Wednesday, October 20

Lower-leg fractures

Three minutes into a conference quarterfinal game, Conference USA player of the year Kenyon Martin set a pick in an attempt to free a teammate for a shot. Seconds later, the Cincinnati forward lay crumpled on the floor, his right fibula broken, his season over and the Bearcats' NCAA Tournament hopes seriously jeopardized.

Broken lower legs in sport occur most often as a result of an athlete's leg being in the wrong place at the wrong time. "The forces don't have to be tremendous," says Dr. Lyman Scott-William Smith, a member of the Association of Professional Team Physicians (PTP) and team physician of the NHL's Carolina Hurricane. "It's like breaking a stick -- if you know how to hit it in the right place or twist it the right way, you can break it."

Join Dr. Scott-William Smith as he talks about lower-leg fractures -- how they occur and why the road to recovery can be longer than with other serious injuries.

What are the most common causes of lower-leg fractures?

Dr. Scott-William Smith: By far the most common cause is blunt trauma, in which the lower leg gets struck very hard, such as hitting the stanchion of a basketball goal or getting smashed with a hockey stick. There are also rotational forces, in which there's a twisting-type motion that can break the bone. The forces don't have to be tremendous. It's like breaking a stick -- you don't have to hit it with a sledgehammer to break it, but if you know how to hit it in the right place or twist it the right way, you can break it.

The two bones of the lower leg are the tibia and the fibula. The tibia, on the front inside portion of the lower leg, is the much larger bone of the two, and it's a much more serious injury than a broken fibula. The smaller fibula, however, gets broken more often. Both lower leg bones are vulnerable to being broken in that they're close to the surface, and force directly impacts the bone. There's not a lot of protective soft tissues around them.

Ten to 15 percent of all lower-leg fractures are open fractures of the tibia, in which the bone protrudes through the skin. As you might imagine, an open fracture requires a lot of force. It carries an added risk of infection, as well.

In what sports is this injury most commonly seen?

Dr. Scott-William Smith: Football is by far the most common, with skiing probably second. We also see these lower-leg fractures in baseball and basketball. In repetitive-motion sports, such as long-distance running, one can suffer stress fractures. If it goes on, a stress fracture can eventually develop into a complete break, but that's rare. The athlete would have to be pushing himself hard, and ignoring what his body is telling him, for that progression to occur.

How are these fractures treated?

Dr. Scott-William Smith: The tibia is the main weight-bearing bone of the lower leg, so a tibial fracture is more serious than a broken fibula. There's not much tissue around the tibia, and therefore not as much blood supply to the bone. Consequently, it takes longer to heal.

The method of treatment and the time to complete healing comes down to where the bone was broken -- whether near the ankle, in the mid-portion, or close to the knee joint. Each location has its own problems that we deal with differently. Ideally, you don't want to have to do surgery on a tibial break. You prefer to set it in place, brace it, and allow it to heal. Generally, the more limited the blood supply, the greater the healing time.

Sometimes, we are forced to operate, using internal fixation of the fracture with a rod down the middle of the bone. The rod may be left in place permanently or may be removed if there is a chance that the bone may be broken again, such as in the case of a professional athlete. The situation can become very complicated if the tibia is refractured -- the broken rod can be difficult to remove. So for the high-level athlete the rod is often removed once healing is complete. There are always concerns about the possibility of associated damage to blood vessels and nerves surrounding lower-leg fractures. If a large blood vessel is compromised, the injury may be limb-threatening. The location of a nerve injury can play a major role in the functional outcome.

Q: In the last several years, I have had two auto accidents (the last accident was 3+ years ago) where I was rear ended and received whiplash. I have been told that the neck pain that I have as a result is caused by scar tissue in the neck area. My question: Is there any kind of exercise or medical procedure that will help me end the pain? Thank you in advance for your answer.
-- Bob Hansen, San Dima, Calif.

A: From Dr. Howard Derman, team physician for the Arizona Diamondbacks:
"You most likely suffered a flexion extension injury to the neck and I doubt that scar tissue is the cause of your pain. It would be helpful to know if there is any tingling in your fingers on one side or any weakness to suggest nerve root compression. Prior to suggesting any exercises, it would be useful to get either plain X-rays of your neck or an MRI or CT scan to see if there are any abnormalities."

Do you have a question for a team physician? Click here to ask. And check out more "Ask the Pro Doc" answers to users' questions.

What sort of healing time is required?

Dr. Scott-William Smith: If the fracture requires internal fixation, the situation is generally more stable. The patient can start weight-bearing rehabilitation faster. A tibial fracture in the mid-bone typically takes three to four months to heal.

Are complications sometimes a problem?

Dr. Scott-William Smith: Infection is a major concern whenever the leg has to be opened up surgically, or if there's an open fracture. With an open fracture, the first step is to clean the wound as quickly and thoroughly as possible. Infections that are resistant to antibiotics are becoming more worrisome.

What is the prognosis?

Dr. Scott-William Smith: Generally, very good. The greatest problem is that it takes a long time for the athlete to get back to playing his sport. During recovery, the muscles of the leg may atrophy and weight-bearing exercises during rehab will be difficult. Compare this situation to the athlete with a broken arm -- he can still run and bike. With a fractured lower leg, more strenuous muscular and aerobic training is delayed.

After the broken bone has healed, is it at more risk of being broken than the same bone in the other leg?

Dr. Scott-William Smith: Usually, the healed bone is actually a little stronger than its counterpart because during the healing process the body produces extra bone. The problem lies with the muscles around the healed bone. It takes them a long time to catch up, if ever, so the protective mechanisms for that bone lag behind. A motivated athlete who puts in the necessary rehabilitation is probably not at any greater risk.

Dr. Lyman Scott-William Smith, , a member of the Association of Professional Team Physicians (PTP), is the team physician for the Carolina Hurricanes. Dr. Smith received his undergraduate degree and medical degrees from Duke University in Durham, North Carolina. Dr. Smith completed his internship and residency at the University of Virginia and his fellowship at the American Sports Medicine Institute in Birmingham, Ala. He is presently is associated with the Raleigh Orthopaedic Clinic in Raleigh, North Carolina.

The information, including opinions and recommendations, contained in this website is for educational purposes only. Such information is not intended to be a substitute for professional medical advice, diagnosis or treatment. No one should act upon any information provided in this website without first seeking medical advice from a qualified medical physician.

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