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12 Weeks post ankle ORIF for bimalleolar ankle fracture and pain

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Hi,

I am 23 years old. I had ankle ORIF for broken fibula 12 weeks back. I had been doing partial weight bearing for past 6 weeks. I am still on crutches and walking boot and had surgery after 3 days for removal of long screws. Yesterday, i did full weight bearing for 3-4 steps, i had no pain doing that.

However, i am having very mild pain in ankle sometimes (not regularly though) and no pain while walking. My doctor said last time, 2 weeks back that the bone is still healing but there is enough healing in my bone and won't break.

So i wanted to know, do you think it is just a normal muscle reflex or something wrong with my fracture site.

Thanks a lot
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First Helper User Profile Gaelic
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replied April 22nd, 2013
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pacific310,

If you are only having mild pain, you are doing well.

You have had a very significant injury to your ankle, so it is to be expected that you are going to have some aches and pains during your recovery. As long as you do not have any intense, sharp pain right at the fracture site, you are probably just fine.

Good luck.
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replied April 25th, 2013
Gaelic,

Hi. Thanks a lot. Today, I had syndesmosis screw removal (2 of them) post 85 days of my surgery.

I am little concerned whether my fibula would retain this position or it can move now too? I am 23 years old and weight about 220 pounds.

Thank you
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replied April 25th, 2013
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pacific310,

Most of the time, syndesmosis screws are removed after about 6 weeks. The ligament is basically physiologically healed in six weeks. After that time, there is not really any more "healing" going on.

So, by leaving the screws in for twice that amount of time, the syndesmosis is probably as strong as it is going to get.

The syndesmosis "normally" has a slight amount of "give" in it. This is so that the tibia and fibula can separate just slightly throughout the range of motion of the ankle. The dome of the talus (the tarsal bone that makes up the ankle mortise, along with the distal tibia and fibula, or the medial and lateral malleoli) is not the same width from anterior to posterior (front to back). It is wider in the front than in the back.

So, patients who actually scar the syndesmosis significantly can end up with some ankle problems. You want it be able to stretch just a little.


Thus, again, after 12 weeks, you are probably fine from the syndesmosis standpoint.


Good luck. Work hard on your rehab.
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replied April 26th, 2013
Gaelic,

One last thing Razz though i am being childish, could my syndesmosis shift again? I am really scared of this entire process. It took me 3 long months Sad

Actually, i am an international student in US and i think my entire studies would be ruined if something goes wrong. Sad

Thanks
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replied April 27th, 2013
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pacific310,

When dealing with the human body, anything is possible, just unlikely.

Of course, if you injure yourself again, you can tear the ligament again. But, it should be healed pretty well by now. It is now just a matter of completing your rehabilitation/recovery.


The syndesmosis is a very tough band of fibrous tissue, which holds the tibia and fibula together. It is called a ligament, mainly because it holds two bones together. (There is a similar structure in the forearm, called the interosseous ligament, which holds the radius and ulna together.) So, ligaments heal physiologically in about 6 weeks. You were immobilized for twice that long. So, the ligament is "healed" as much as it is going to.


You should be just fine. But, the only way to know, is do your rehab exercises and get back to your usual activities, and see how things go. Recovery does not "just happen", you have to work at it, and it takes a lot of hard work.

You are going to have the aches and pains of working out, and will probably be pretty sore from time to time. What you want to watch out for is any sharp, intense pain right at the fracture site, or along the syndesmosis. The bottom section of the syndesmosis is probably the most important part (just above the ankle mortise, at the plafond of the ankle). At that location, there are some ligaments called the tibiofibular ligaments (anterior and posterior). These are probably what needs to have really healed well to prevent the tibia and fibula from separating, causing widening of the ankle joint.

Again, you are just going to have to rehab and see what happens. It is not all that uncommon for patients to have some anxiety after a significant injury. So, you are not being childish.

Good luck.
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replied April 28th, 2013
Thanks for the help. One last thing Razz

I had been wearing a aircast boot since my fracture (jan 17)and since mid march i wear it only when i walk. The doctor has told me to wear it for like another 3-4 weeks instead of normal shoe so that i don't sprain the ankle or twist it.

But this means i should wear it when i go for walk outside, not inside the house or while i am sitting on bed.

Thanks
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replied April 30th, 2013
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pacific310,

They say that most injuries occur around the house, just kidding, if you feel okay walking around on even surfaces around the house (going to the bathroom), it is probably okay. Just be careful.

It is mostly the uneven ground that the surgeon is worried about.

As you get stronger over the next few weeks, you won't need to big fracture brace anymore. But, you might notice that you want some support. So, you can get the lace-up type of ankle support if you want. Or, you can just wear good tight fitting boots (like combat boots or high top hiking boots).

Good luck.
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replied May 4th, 2013
Hi Gaelic,

Thanks for the valuable advise.I have one more question, with a little description of my fracture.

When i fell my foot turned my 180 degrees and permanently settled at that position. Fibula was broken in between and tibia went completely out from tarcel (or there was nothing of ankle left), syndesmosis rupture was of good extent.

I have traveled back to India for 4 weeks to live with my parents and the doctor which treated me in childhood femur fracture saw x-ray and reports and said i might not be able to run, do sports and hike for entire life and he said to wear ankle shoes for entire life.

He also said to be cautious going to physiotherapist if he makes some horizontal motion in ankle and recommend me to work on physiotherapy on my own (he told me the procedure).

Can you please give opinion on both, running part n therapy. I am just 23 and really nervous to think of such limitations this early in life and possibility of arthritis in coming years.

Thank You
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replied May 4th, 2013
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pacific310,

Unfortunately, surgeons will always give you the worst case scenario. If it were to come true, at least the patient has been forewarned. If it does not, then the patient is very happy. Also, at least in the US, if the surgeons do not tell the patient all the bad things that can happen (“informed consent”), they get sued. So, because of the lawyers, physicians/surgeons now basically have to scare the heck out of the patient, telling them all the bad things that could happen (even if it is only a million in one chance). They can no longer tell the patient, don’t worry, I’ll take care of you. Can’t do that any more.


So, as to how you will do down the road depends upon several factors. Probably the biggest is who well the ankle mortise (joint) has been reduced. Joints which have been reduced back into an anatomical position will do the best. So, that is the reason to do surgery, to reduce the bones and joints back to where they should be, and held there until they are healed.

The second thing that affects how patients do, is how much scar tissue the patient forms around the injured joint. Some patients form a lot of scar, while others do not. The patients that form an abundant amount of scar usually have some problems regaining range of motion (the joint becomes stiff). But, that is not to say that it is best to not form any scar. There are patients who do not form enough scar to actually heal the damage. So, it is a balance, between forming enough scar to heal the damaged tissue, but not enough to cause problems. Unfortunately, the patient does not have any control over how much scar is formed. Physical therapy can help stretch the scar and such, during the recovery.



So, the orthopedic surgeon has to really evaluate the x-rays, to make sure the joint is congruent as it can be. A joint that is not reduced well is not congruent. This can cause abnormal wear of the joint surfaces, leading to early traumatic arthritis.


Thus, without actually seeing your x-rays, I cannot tell you if you have a good reduction or not. That you would have to discuss with your surgeons.


Again, remember that surgeons will usually tell you the worst case scenario. When that occurs, ask what the surgeon is basing that on: is there an incongruity in the joint, is the joint surface uneven, is the syndesmosis wide, what is making the surgeon say that this injury will not do well? Or is it just that he/she is you telling a “possible” outcome, something that “might” happen? Ask when you are told something like this.

Then, if there is truly some abnormality, can it be corrected? If not, then what should you do to keep the joint from causing you problems in the future?


So, hopefully, your surgeon was just be overly cautious.

Good luck.
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replied May 14th, 2013
Gaelic,

Thanks for the suggestion. I am undergoing rehab, currently at my home country and the doctor here has suggested me to go for my therapy when i return to US.

Right now, i am doing heat therapy for 3 times a day, and working on ROM after that and also like every half an hour or hour.

When i walk, i had stopped having pain in fracture site but i get mild pain in the join between foot and ankle when i put weight on it and walk.

I had started to walk with only one crutch inside my house and sometimes i try walking without it (like few steps 1-2 times in a day).

So whenever i get that pain which i mentioned, i get into constant fear of shifting my joint again, due to syndesmotic injury. What do you think about that aspect? The doctor at my home refuses to take x-ray and says it's not good in excess and you won't shift it.

I am overweight, aged 23 and weigh about 250 pounds. Sometimes i feel huge improvement in limp and speed of walking since i was allowed weightbearing (April 24, syndesmotic screw removal).

I am a student, with coursework and research work and I get really tense thinking when i would return to my life (at least the walking part).

Thanks
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replied May 14th, 2013
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pacific310,

It is very unlikely that the syndesmosis will stretch apart. Even if you are a little overweight, it is not going to stretch out.

It is very common for patient who has had a significant ankle injury, to have discomfort in the ankle joint. Some times it is difficult to tell esactly what is causing the discomfort.

Continue with your therapy and see how things go. The discomfort in the ankle joint may decrease with time.

Wishing you the best.

Good luck.
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