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No signs of healing after 6 weeks

on 9th sept 2011 I broke tip of tibia near ankle and fibula about 1-1.5" above that. 2 screws in tibia 5 screws, 1 plate and a diastasis screw in fibula. Had 3rd xray at 6 weeks show no change in fibular. The bones are not properly aligned surgeon said this was because it was shattered and bone turned to dust, there shows a clear gap and a crack measuring almost 2" running up from gap.
I'm still in a cast but they said after this week I can go into a cam boot. At the start they said total time off work be 12 weeks but then after surgery I had to have diastasis and 1 screw removed at the 12 week mark, no one will really say what the recovery time will be
My question is even if after 6 weeks no change will this set the trend and will it take a lot longer or it it normal not to show no change?
I'm desperate to get back to work and riding my horses.
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First Helper nazish
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replied October 17th, 2011
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maximas21,

From the description of your injury and fixation, you have sustained a bimalleolar ankle fracture, with rupture of the syndesmosis ligament. So, you have a significant injury.

The medial malleolus is usually fixed with two partially threaded lag screws. The lateral malleolus is usually fixed with a plate and screws; length of which depends upon how long the fracture line is. If the rupture of the syndesmosis results in a diastasis of the tibia and fibula, then one or more screws are placed across the syndesmosis to eliminate the diastasis.

The syndesmosis screw is usually removed, so that the tibia and fibula can actually move away from each other (just a tiny amount) when ambulating. If the screw is left in place, once the patient starts to walk, it could cause pain and/or the screw can break. So, once the syndesmosis has scarred down enough (healed), which is usually around 6 weeks or more, the screw is taken out.


You sort of confused me with the statement: "...At the start they said total time off work be 12 weeks but then after surgery I had to have diastasis and 1 screw removed at the 12 week mark, no one will really say what the recovery time will be..." If your fracture was on 9 Sept 2011, you are only about 6 weeks out from the injury, so how could you have had the screws taken out at the 12 weeks mark? This is confusing.


You state that there is no change on the x-rays, but the surgeon is going to allow you to start weight bearing in a Cam-Walker. By allowing you to go to a removable brace and weight bear, then there has to be sufficient healing to allow this.

The first bone that is laid down in not visible on x-ray. This is called osteoid. It is the "glue" that holds the fracture fragments together. As healing progresses, the body will then calcify the osteoid, and it will start to show up on x-rays. But, really early signs of healing include the rounding of the fragment edges, the fracture line becoming kind of fuzzy, and resorption of the bone edges around the fracture site. These all tell the surgeon how the fracture healing is progressing.


So, though you would like to see abundant callus as soon as possible, it does occasionally take some time to show up.

In terms of ankle fracture healing times, bony union can usually be achieved around 6 to 8 weeks. But, that is just the first step. Once the bones have united, then the soft tissues all have to be rehabilitated. The joints have to regain motion and the muscles have to regain their strength. That can take anywhere from a month to 6 months or more, depending upon how badly they were injured and how long they had to be immobilized.

But, in general, 12 weeks is a good estimate for bimalleolar ankle fractures to be healed and the patient returning to a sedentary job (desk job). But, heavy manual labor and sports can take quite a bit longer. And in some cases, it may take as much as 12 to 18 months (yes, months) before the final outcome is known.


It is best to discuss how long you will be out with your surgeon. He is the one that has actually seen the bones and soft tissues, and how badly they were injured. He also is the only one who knows how stable the fixation is and how much stress can be applied to it.

However, there are some things you can do. Such as do not use tobacco products. Nicotine affects the small vessel circulation in the new bone formation. Eat a good diet, with a little extra protein. When the surgeon allows weight bearing, try to follow his instructions. Placing stress across the fracture site will stimulate the body to heal the fracture faster. This is Wolff's Law - bone will respond to the stresses applied to it. That is why bones will get stronger and stouter when you lift weights and work out, and why osteoporosis occurs when minimal stress is applied to the bones (aging, space travel, injury, etc).


Wishing you the best. Hope your fracture heals well and you can get back to work soon. Good luck.
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replied October 17th, 2011
Sorry to sound confusing. I am 6 weeks post op I have sugery booked in Decemeber to removed the screws. Should of worded it better.
I'm a nurse so no sitting desk job for me, I see my doc again tomorrow so hopefully they can explain more but whenever I ask I get nothing and just a change in subject.
Maybe I should be a bit more demanding with answers.

Thanks for your responce Smile
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replied October 18th, 2011
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maximas,

That is much clearer. It is very common to schedule to remove the syndesmosis screw, at anytime from 6 weeks to 6 months. It is sort of a matter of the way the surgeon was trained, as there is no real consensus as to when it should be removed. But, if it is left in, after significant weight bearing, the screw usually breaks. Some surgeons feel that this is no problem and causes no problems, and as such, they just leave the screw in.

But, most patients sort of freak, when they see a broken screw, even if it is causing no problems. The reason the screw is removed (or left to break) is that the distal articulation of the tibia and fibula moves away from each other, just a tiny amount, during ambulation. This physiologic spreading allows the talus to move through the mortise of the ankle more easily. The talus us wider in the posterior portion of its dome, so when the ankle goes through the full plantar flexion to dorsiflexion, the wider part of the dome comes between the tibia and fibula, spreading them apart just a bit. The the tibia and fibula can't spread just that tiny amount, impingement symptoms develop, and the patient ends up with a painful ankle during dorsiflexion.


Hopefully, your fractures will show some healing on x-ray at your next appointment. If is kind of satisfying to see the fluffy new callus being laid down.


Once the fractures have completely healed and the patient has rehabed the limb, sometimes the other hardware is removed. It is not mandatory for the implants to be removed. If they are not causing any problems, they can stay in forever. But, sometimes the fibular plate is just under the skin and, as such, the patient's shoes rub on the area, causing pain. So, the plate is removed. But, this is a long ways off.


Be sure to ask the surgeon any and all questions that you may have. Sometimes it is helpful to write down the questions you want to ask. That makes the appointment time more efficient and you don't forget to ask something. And don't let the surgeon leave the room till your questions have been answered to your satisfaction.

Wishing you the best. Good luck.
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replied October 26th, 2011
Anyone with this kind of injury - talar dome lesion?
Hi there, just found this site, not sure if anyone can respond for me...9/10, twisted my ankle...2 weeks later had an MRI - Talar Dome Lesion...put in lace up boot thing..walked around, continued w/my life, but did not get any straight answers from my first ortho DR....went to another Dr, re read my MRI and have a fracture on the Talus with a 1.5x1.3 lesion on the talus.....along with cuboid and anothe small bone chip..given an air boot crutches and told to be "non weight bearing"...that's tuff to do, but I do my best, anyway, still ice during the day and take Aleve twice a day...pain still and some swelling...how long does this go on? Will I ever be able to fence again...that's how I injured myself in the first place, an overzealous fencing move backwords...any feedback from anyone with this???? thanks
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replied October 26th, 2011
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hobbles,

Welcome to eHealth. If you have a new questions, it is usually better to start a new post, rather than adding onto an existing thread, Members will see that it is a new question and are more likely to read it. But, that is neither here nor there.


Talar dome injuries come in two basic varieties. One that is most commonly due to an ankle sprain type of injury and one that develops as an osteochondral defect (OCD). The traumatic type is usually on the lateral side of the talar dome and the OCD on the medial side. But, this is not a hard and fast rule.

What these have in common, is that they both involve injury to the osteochondral surface. Here the cartilage covering and a small piece of bone become separated from the rest of the dome. The defect can be partial or complete.

In the acute type, nonweight or partial weight bearing is usually advised, in the hope that the defect will heal back, bone to bone. Then the defect around the edge of the cartilage, will fill in with fibrocartilage.

If, however, this healing does not occur, then the problems usually start. Chronic pain and sometimes a clicking feeling. The osteochondral fragment can become detached, and impinge in the joint, causing locking of the joint.

If the defect does not heal on its own, then you are usually looking at having to have surgery. This can vary depending upon the severity of the injury. It could be an arthroscopic procedure with percutaneous pinning of the fragment. Or it could consist of excision of the fragment. In some cases, an open procedure has to be done with to actually internal fix the fragment, if possible, and possibly to bone graft it as well.


So, this injury is not uncommon, but can be difficult to treat. You might want to see an orthopedic foot and ankle specialist, especially if the fragment does not heal readily. Anyone doing surgery on this lesion should be well versed in its treatment options.

Good luck. Hope you get back to fencing very soon.
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replied October 27th, 2011
Gaelic, thank you for your response...I should be able to preform the surgery (if need be) on this from all of the interent reading that i have done....Dr did say that my TDL is very rare as it is right in the middle of the talus.....usually found in folks that fall from great heights or planes! I do have the clicking and it is still very painful - I see my Dr tomorrow for a weekly follow up....he really insist on the NWB route, again, that's a pretty tall order to fill....type A and pretty stubborn asking for help.

BTW, I wasn't familiar with how to post on the site, but will do for sure in the future....thanks for the note on doing that.....makes total sense!
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replied October 27th, 2011
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No problem on the posting.

Yes, a central talar dome lesion is quite rare. It is much easier to knock off a corner than it is to squash the center.

It is difficult to be nonweight bearing, but you do not want to displace the osteochondral portion. Hopefully, you have not depressed the dome too much. That usually results in an noncongruent joint and the development of traumatic arthritis. In these cases, usually the depressed segment has to be pried up and bone graft put in under the dome to hold it up. And that is a big operation for the ankle.

The other problem with talar dome injuries is their pepensity to develop avascular necrosis (AVN). AVN can lead to collapse of the whole dome, which would be a pretty big problem.


So, hang in there. Try to stay off the ankle if you can. Hope you do well. Good luck.
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replied October 28th, 2011
wow, went to the Dr's this morning and we talked about AVN...scheduled for an MRI or Bone scan in two weeks to see if there has been any healing..now mind you, I did this on September 10 - walked around on it for about 3 weeks before I found the DR that told me to stay off of it.....have a "hands free" leg device so that I don't have to use crutches...not sure what's going to happen, this is pretty scary to me all of this....I'm a really active person and having the thought that I have a long recovery is making me a bit depressed....maybe I'll take up knitting or something........
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replied October 28th, 2011
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hobbles,

I know it's hard, but try not to worry till you have something to worry about. And, I don't think you would be happy knitting. Try to stay active, physical activity is very important to both our physical and psychological health.

Swimming is a great activity when you can't weight bear. You can try one legged stationary bicycling, but it doesn't do anything for the injured leg. Some gyms have upper body cycling machines for cardiovascular workouts.


I know fencing is very demanding on the ankles and thighs, especially with the lunges. My daughter and son-in-law both fence, but not at the level which you do. They also participate in an organization called the SCA, Society of Creative Anachronism, which keeps the arts, sciences, traditions, etc of the Renaissance period alive. They are both involved in the rapier fighting of the organization. My son-in-law is by no means a competitive fencer, but enjoys the activity very much.


So, try not to worry. Stay fit. And, hopefully, this lesion will heal on its own. If it doesn't, you can address the issue then. Good luck.
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replied October 29th, 2011
thank you for the "cheering up".....I will keep positive thoughts on my mind.....swimming would be an option for me and will try and do that a couple times a week...it's a good work out.

Rapier, that's an awesome weapon....beautiful and a heavy piece....my weapons are foil and epee.....

thank you again Gaelic for your thoughts and advice!
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replied April 10th, 2012
i had an spiral fracture of distal humerus on 29feb.....had a surgery ORIF a plate with 6 screws with associated radial nerve injury ..most likely post intreossii in that accident as i cant extend my fingers but the wrist...its been around 5 weeks i had an xray but there is no recovery sill..the x ray is as ..as it was before....w8ng for the reply
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