Hip Injury with Inability to Wiggle Toes: Emergency Evaluation Required
You must seek immediate emergency department evaluation because inability to wiggle your toes after a hip injury indicates potential nerve injury—most commonly to the sciatic nerve or its peroneal division—which requires urgent assessment to prevent permanent disability. 1, 2
Immediate Actions
Go to the emergency department now. Do not wait or attempt home management. 1
The inability to move your toes after hip trauma represents a neurological emergency that demands:
- Immediate imaging with hip radiographs (anteroposterior and cross-table lateral views) to identify fractures, as hip fractures cannot be reliably diagnosed by physical examination alone and delays in diagnosis increase mortality and complications 1
- Urgent neurovascular assessment by a physician to document the extent of motor and sensory deficits, as complete motor and sensory loss carries the worst prognosis for recovery 2, 3
- Pain control with scheduled acetaminophen (not as-needed dosing) as the foundation, with opioids added only if acetaminophen is insufficient 1, 4
Why This Is Urgent
Nerve injury occurs in 1-2% of hip trauma cases, with the peroneal division of the sciatic nerve being most commonly affected. 2, 3 The sciatic nerve controls toe movement, and injury can result from:
- Direct nerve compression or stretch from fracture displacement, hematoma, or abnormal limb positioning 2, 5, 6
- Compartment syndrome requiring emergency fasciotomy if present 4
- Vascular injury compromising nerve blood supply 6
Delays in diagnosis and treatment of hip fractures are associated with increased mortality, complication rates, and hospital length of stay. 1 The 1-year mortality rate for hip fractures is 22% in women and 33% in men. 1
What to Expect in the Emergency Department
Imaging Protocol
- Standard hip radiographs (AP pelvis and cross-table lateral hip views) will be obtained first, as this is the initial imaging modality of choice 1
- Advanced imaging (MRI or CT) may be ordered if radiographs are negative but clinical suspicion for fracture remains high 1
Neurological Documentation
The emergency physician will assess:
- Motor function: ability to dorsiflex the foot (lift toes up), plantarflex (push down), and wiggle individual toes 2, 5
- Sensory function: numbness or altered sensation in the foot and leg 5
- Pain characteristics: presence of burning, shooting, or causalgic pain, which indicates worse prognosis 2
Pain Management Strategy
- Scheduled acetaminophen 1000 mg every 6 hours (not PRN) as the analgesic foundation 1, 4
- Avoid NSAIDs until renal function is confirmed, as approximately 40% of fracture patients have moderate renal dysfunction 4, 7
- Femoral nerve block or fascia iliaca block may be administered for superior pain control 4
- Opioids prescribed cautiously only if acetaminophen alone is insufficient 1, 4
Prognosis and Recovery
The prognosis for nerve recovery depends critically on the severity and timing of intervention:
- Patients with some motor function immediately after injury have a good prognosis for recovery 3
- Complete motor and sensory deficits carry the worst prognosis 2, 3
- Recovery within 2 weeks of injury predicts good overall outcome 3
- Overall recovery rates: approximately 41% achieve complete recovery, 44% have mild residual deficits, and 15% have poor outcomes with persistent weakness limiting ambulation 3
Critical Pitfalls to Avoid
Do not delay seeking care. Each hour of delay increases the risk of:
- Permanent nerve damage if compression is not relieved 2, 5
- Increased mortality if fracture treatment is delayed 1
- Compartment syndrome progression if present 4
Do not assume the injury is minor because you can bear weight or because pain is tolerable—nerve injury can occur without severe pain, and hip fractures cannot be excluded by physical examination alone. [1, @14@]
Do not take NSAIDs before medical evaluation, as they may worsen renal function and complicate surgical management if needed. 4, 7