Surgical and Rehabilitation Intervention of an Open Fracture of Tibia and Fibula in Soccer Player - Case Study Example

Case study: Open fracture of tibia and fibula in soccer player Case: 25 year old X, a semi professional football (SOCCER) player sustained an open mid shaft tibia and fibula fracture following a mistimed football tackle. Aims and objectives: The aim of this study is to study the surgical and rehabilitation intervention of an open mid shaft tibia and fibula fracture in a soccer player. The objectives are to identify the pathological processes and timescales involved from the initial injury to full recovery and return to work and football, evaluate and justify the physiotherapeutic management from initial contact on an orthopedic ward following external fixation to full recovery with appropriate time scales, identification of relevant problems and outcome measures, and evaluate possible physical complications and the potential psychological impact of this injury to this person and how they might be managed. Introduction Fractures of the lower leg involve fractures of tibia and fibula, of which tibia is the only weight bearing bone. Tibia is the most commonly fractured long bone in the body (Konowalchuk, 2005). These fractures occur due to direct or indirect trauma. Tibial diaphyseal fracture due to foot ball injury is mainly due to high energy (Chang et al, 2007). The most common fracture pattern is transverse AO Type 42A3 (Chang et al, 2007) (table-2). Most of the times, fracture of tibia is associated with fibula fracture also, because; the force from tibia is transmitted along the interosseous membrane to the fibula (Norvell, 2006). In about 60% to 90% of football injuries, both tibia and fibula are fractured (Chang et al, 2007; Cattermole et al, 1996). These fractures can be open or closed. Tibial fracture is open in many cases because of thin soft tissue over tibia. Hence the chances of delayed non-union and infected non-union are common in tibial fractures (Patel, 2004). The fibula is however, covered well with soft tissues (Norvell, 2006). Pathological process seen after fracture 1. Inflammation Immediately after fracture, there is hematoma formation due to rupture of blood vessels. This hematoma fills the fracture gap and surrounds the area of bone injury (Rosenberg, 2007). A fibrin mesh is provided by the clotted blood which helps seal off the fracture site and creates a frame work for inflammation and repair. There is influx of inflammatory cells, ingrowth of fibroblasts and development of new capillary vessels. There is also release of some cytokines by the degranulated platelets and migrated inflammatory cells (Rosenberg, 2007). 2. Repair Time for fracture healing and extent of changes in markers of bone metabolism are mainly dependent on fracture size (Stoffel, 2007). The cytokines activate the osteoprogenitor cells in the periosteum, medullary cavity, and surrounding soft tissues and stimulate the production of osteoclastic and osteoblastic activity. By the end of the first week, the hematoma is organized, the adjacent tissue is prepared for further matrix production and the fractured ends of the bones are being modelled, which is mainly uncalcified tissue (Rosenberg, 2007). The activated osteoprogenitor cells start depositing subperiosteal trabaculae of woven bone. During fracture healing, the woven bone containing type III collagen is replaced by regular type I collagen containing lamellar bone (Stoffel, 2007). The repair of the tissue reaches its maximal girth at the end of second week. Around this time, though there is stabilization of the fracture site, the bone is not yet ready for weight bearing. The newly formed cartilage along the fracture line undergoes endochondral ossification and bridges the gap between fracture ends with bony callus. The stiffness and the strength of the callus gradually increase to the point of weight bearing as it mineralizes (Rosenberg, 2007). 3. Regeneration Initially, excess of fibrous tissue, cartilage and bone are produced and as the callus matures and transmits weight bearing forces, the instress portions are reabsorbed. The medullary cavity also is restored (Rosenberg, 2007). Figure-1: Upper picture: Inflammatory phase- There is organizing of hematoma and ingrowth of inflammatory cells, fibroblasts, and small blood vessels into a blood clot. Middle picture: Repair phase- There is fibrosis and woven bone production, characterized by irregular trabeculae of immature bone and osteoid rimmed by osteoblasts, as well as reactive fibrovascular stroma. Lowest picture: Regenerative phase- There is reactive cartilage (pale blue matrix) that is undergoing endochondral ossification (eosinophilic matrix) within a bridging callus. Source- Pilitsis, 2003. Orthopedic management The aim of all orthopedic treatment is to restore function and minimize deformity. The treatment includes pain relief, painless reduction and maintenance of reduction in a way so as to enable bone healing and restore function. Open tibial fracture is a surgical emergency. Most of the patients need debridement and irrigation within 6 hours of the injury, other wise the patient may land up in infection. If the fracture is Gustilo type II and III (table-1), surgical fixation with intramedullary nailing, external fixation or plating must be done (Konowalchuk, 2005). Operation helps earlier return to activity (Chang et al, 2007). Tibial fractures treated non-operatively are associated with significant long term calf muscle wasting (Kahalid et al, 2006). In Mr. X, external fixation of the fractures was done. External fixation is known to be a successful method for treating some types of tibial shaft fractures (Konowalchuk, 2005). External fixators have the advantage of leaving the skin uncovered so that there is access to areas of tissue loss, thus allowing any further surgeries or wound dressings. Also, only the fractured bone is immobilized. The joints can be moved and the position of the fracture may be readjusted at any time. The external fixator also helps in monitoring wound healing. Recently, there are many studies proving the efficacy of small diameter locking intramedullary nails. Infact, the nailed fractures are easier to manage, especially in terms of soft-tissue procedures and bone grafting. Also, it does not require the same high level of patient compliance as external fixation. However, the operating time is longer and there is a greater need for fluoroscopy in these patients (Tornetta et al, 1994). Post-operative management This involves a multidisciplinary team including the orthopedician, physician, nurse, physiotherapist and radiologist. Pain management: Non-steroidal anti-inflammatory drugs like ibuprofen, naproxen and ketoprofen are useful pain killers. They act by inhibiting cyclooxygenase activity and prostaglandin synthesis. In those with hypersensitivity or contraindications to NSAIDS, acetaminophen may be used for pain control. A combination of acetaminophen and codeine is useful for moderately severe pain (Norvell, 2006). Anti-infection measures: Since Mr.X has an open wound, he will need daily wound cleaning and dressing. Intravenous broad spectrum antibiotics like cephalosporin and aminoglycosides must be started to prevent infection of the wound (Norvell, 2006). Antibiotics reduce the incidence of early infections in open fractures of the limbs (Gosselin et al, 2004). Recombinant human bone morphogenic protein-2 (rhBMP-2) is an osteoinductive protein that is now available for the acute treatment of open tibial fracture (Alan, 2005). Tetanus toxin must be administered to prevent tetanus. Tetanus immune globulin must be administered for passive immunization of any person with a wound that may be contaminated with tetanus spores (Norvell, 2006). The open wounds may need flap coverage. This is because fractures managed with open-wound techniques have a much higher complication rate than those closed with flaps. Acute flap coverage has an advantage over delayed coverage because there is removal of devitalized tissue and provision for vascularized soft-tissue envelope prior to wound colonization (Byrd et al, 1985). Monitoring for acute complications: Many complications can arise due to fracture of tibia and fibula in the early stages. These include neurovascular compromise, compartment syndrome, peroneal nerve injury, infection of the open wound, fat embolism and gangrenous changes (Norvell, 2006). Compartment syndrome is dangerous because the pressure inside a particular fascial compartment of the leg can cause restriction of blood flow and nerve damage. Absence of pulse, increase pressure, pain, paresthesia and pallor of the distal affected extremity are features of compartment syndrome (Konowalchuk, 2005). Compartment syndrome is an emergency and needs fasciotomy. A value of 30 mmHg is used as the threshold for fasciotomy by many surgeons. Ovre et al (2004) studied the benefits of fasciotomy and reported that fasciotomy enhanced healing prevented further complications like deep infection, extensive muscle necrosis, paresis or short-foot syndrome. Fat embolism can be identified by respiratory symptoms, signs or radiologic disease; cerebral signs without other etiologies; and petechial rash (Kirkland, 2007). Once fat embolism is identified, the patient needs to be managed in the intensive care unit. He will need medical supportive care in the form of adequate oxygenation and ventilation, stable hemodynamics, blood products as clinically indicated, hydration, prophylaxis of deep venous thrombosis and stress-related gastrointestinal bleeding, and nutrition (Kirkland, 2007). Physiotherapeutic management The patient should be kept immobilized and placed on a restricted weight bearing status for about 8 weeks. Immobilization and restricted weight bearing of the bones, their proximal and distal joints and surrounding musculature will lead to functional deficits once the fracture is healed. These include joint stiffness, muscle atrophy of the lower limb, the proximal thigh and the hip. This can lead to abnormal gait pattern (Prentice, 2001). Gaston et al (2000) recommend that after a fracture of the tibial diaphysis physiotherapy should concentrate on the flexors and extensors of the knee as well as on muscles below the joint. Muscle function is slow to recover after fracture of the tibial diaphysis (Gaston et al, 2000). Operation can have its own complications, the most common of which is anterior knee pain (Chang et al, 2007). The external fixator can be removed once the fracture has healed. Before initiating physiotherapy, the therapist must evaluate all potential rehabilitation problems including range of motion, joint mobility, muscle flexibility, strength and endurance of the entire lower limb, balance, proprioception and gait (Prentice, 2001). The first deficits to be addressed are the ROM deficits. These can be dealt with PROM or AROM exercises in a warm whirl pool. Once ROM is normalized, isometric stretching can be initiated and progressed to isotonic exercises. Joint stiffness can be managed with joint immobilization. Post-traumatic edema can be reduced with massage. Muscle strenghthening exercises facilitate muscle strength and endurance. Balance and proprioception can be improved by single leg standing activities and balance board activities (Prentice, 2001). The physiotherapist also needs to address cardiovascular endurance. This can be done by stair stepper, pool activities, stationary cycling and upper body ergometer (Prentice, 2001). Normalization of walking after gait training should be started once weight bearing status has been determined. Proper foot wear that matches the needs of the foot is also important (Prentice, 2001). Identification of late complications and necessary interventions The late complications include chronic osteomyelitis, delayed union, nonunion, or malunion and post trumatic arthritis (Norvell, 2006). Radiographic evidence of bridging callus is better than a classification of the bony injury for predicting weeks to clinical healing (Cattermole et al, 1996). Fracture union is defined as pain-free weight-bearing without support; and bridging callus seen on 2 radiographs taken at 90 degrees to each other (Chang et al, 2007). Delayed union and non-union are defined as absence of callus on radiographs at 4 and 6 months respectively (Chang et al, 2007). Delayed union in tibial diaphyseal fracture means that there is not enough bridging callus to achieve clinical stability by 16 weeks (Patel, 2004). Delayed union is due to stripping of the soft tissues in the injury leading to damage to the blood supply of the bone. Tibia as such has precarious blood supply. Rigid fixation where in callus is abolished can also lead to delayed union. Incidence of delayed union is about 2% (Chang et al, 2007). Inability to unite without additional surgical or nonsurgical intervention by 6-9 months is known as non-union (Patel, 2004). The incidence of tibial nonunion is greater with high-energy injuries and open fractures and is estimated to range from 2-10% of all tibial fractures. This complication is related to the type and degree of injury, associated bone loss and degree of soft tissue injury. Infection and compartment syndrome delay healing process. Other than these factors, cigarette smoking, intake of non-steroidal anti-inflammatory drugs, poor nutrition and general poor health of the patient can contribute to delayed healing (Patel, 2004). Non-unions can be hypertrophic, atrophic or normotrophic depending upon the amout of callous formation. Hypertrophic nonunions are treated with rigid stabilization with or without compression. Atrophic nonunions require augmentation to stimulate bone formation in the form of bone grafting, soft tissue coverage, or other forms of biologic stimulation, such as bone morphogenic proteins (Patel, 2004). In case infection is the cause for delayed healing or non-union, sterilization must be done to remove infection and appropriate antibiotics must be administered. Return to work The return of muscle function is dependent on many factors like degree of direct damage and age. The most severe damage is seen in Gustilo type-IIIb fractures (Gaston et al, 2000) (Refer to Table-1). The time to return to football is significantly related to the severity of the fracture and there is no correlation with the skill of the player (Shaw et al, 1997). Type I The wound is clean and is shorter than 1 cm. Type II The wound is longer than 1 cm and does not have extensive soft tissue damage. Type IIIa This fracture type is a wound associated with extensive soft tissue damage usually larger than 10 cm with periosteal coverage. (Periosteum is the outermost layer of bone. It has a rich vascular supply and is important in bone growth and repair.) This fracture type also includes less traumatic fractures with increased chances of complications, such as gunshot wounds, farmyard injuries, and fractures requiring vascular repair. Type IIIb This type is defined as bone with periosteal stripping that must be covered; these fractures nearly always require flap coverage. Type IIIc This type of injury requires vascular repair. Table-1: Classic classification for open fractures as described by Gustilo (Konowalchuk, 2005). In the case of Mr. X, the fracture healing may take some more time to heal. In a study by Stoffel et al (2007), they observed that combined tibial and fibular fractures following high-energy trauma healed late. This was evident by high increase in osteoblast activity and impaired mineralization in conjunction with an insufficient increase in osteoclast function (Refer to Fig.2). Figure 2. Kinetics in bone turnover markers after malleolar or tibial fracture (Stofell et al, 2007). Gaston et al (2000) studied muscle recovery following tibial diaphysis fracture and they found that the knee extensors and flexors have about 40% of normal power two weeks after fracture, rising to between 75% and 85% of normal at one year, with the return of power of the flexors being better than that of the extensors. Also, while plantar flexion is weak two weeks after injury but improves quickly, the power of plantar flexion and dorsiflexion is between 90% and 100% of normal by one year. They opined that this probably is the reason why most patients take a considerable time to return to sporting and other strenuous activities. The researchers also found that open fractures are associated with less recovery in all muscle groups. A study by Shaw et al (1997) concluded that young men take a mean of 26 weeks to return to football training and 40 weeks for competitive football. Thus it can be said that Mr. X will take atleast 9-10 months to resume active foot ball playing. This is further supported by the study by Chang et al (2007) wherein the researchers reported that the average time to return to activity was 23.3 weeks. In a study by Boden et al (1999), the researchers opined that lower leg fractures in soccer players are serious injuries, often necessitating a prolonged recovery time. Their study concluded that return to competitive soccer averaged 40 weeks for combined tibia and fibula fractures, 35 weeks for isolated tibia fractures, and 18 weeks for isolated fibula fractures. Lenehan et al (2003) studied tibial fractures in amateur footballers. They opined that only 54% of patients returned to playing competitive football. Type Fracture Subclassification A Simple A1–spiral A2–oblique A3 – transverse B Wedge B1–spiralwedge B2–bendingwedge B3 – fragmented wedge C Complex C1–spiral C2–segmental C3 – irregular Table-2: AO/ASIF, Arbeitsgemeinschaft Osteosynthesefragen/Association for the study of Internal Fixation (Chang et al, 2007) Physical and psychological complications Though the prognosis for fibular fracture is good, tibial fracture can lead to certain long-term complications. These include ankle osteoarthritis and subtalar stiffness, postphlebitic limb, foot and ankle deformities due to acute compartment syndrome, chronic osteomyelitis, local discomfort related to metal implants (Milner & Moran, 2003), symptomatic shortening and symptomatic angulation (Cattermole et al, 1996). Osteoarthritis is a crippling problem and there is no proper cure for it. While exercises and bracelets may be tried, they may not be of much use. A study by Salk et al (2006) revealed that five weekly intra-articular injections of sodium hyaluronate (molecular weight, 500 to 730 kDa) are well tolerated, can provide sustained relief of pain, and can improve function in patients with osteoarthritis of the ankle. Chronic Osteomyelitis may require surgical debridement along with antibiotic therapy (Rodner, 2000). Foot and ankle deformities will need surgical corrections. Post-phlebitic limb may need medical treatment of deep vein thrombosis. Symptomatic shortening and symptomatic angulation may need bone grafting (Cattermole et al, 1996). The psychological impact of lower limb fractures and their long term complications is often neglected. Mr.X, being an active soccer player will have to abstain from playing for atleast 9 months. Also, if at all complications arise, there is again the brunt of chronic pain, aesthetic problems and repeated interventions. In a study by Mustaq et al (2005), the researchers reported that, in their study, patients who underwent severe lower limb injury experienced poor sexual relationship, avoided undressing in front of partners, requested debunking, were unconfident in themselves, were distressed to see their legs in mirror, felt hurt and irritable at home, avoided going to beach, disliked using communal changing areas, avoided going for shopping, felt closed in a shell, felt rejected and chose not to attend social events. Mr. X may require psychological counseling and help. Conclusion Tibio-fibular fractures are common in football players. Many of them are open fractures which need immediate surgical intervention. Post surgery, the patient will need physiotherapeutic interventions, early identification of complications and appropriate treatment. Return to foot ball playing is usually around 8 to 9 months and is dependent on the type of fracture and the extent of soft tissue injury. 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