Leg Fractures K

K

P. B

Epidemiology of Leg Fractures

As participation in football expands, an increase in the number of injuries is inevitable. Contusions, ligament sprains, and muscular strains to the lower extremities are responsible for 50–80% of all soccer injuries. Court-Brown [1]

reviewed 523 consecutive tibial fractures in a Scottish trauma centre and clas- sified them according to their epidemiology: 22.3% were isolated tibial shaft fractures and 77% were combined with fibula fracture; 30.9% of all analysed fractures were caused by sports activity, of which 80% were documented as soccer injuries. Lenehan analysed 50 consecutive tibial shaft fractures in adult footballers treated over a 5-year period in Ireland. Although most of the frac- tures were classified as A injuries (AO classification) with a low incidence of complications, only 54% of all players returned to playing competitive sports[2]. Templeton documented 329 tibial diaphyseal fractures in a 54- month period. Sports injuries in general accounted for 73/329 of these frac- tures, and soccer was responsible for 79.5% of all sports injuries. All his patients were male, and the age range was 8–48 years. Five children under the age of 15 years were included in this series; 93.9% of the diaphyseal fractures were at the middle or junction of the middle and distal third [3].

In our database, we found 42 tibial diaphyseal fractures related to soccer injuries. In addition to this number, we had documented two stress fractures in professional soccer players in the first and second Austrian division. All patients who sustained a diaphyseal fracture during soccer were male, and their age range was 12–31 years. Four athletes were professionals and playing first- or second-division soccer league, and 38 players were amateurs or semi- professional playing regularly in a low division.

Classification of Fracture Type

All fractures were classified according to AO–ASIF classification, and for soft

tissue damage, Gustilo-Anderson classification was used (Tables 1 and 2).

Out of 42 fractures, 6 were isolated tibial shaft fractures: 1 was classified A2, 4 were A3, and 1 was B2. There was no C fracture according to the AO classi- fication, and all fractures were closed. Thirty-six were diaphyseal fractures combined with fibula fracture, and all were in the middle third or at the junc- tion of the middle to distal third. Two were classified A1, 7 A2, and 18 A3.

There were 8 B2 fractures and 1 C3 fracture. According to the Gustilo- Anderson soft tissue classification, 3 were grade I open fractures: 1 A3

1 B2, and 1 C3

Table 1.Classification of isolated tibial fractures (n=6)

AO classification Number

A1 -

A2 1

A3 4

B1 -

B2 1

B3 -

C1 -

C2 -

C3 -

Table 2.Fracture classification (n=42)

AO classification Gustilo-Anderson classification

Tibia plus fibula fractures (n=36) Open (n=3) Closed (n=39)

I II III

A1 2 - - -

A2 7 - - -

A3 18 1 - -

B1 - - - -

B2 8 1 - -

B3 - - - -

C1 - - - -

C2 - - - -

C3 1 1 - -

Treatment

Operative treatment of diaphyseal tibial fractures has been widely accepted in the German-speaking area over the last 30 years. Open reduction and plate fixation was a common procedure for operative treatment in the 1970s and 1980s. Development of nailing systems and especially outcome research of unreamed interlocking nailing has replaced plate fixation over the last decade. The rationale of unreamed nailing was based on the significantly lower infection rate, incidence of skin necrosis, and re-fracture following removal of implant compared with plate fixation.

Immobilisation and cast fixation for treatment of B3 fractures is widely accepted in the English speaking countries, especially in the United States.

Templeton in his series treated 44/57 conservatively and reported significant- ly fewer complications compared with operative treatment [3]. There were 9/44 complications in conservatively treated patients: 1 re-fracture 11 months later, 3 delayed or non-union that required late operative treatment, and 4 angle deformation more than 10°. Twelve patients were treated operatively by intra-medullary nailing, and 5/9 had delayed or non-union and 2/9 deep infection, which is an unusually high complication rate. Boden reported a 53% major complication rate in 15 diaphyseal tibial fractures combined with fibula fracture; 3/15 primarily treated with cast immobilisation required late operative treatment with intramedullary nailing, and 2/15 developed lower- leg compartment syndrome requiring fasciotomy [4].

In our series of 42 acute tibial fractures, 7 patients were treated conserva- tively. Plaster cast immobilisation was the treatment option in isolated closed tibia fractures (A3) in patients with open physis (3/6) (Figs. 1, 2). One patient with an isolated B2 tibia fracture, and 2 patients with tibial and fibula frac-

Fig. 1.Isolated tibia fracture in adolescent soccer player (A3).

Conservative treat- ment

ture (B2) were treated conservatively by calcaneus traction for 3 weeks fol- lowed by a long-leg plaster and cast immobilisation for 8 weeks. One patient with an A3 fracture was treated immediately by plaster cast for 12 weeks but required 1 manipulation under anaesthesia. Open reduction and plate fixa- tion according to the AO technique with simultaneous fasciotomy of tibialis anterior compartment was performed in 8 patients. There was 1/8 delayed healing with fatigue fracture of the plate, which required revision operation during which plate removal was carried out, and reamed intra-medullary nailing was performed 4 months following primary surgery. In 27 patients, primary intra-medullary nailing was performed. An unreamed interlocking nail was used in 18 patients, and reamed nailing in 9 (Figs. 3–6). Two patients required early revision and fasciotomy due to compartment syndrome, and 2 patients with an unreamed interlocking nail required revision because of delayed healing (Figs. 7, 8). Reamed nailing and fibula osteotomy was carried out in these patients.

Re-fracture rate in the entire series was 2/42. One patient sustained re-

fracture of the tibia following conservative treatment 10 weeks following cast

removal due to a minor injury. One patient sustained re-fracture of the tibia

4 weeks following plate removal (Figs. 9, 10). Both patients required operative

treatment and stabilisation by reamed nailing. Return to sports required

rehabilitation of 18–52 weeks; of 3 professional players, one did not return to

his previous competitive level in the first division. Two players were treated

for a stress fracture of the tibia in the middle third. Diagnosis was made by x-

ray and confirmed by MRI. Initial treatment was complete rest and immobil-

isation for 4 weeks in both players. One returned to his previous level of activ-

ity following a prolonged rehabilitation program after 8 weeks. The second

Fig. 3.Tibial shaft fracture (A2) com- minuted fibula fracture

Fig. 4. Closed reduction – unreamed interlocking nail UTN

Fig. 5.Healing after 16 weeks – 1 distal interlocking screw broken

Fig. 6. X-ray before removal after 9 months

Fig. 7. Diaphyseal fracture (B2). Closed reduction – reamed AO nail + fasciotomy

Fig. 8. Solid healing in anatomic position

Fig. 9. Diaphyseal shaft fracture (A3) grade I, open. Open reduction, plate fixa- tion

player required intra-medullary nailing due to persistent pain 8 weeks after diagnosis of the stress fracture.

Prevention

The mechanism of kicking in soccer may be associated with the generation of high kinetic energy. Since soccer is a contact sport, the kicking leg can cause severe injuries. During miskicks or slide tackles, the energy may be transmit- ted to an opponent’s lower leg, resulting in a fracture. Shin guards have become the only protective device for the lower leg in soccer players.

Experimental studies by van Laack [5] have shown that shin guards decrease the magnitude of forces by prolonging the amount of contact time. Bir found by testing mechanical properties of commercially available shin guards that the load forces were reduced by 41–77% [6]. Francisco analysed mechanical

Table 3.Complications and treatment

Nailing Conservative Plate Unreamed nail

Compartment syndrome 2/27 - - -

Manipulation under - 1/7 - -

anaesthesia

Delayed union - - 1/8 2/18

Re-fracture - 1 1 -

Fig. 10.Fatigue frac- ture of plate revision – reamed intrame- dullary nailing and bone grafting healing after 6 months

properties of different shin guards and found that those with compressed air were most effective [7].

Isolated or combined diaphyseal fracture of the tibia and fibula in soccer players is not a benign fracture although in most cases, they are classified as a simple fracture according to the AO classification. The complication rate following conservative as well as operative treatment is high, and time out of competitive sports is quite long in some players. Prevention is extremely important, and attention should be focused on protection equipment.

References

1. Court-Brown CM, McBirnie J (1995) The epidemiology of tibial fractures. J Bone Joint Surg Br 77:417–421

2. Leneman B, Fleming P, Walsh S, Kaar K (2003) Tibial shaft fractures in amateur foot- ballers. Br J Sports Med 37:176–178

3. Templeton PA, Farrar MJ, Williams HR et al (2000) Complications of tibial shaft soc- cer fractures. Injury 31:415–419

4. Boden BP (1998) Leg injuries and shin guards. Clin Sports Med 17:769–777 5. Van Laack W (1985) Experimentelle Untersuchungen über die Wirksamkeit ver-

schiedener Schienbeinschoner im Fußballsport. Z Orthop 123:951–956

6. Bir CA, Cassatta SJ, Janda DH (1995) An analysis and comparison of soccer shin guards. Clin J Sport Med 5:95–99

7. Francisco A, Roger W (2000) Comparison of soccer shin guards in preventing tibia fracture. Am J Sports Med 28:227–233