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Old 07-16-2013, 07:50 PM   #1
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Unhappy Nonunion Avulsion Fracture - a year out.

Good Evening everyone!

My name is Amanda and this is my first post to the boards.

A little back ground about my issue. I moved to Florida December 2011. While moving I don't know if I tweaked my knee or my ankle. Got settled and found a new PCM. Told him about the issues and I ended up with an x-ray, MRI, a script for Nambutone and Proxicam. Plus went through three months of three days a week PT.

Literally my 3rd day back at the gym, I was doing boxjumps and came off the box wrong. I heard and felt the snap pop as did my trainer and husband. I wrapped my ankle with tape and limped home. I couldn't put any pressure on my foot. I wanted to "tough" it out and just let the sprain heal on its own. Big Mistake. I was in the ER 36 hours later with a black foot the size of a softball. They cast it with the fiberglass incorrectly after they took an x-ray. The doc came back with an avulsion fracture. Told me to follow up with Ortho. Well at this point I had no insurance as my Tricare ended. So, I head back to the ER to have the correct cast reapplied. Was told to follow up with Ortho again and I explained that I don't have the $700 that they want up front to see me since I have no insurance. For the next 4 weeks I take off the fiberglass cast to shower and to ice it then put it back on. I'm a medic and was trained how to apply them, thus why I knew they did it wrong the first time. In anycase, 4 weeks go by and I start using kinesio tape which brought me pain relief and i brought a brace. It's the kind you slide on, lace up, figure 8 the velcro straps around the ankle and up the side then take the last one around the top of the ankle.

Fast forward to a move to Minnesota and a cold winter. Took a job as a unit coordinator with Mayo Clinic in May. I'm on my feet alot walking around the units and all over campus. My third week there I was having sharp hip pain that went down my leg. Saw the doc and he thought siatic nerve. I get a script for Flexeril. Get in to see my primary for a physical in June. She ordered a x-ray and it showed an ossicle. Then I'm sent to Ortho. The PA seen me and told me since I'm a year out on my injury and from the xray he can see that its a nonunion heal. He then refers me to a ankle specialist. He looks at me and orders an MRI stating that its to determine what surgery I need, not if.

Had my MRI monday. And here are the results-

MARROW: No acute fractures or contusions. 5x5mm ossicle inferior to the lateral malleolus is compatible with old remote nonunited avulsion fracture.

ALIGNMENT: No subluxation.

ARTICULAR CARTILAGE: There is an osteochondral lesion of the anterior lateral aspect of the talar dome that measures 4mm transverse by 3mm anterior-posterior. This osteochondral lesion has the subchondral cyst formation and associated subchondral marrow edema.

SYNOVIUM: Moderate effusion of the tibiotalar joint.

LIGAMENTS: Anterior and postterior inferior tibiofibular ligaments are intact. Anterior talofibular ligament is intact, though thickened from probable old healed injury. Posterior talofibular ligament, calcaneofibular ligament, deltoid ligament, spring ligament all intact.

GANGLIA: None

TENDONS: Achilles tendon is intact. Peroneus brevis and longus tendons are normal. Posterior tibialis tendon is normal. Flexor digitorm longus tendon is normal. Flexor hallucis longus tendon is normal. Normal anterior tibialis tendon, exterior hallucis longus tendon and extensor digitorum longus tendon.

PLANTAR FASICA: Intact.

MUSCLES: No atrophy.

SINUS TARSI: Normal

IMPRESSION:
1. Normal peroneal tendons.
2. Osteochondral lesion of the talar dome.
3. Moderate tibiotalar joint effusion.
4. Chronic nonunited avulsion fracture lateral malleolus.
5. Probable old healed injury of anterior talofibular ligament.

I wear my brace to work for 12 hours a day, come home and ice my ankle. I'm up to 2400mg (800mgx3 per day) of Motrin. Now my knee is swelling and starting to hurt as well. At this point I'm waiting for a follow up to discuss this with the doc.

Have any of you seen something like this or had something like this? I'm terrified of surgery simply because I know I will be immobile for a few weeks.

Last edited by Administrator; 07-16-2013 at 08:28 PM.

 
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Old 07-17-2013, 07:57 PM   #2
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Re: Nonunion Avulsion Fracture- a year out.

First, let me say Welcome to the boards. We are a friendly group of individuals that are supportive and always willing to suggest tips or useful tricks to help. I am sure someone will come along soon that has had the same sort of injury and can offer some words of encouragement or advice. I wish you the best at your appointment, please keep us posted on the results.
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Old 10-11-2013, 11:03 PM   #3
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Re: Nonunion Avulsion Fracture- a year out. UPDATE 10/11

It has been awhile since I have checked in!

August 26 I had a cortisone injection and the OS started me on PT once a week. PT has gone ok. I don't know if the pain reduction is from the injection or PT or both.

I saw the OS Thursday and was given two options.

1- Surgery. Bromstom, clean up of scar tissue and possible drilling into my bone. He kept saying that I have a old divet in it and that could be a source of my pain. But that he wouldn't know until I'm on the table. And if he sees that something's messed up he will drill to increase blood flow and fix it. Depending on what he does will depend on my down time. He quoted 12-18 weeks housebound.

2- Long term PT. Basically icing when I need it. Keeping up with my bands, ROM drills and the other things taught in PT. I would go to a few more sessions with the therapist then be released to self manage. I would be in a brace or compression sock most of the time depending on my activity.



I was shocked. Neither choices I wish to entertain. Both have pros and cons. The main reason for surgery is to get stability back. I'm to the point of rolling my ankle if there is even a slight change in the ground. Which alone is terrifying. I went down three weeks ago walking across the parking lot going to PT. I really want a second opinion but due to being a Mayo employee and carrying their insurance I'm stuck with Mayo Clinic Ortho unless I want to pay 100%.

Any suggestions? Or thoughts? I will have more details on Tuesday when I get back to work and pull my MR. I was kind of in a haze and forgot 40% of the conversation once he started giving me the time tables.

 
Old 10-12-2013, 01:15 AM   #4
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Re: Nonunion Avulsion Fracture- a year out. UPDATE 10/11

Hmmm. I think mayo clinic ankle orthopedic doctors are well respected and I was going to consult with one if I needed surgery. I dont live far from them. What did he say about your ocd? How agressive is he with pt after surgery? How long nwb? Some doctors want u in a cast for many weeks and some just a couple and are more agressive with weight bearing. Can u call your nurse and get all that info. Again. Your pt might help with your ankle. I believe you are rolling it a bunch due to ankle laxity. But if you are getting pt youll know if that helps within 3 months right? The experts have been through this and will know and cann post. My ankle is ridiculous loose and im worried my pt wont help. Only 2 weeks for me. Too soon to tell.

 
Old 10-12-2013, 01:23 AM   #5
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Re: Nonunion Avulsion Fracture- a year out. UPDATE 10/11

Oh and I dont think its a good idea to release you from pt and just send you home with exercises. I have pt for 6 weeks 2 to 3 times per week. We r busy every session. And I do new things every session to further do rom and strengthen my ankle. I just became weight bearing but you obviously have a problem. Im in a sports pt clinic. Athletes are everywhere. Its awesome. I know if I want to learn to run again that they will help me (no thanks I hate running but you get the point). Anyways they r very agressive and wouldnt just get me by . They treat all the college highschool and our sport teams .

 
Old 10-12-2013, 06:46 AM   #6
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Re: Nonunion Avulsion Fracture- a year out.

If he doesn't drill-
2 weeks foot elevated, nwb
4-6 weeks in air cast boot, wbat
PT after
Minimum 8 weeks no driving

If he does drill-
4 weeks foot elevated, nwb
6-12 weeks in air cast, wbat
PT after
He said if this happens I'm looking at 16-18 weeks of downtime

He sent me to PT during our first visit. Once a week for 30 minutes plus doing the daily drills at home/work. This was in hopes of gaining stability back. I have some but not very much. I still feel wobbly and still have pain. OS said that surgery may not fix the pain or the swelling and that the main reason for it would be to fix the instability and clean up my ankle. He also explained that the swelling may never go away.

I talked to my PT therapist and he said that if it was him that he would take the conservative route and maintain PT. Gradually increase my activity and see how it goes. If the inversions keep happening then have surgery. My goal is to get back to CrossFit on a full time basis and be able to do my lifts and maybe minimal sprints. I can live without running but I can't live without lifting.

The reason I question PT is for the simple fact of this being the second time around. The first time I was in Florida and was having knee and ankle pain for a few weeks after a inversion while I was moving. Family doc just sent me to PT 3 days a week for an hour each session. I did that March 12-May 12. I went back to CrossFit July 12. My 3rd day back I jump off a 24inch box and end up with an avulsion fracture. This was 3 weeks after Tricare insurance stopped. With no insurance no Ortho would see me without $500-1000 upfront. So I wore the fiberglass splint for four weeks taking it on and off to shower and ice. The only reason I know how to take it off and on is because I was trained in the ER when I worked there. From there I wore a lace up figure 8 brace when I was doing things beyond normal range. I also used kinesiology tape which worked very well.

 
Old 10-12-2013, 07:25 PM   #7
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Re: Nonunion Avulsion Fracture- a year out.

Id go with what your pt says. Like your doctor said, surgery doesnt guarantee no pain, it just willl fix your laxity. Id do pt and maybe try to find one that does the athletes in your city if you can. The literature says the outcomes are the same whether you wait and do pt first or not. You might as well wait. And winter is here soon. I personally dont want to do crutches on the snow and ice

 
Old 10-13-2013, 09:54 PM   #8
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Re: Nonunion Avulsion Fracture- a year out.

I'm sorry that you're having a rough time with your ankle, acj. I don't know if I can give you a different perspective on things but I will tell you what I'm dealing with and hope I can make some suggestions for you to look into that might help.

I had surgery to reconstruct my ankle in Feb. 2013..8 mos ago. The list of stuff they did is in my signature line...heck, I don't even remember the technical names any more. Long story short...I had an extra bone in the arch of my foot, born with it...over my lifetime, it has caused my foot to break down, foot go flat, ligaments were so loose I was rolling my ankle all the time and falling. In the past 10 yrs, I have had 5 knee surgeries to repair torn meniscus...from falling! Then my foot became so painful that I couldn't live with the pain any longer. So I had the surgery. Now, I had a lot of procedures done....I was put in a fiberglass cast 3 wks after surgery and wore that for 7wks..all nwb. Then I was put in a walking boot, and started PT. I went back to work after 3 wks...I rented a wheel chair to sit in at my desk so I could elevate my leg all day and used my knee scooter to get around. I was fine with that. Up till a few wks ago, I was a star patient and my surgeon was bragging about my wonderful healing process. I had an Allergraft bone graft done (donor bone from a cadaver) and have a 6" screw in place. I also have a plastic "anchor" attached to my 2 ligaments they tightened to keep then tight.
I started having pain....just like you described, a snap pop feeling just in normal walking...thought the Peroneal tendon they repaired was acting up. Went to the OS and they took an xray....Non-Union of the bone graft! It was completely healed closed in April. Now, suddenly, it is split wide open right thru the screw! I am back in the walking boot fo 2 mos. Here is the interesting thing I want to tell you about...they ordered an ultrasonic bone stimulator for me to use at home, twice a day. It's the Exogen bone stimulater...FDA approved. Uses ultrasound stimulation directly to the bone to wake things up and make your body produce more protein and blood to flood that non-union area so the bone grows double time. There's a 90% chance that this will make the bone grow and fuse together again. If not, then I have to have another surgery. I am praying this bone stim. works! I had never heard of it before. I wonder why they don't use it all the time for people who have bone grafts?! They use it a lot on athletes to get them healed quicker so they can get back in the game. Maybe this could be an option for you!
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Old 10-15-2013, 01:00 PM   #9
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Re: Nonunion Avulsion Fracture- a year out.

OS note-

The patient is, I think, still suffering from the results of the ankle sprain. She has, still, feelings of instability. She is having some swelling. While she does not have any mechanical symptoms, the osteochondral lesion of the talus that is seen on the outside MRI may be contributing to this. She also, on that MRI, has some tissue in the front of the ankle that may be causing some irritation of the ankle as well.
We talked about treatment options in detail with the patient. I think she can either continue with the comprehensive nonoperative treatment program that she is already doing, or she can consider surgery. I think surgery, for her, would be an examination under anesthesia, a right ankle arthroscopy, debridement, and microfracture as needed, and a possible Brostrom-Gould ligament repair. I discussed risks, benefits, and alternatives to surgery with the patient as well as expected postoperative recovery and outcomes. She expressed understanding. I think the postoperative recovery process is more than what she was anticipating, and she is going to have to consider this as to what she can do. All questions were answered.
DIAGNOSES
#1 History of right ankle sprain (date of injury July 2012)
#2 Right lateral ankle instability
#3 Right lateral ankle and foot pain


I went to PT this morning and was doing ok. Still have pain across the top of my foot and around my ankle. Swelling is still apparent. Went back to taping and brought a compression sleeve. Ran after my daughter Sunday in the yard and had sharp pain when my foot struck the ground. I switched from heel strike to ball strike and still had pain. I hate feeling as if I'm running out of options.

If any of you have had what the OS recommends please tell me about your experience.

 
Old 10-15-2013, 02:46 PM   #10
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Re: Nonunion Avulsion Fracture- a year out.

Quote:
Originally Posted by acj678 View Post
OS note-

The patient is, I think, still suffering from the results of the ankle sprain. She has, still, feelings of instability. She is having some swelling. While she does not have any mechanical symptoms, the osteochondral lesion of the talus that is seen on the outside MRI may be contributing to this. She also, on that MRI, has some tissue in the front of the ankle that may be causing some irritation of the ankle as well.
We talked about treatment options in detail with the patient. I think she can either continue with the comprehensive nonoperative treatment program that she is already doing, or she can consider surgery. I think surgery, for her, would be an examination under anesthesia, a right ankle arthroscopy, debridement, and microfracture as needed, and a possible Brostrom-Gould ligament repair. I discussed risks, benefits, and alternatives to surgery with the patient as well as expected postoperative recovery and outcomes. She expressed understanding. I think the postoperative recovery process is more than what she was anticipating, and she is going to have to consider this as to what she can do. All questions were answered.
DIAGNOSES
#1 History of right ankle sprain (date of injury July 2012)
#2 Right lateral ankle instability
#3 Right lateral ankle and foot pain


I went to PT this morning and was doing ok. Still have pain across the top of my foot and around my ankle. Swelling is still apparent. Went back to taping and brought a compression sleeve. Ran after my daughter Sunday in the yard and had sharp pain when my foot struck the ground. I switched from heel strike to ball strike and still had pain. I hate feeling as if I'm running out of options.

If any of you have had what the OS recommends please tell me about your experience.
If you just had the sprain id just wait and see. But I do not have any knowledge about ocd. Id try to wait and see what other peoole that have experience with ocd would say. Good luck. Nwb with a 3 year old will be tough. Id definitely line up help before comitting to any surgery.

 
Old 10-15-2013, 10:37 PM   #11
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Re: Nonunion Avulsion Fracture- a year out.

I have had sprains since high school. It has been chronic with a bad inversion every 12-16 weeks and weekly give ways. The last major one happened July 2012 and it was an avulsion fracture. My daughter is 6 (will be 7 in January). The earliest I can get in with the OS for surgery is December.

 
Old 10-26-2013, 10:16 AM   #12
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Re: Nonunion Avulsion Fracture- a year out.

Finally commited to a date, Friday the 13th of December.

So, any suggestions to get me to the date with out calling and rescheduling or canceling?

Also! Thoughts about the holidays?

And being in MinneSNOWta, handleing the cold, ice and snow?

Thanks in advance!!

 
Old 10-26-2013, 02:32 PM   #13
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Re: Nonunion Avulsion Fracture - a year out.

Congrats on setting a date for surgery. For me, knowing my ankle would be fixed helped me not canceling. I was more calm the night before, and I knew it was the right decision. Of course I only had a 2 week wait when I had mine.
My surgery was actually Dec 11 last year, and in southern IL we don't get a ton of snow, we get more ice usually. I tried to stay indoors when the weather was bad. I couldn't drive with it being my right foot, so I always had my mom or sister with me and they were always watching to make sure I wouldn't fall. Also if you are out and it's wet, make sure you wipe off the crutches. I took a nasty spill 3 days out from surgery from wet crutch tips. I've seen on here that you can order tips or spikes for the bottom of the crutches. You may want to check that out.
Good luck! If you have more questions feel free to ask!
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Old 10-27-2013, 05:10 PM   #14
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Re: Nonunion Avulsion Fracture - a year out.

Id consider getting groceries delivered and premaking your favorite meals. My husband was helpful but even with a good list, you cant just go to the store when nwb. I had to have cheese sticks and toast a few times because my husband considers salami and cheese a great choice ; /. I actually lost weight nwb and gained a few back when I felt well enough to shop for myself. Good luck with surgery in december. My ankle is still quite loose. I pray im not next.

 
Old 12-18-2013, 06:29 AM   #15
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POST OP UPDATE Nonunion Avulsion Fracture - a year out.

Post Op Update- Surgery went well (13DEC13). The only hiccup was bringing me out of anesthesia. As far as my ankle, the Doc said it was worse than what the MRI showed and that my joint was "angry". I had a piece of cartilage flapping around that he fixed, an osteochondral defect that was also fixed and he also did the micro-fracture. I did end up having a modified Brostrom-Gould repair of my ligament. They did nerve block me from the knee down which was wonderful. That wore off 24 hours later. i am suppose to be NWB for 6 weeks then switch to the cam boot for 6 weeks. However, the help I was suppose to have (my husband) has decieded to bail and ask for a divorce. We have no family within 1500 miles and 1 set of mutal friends. Our daughter is 6 and has the rest of the week of school and I have my first post op on 24DEC. I don't know what to do at this point other than taking the cast off and wearing the cam boot since I now have to drive. Any suggestions?

 
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