Here I am, four months later, and still on crutches. My whole foot swells up and turns a deep reddish purple if I leave it down for any amount of time, even when I sleep, so I keep my foot elevated above my heart constantly when I'm awake.

About three(?) weeks before I got the crutches, I hobbled around on my heel with a cane. Since I've heard of people walking with a broken toe and my doctor merely told me to wear supportive shoes, it seemed ok to do that at the time, but I'm wondering if putting the pressure on my heel affected the healing time, or even made the injury worse.

I've done a lot of research on this, but I'm still stuck with the following questions: Is it totally unheard of for a toe fracture to take this long to heal and still cause purple swelling of the whole foot? Also, can walking on the heel for a few weeks immediately after the injury affect the healing time of a phalange? Could my doctor have missed something in her diagnosis?

Thank you for your time.
 Dr. Chan Lowe - Mon Oct 08, 2007 11:42 pm

User avatar Hi Ugh,

This seems like an extremely long time for a toe fracture to heal. I would recommend you see an orthopedic surgeon to have this evaluated better. They are the bone experts.

Best wishes.
 ugh - Thu Oct 11, 2007 9:50 pm

Thank you, Dr. Lowe. :)

Orthopedic specialists wouldn't take me without a referral, so since I don't have a family doctor, I went to a walk-in clinic yesterday evening. They took full-foot x-rays, said my bones had a moth-eaten appearance, gave me possible causes including vascular, bone infection, osteoporosis, and cancer, and put in his diagnosis that my first metatarsal was fractured, even though he said it might be a sesamoid bone he was seeing on the x-ray. They called ortho first thing this morning to schedule an appointment, then called me back and said I needed to go to the ER instead, because ortho couldn't perform all of the tests I needed.

The ER doctor didn't understand why I was sent there instead of ortho (I suspect it having something to do with me not having insurance?). They took my blood pressure, my temperature and drew blood, I showed him the x-rays from last night and the ones from 4 months ago, answered a few questions while he pushed in various places, then the ER doctor said he saw an orthopedic specialist walking around and took the x-rays to show him.

Before I go further, two of the places I feel pain are between my 1st and 2nd toes and my heel, but only when considerable pressure is applied.

After he came back from talking to the ortho specialist, he said he was pretty sure it was reflex sympathetic dystrophy and that the specialist agreed. He also said the specialist didn't see a problem with my bones, so I guess this means both sets of x-rays were underdeveloped, since the ones from 4 months ago appeared to have this same "moth-eaten" appearance when I compared the two sets.

When the blood test came back, there was no sign of infection. However, I don't know if they were only checking for bone infection, or if soft tissue infection would show up in the test they ran.

The ER sent me home with a prescription for Anaprox, told me to follow up with the doctor from last night (who had me quite worried with all of his possibilities), and said I might need physical therapy and a neurologist.

Coming home and reading up on it online, I don't trust the ER doc's diagnosis. My foot doesn't sweat, nor do I feel pain unless there is pressure applied, and I have never felt the burning sensation. My condition has not progressed in all this time. It has merely stayed the same, except for the fact that I used to feel pain in the area of my initial fracture when I moved it, until just a few weeks ago. I'm wondering if the ER doctor didn't know enough about reflex sympathetic dystrophy or didn't pay attention to my answers, and perhaps was too suggestive when he spoke with the orthopedic specialist. Unfortunately, I didn't witness that conversation to know what was said.

Also, there is the issue of the clinic doctor's diagnosis of a fractured 1st metatarsal, which might be a sesamoid bone he was seeing (the ER doc said it was a sesamoid). I do feel pain there when pressure is applied, but I can't conceive of any possible way I could have fractured anything in that area. Could it be my flexor hallucis longus tendon that hurts there when it's pressed, and what about my heel?

Sorry for asking so many questions, and thanks again for your help so far.
 ugh - Sat Oct 13, 2007 4:03 pm

Hi Dr. Lowe,

Yesterday I tried standing, gradually applying pressure to the injured foot until there was equal pressure on each foot, and felt intense pain in my ankle or heel, I'm not sure which. Also, when I go to step forward on my injured foot, I feel similar pain in my big toe joint where my toe connects to my foot. I can move my ankle and toe in any direction and it doesn't hurt; but the more pressure I put on either area, the more it hurts, being intense if I put enough pressure on it to walk.

Today, my knee hurts if I lift my knee toward my chest from a sitting position. I just noticed this symptom today, so I figure it has something to do with standing yesterday. My ankle and toe joint feel the same as yesterday, moving feels ok, but applying pressure hurts.

As a reminder, I hobbled on a cane and my heel for a few weeks after my toe fracture; after that, I used crutches without applying any pressure whatsoever on my injured left foot or my left leg for the rest of these 4+ months, keeping it elevated constantly all that time.

I really want to see a specialist to properly diagnose my problem(s), but the orthopedic specialist wouldn't take me due to lack of insurance when my doctor tried to set an appointment. So, I'm stuck with trying to get whatever free advice I can get for now, in hopes that I can get medicaid when I apply next week.

I also tried to take pictures of my x-rays with a cheap digital camera, which I'm sure you know can be a daunting task. The quality isn't that great, but I'm posting them in case it helps for my previous post. I kept different shots of each one, because they show more or less details in different areas.

Front view
Angular view

My question for this post is, can non-use of my left foot and leg cause atrophy in my joints, and could that be what's causing the pain when I apply pressure? Or could I have swollen tendons from lack of use? Other suggestions?

Thank you so much for any information you can give me.
 Dr. Chan Lowe - Sun Oct 14, 2007 12:07 am

User avatar Looking at the x-rays posted I cannot see a fracture but the x-rays are a little hard to read. I do see what looks like a sesamoid bone.

Reflex sympathetic dystrophy can be quite painful and generally is treated with physical therapy to help relax the muscles and nerves.

A tendonitis can also cause pain when walking or putting pressure on it.

Following up with your doctor is important. Seeing an orthopedic specialist will be very helpful if at all possible.

Best wishes.
 ugh - Sun Mar 23, 2008 10:58 am

For others who may find this information useful, here's what happened.

After breaking my toe, I hobbled around on my heel with a cane for a couple of weeks, as mentioned in my first post. This caused unnatural use of the injured foot and it started to cause pain in my heel and other places of my foot that weren't broken, so I switched to using crutches with my injured foot off the ground, and continued using crutches this way for about four more months, not using the injured foot at all, because the pain never went away. The toe itself, however, was fully healed, albeit a little crooked because I didn't go back for that initial one-week followup after having the fracture reduced (set) and my toe buddy-taped.

The pain in weird places turned out to be Complex Regional Pain Syndrome (CRPS), otherwise known as Reflex Sympathetic Dystrophy (RSD). This is a condition of the nervous system that can occasionally occur after a relatively minor injury, usually when the injured limb is used unnaturally as a result of that injury. Mistake #1 was using the cane improperly and keeping my toes off the floor when I hobbled around on my heel.

The moth-eaten appearance... remember, this is after four months or so of not walking on the foot at all, suspending it in the air while I walked on one foot and two crutches during that whole time... That's right, bone atrophy. It was porous because it hadn't been used in over 4 months, not because of some disease. That was mistake #2, babying it for all those months when I should have been using it, at least a little bit, despite the pain.

My orthopaedic specialist explained all of this to me after we spent 3 hours in her office last October, looking at my foot and the x-rays, going over my medical history and physical lifestyle, and creating a detailed timeline of my condition over the previous 4 and a half months. She was very thorough and very straight-forward, and I truly appreciate all that she has done for me. I haven't been back for a few months, but have an appointment for a followup next weekend.

I still have some pain in my foot from the RSD, but I'm walking on it normally, and luckily it isn't nearly as severe as many of the cases I've read about. But for all of you people out there who are reading this after fracturing a toe, ankle, or whatever, if it's too painful to walk on it, it's better to stay off of it for a week or two until you can flex it normally while walking, than to end up with a possible lifetime of RSD.

Don't stay off of it too long or it will atrophy from non-use. You can regain bone mass with physical therapy afterward, but the more your bones atrophy, the longer it takes to reverse it, and the more you risk another fracture from the thin bones while you're trying to build them up again (which luckily didn't happen to me). Do ask your doctor how to use a cane properly, and follow those instructions. It should be held opposite the injured foot, not on the same side as the injury, and I repeat, the movement of your foot needs to be natural, even if you're not putting your full weight on it.

If I am wrong in any detail here, I'm sure a doctor will correct me. However, I speak from what my orthopaedic specialist has told me after thorough examination, as well as from my own experience.

Of course, pain where you don't expect it isn't necessarily CRPS/RSD, and you should see a qualified specialist to make that diagnosis. But I hope this information will help prevent someone else from getting it, because I've read some horror stories from people whose condition is far more severe than mine, even when the initial injury was no worse.

Thanks again for your time. :)

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