Sunday, October 11, 2015
Baseball isn’t supposed to be a contact sport, but the collision between Ruben Tejada of the Mets and the Dodgers’ Chase Utley proves that the exception to the rule is what we remember. Regardless of whether Utley’s slide was legal, it resulted in Tejada fracturing his fibula, the shin’s strut bone, and ending his season. From a medical perspective, it’s an interesting injury because it is an exception to how other fracture types are treat
The tibia and fibula are the bones that make up the shin, but the tibia is the only one that is weight bearing, meaning that the fibula is just along for the ride. The proximal (upper) of the fibula at the knee, called the fibular head, has numerous ligament attachments that help with stability of the knee. The distal (lower) fibula at the ankle, called the lateral malleolus also has ligaments that protect and stabilize the ankle. Because the fibula and tibia form a ring with the knee and ankle, breaking just one of the bones is unusual, since it is tough to break a ring in just one place. Think of trying to crack a pretzel in just one spot.
Unless there is a direct blow to the midshaft of the fibula, the search is often undertaken to look for an additional injury to the ring. This can be a torn ligament at the knee or ankle, or an occult for hidden fracture of the tibia. Since broken and torn parts of the body bleed and swell, the hunt is usually done by physical examination, but if there is uncertainty, an x-ray of the two joints may be helpful.
As it turns out, the forearm has the same anatomy and injury perspective when it comes to ulnar shaft fractures. The radius, elbow or wrist is often damaged when the ulna breaks, except when there is a direct blow. The midshaft ulna fracture is often called a nightstick fracture because the arm is brought up to protect the face and head against a watchman’s nightstick.
But back to the leg. While most broken bones need to be immobilized, a midshaft fibula fracture needs little to be done to it. The treatment is rest and weight bearing as tolerated. Sometimes a knee immobilizer or soft splint is placed for comfort for a few days, but otherwise, the bone heals nicely in 6 to 8 weeks and activity is based upon pain tolerance. Unfortunately for Mr. Tejada, the body does not particularly like having pain and the ability to walk or run would be severely limited by a limp should he try to return to play immediately. The progression of healing allows assisted weight bearing with crutches followed by walking crutches and finally running. The length that each step has to take depends upon pain and listening to the body as it heals.
The anatomy of the fibula is relatively simple but there are structures that can be damaged depending upon where it is damaged and how much force was involved. If the fibular head is fractured (remember that fracture, broken and cracked all mean the same thing and one term does not presume a more significant injury), there is a risk that the peroneal nerve that wraps around it can be damaged. This can lead to foot drop and numbness to the top and outside of the foot. If the distal part of the fibula is fractured, there is often associated other bone fractures and ligament damage.
It is of little consolation to Mr. Tejada and his teammates that his injury is rare, doesn’t need surgery or a cast and will get better by itself. As with most things with medicine and life, timing is everything and the fibula fracture means that his season is over, just as the World Series is within sight. The same injury in spring training wouldn’t have seemed so bad.This entry was tagged chase utley, crutches, fibula, fracture, ruben tejada, shin
Tuesday, September 29, 2015
Writing about injuries is not always easy when relying on press releases, sports stories and snippets of interviews. Sometimes, the story falls in your lap. The Steelers’ Ben Rothlisberger gets hit, hurts his knee, hobbles off the field and by morning has an MRI confirming a medial collateral ligament tear…prognosis 4-6 weeks before return to play. Sometimes, though, there needs to be detective work because the information is more opaque. The NHL is a constant frustration with their upper body/lower body injury mantra.
But it’s Lionel Messi’s knee injury that posed a challenge. His team FC Barcelona tweeted that “Messi has a tear in the internal collateral ligament of his left knee. He will be out for around 7-8 weeks.” It seems relatively transparent and open, telling the world and especially Barca fans about Messi’s injury. The only problem is that the knee doesn’t have an internal collateral ligament, so tearing it is a little problematic. The challenge then, is to sort out the real injury.
Clue one is provided by photos of the injury. As he lay on the ground, Mr. Messi reaches down and rubs the inside part of his left knee.
Clue two is that the recovery time is measured in weeks, not months.
Clue three is that no surgery is planned. Argentina national team doctor, Donato Villani, was quoted by the Argentine paper, Ole: “The injury was to the ligament on the inner part of the knee, a ligament that is extra-articular, that obviously suffers injury like any other ligament, but this one is outside the joint. He avoided a valgus force injury of the joint; it is not a tear that needs surgery.”
As it turns out, the knee joint has four ligaments that provide it support and stability. The anterior and posterior cruciate ligaments prevent the knee from sliding forward and backward, while the medial and collateral ligaments prevent side to side motion. This allows the knee to do what it’s supposed to do, flex and extend, like a hinge. Each ligament has the potential to be torn and the treatment approach is different for each.
It’s important to remember that a torn ligament is called a sprain. Grade 1 sprains describe a ligament whose fibers have been stretch and a grade 2 sprain happens when the fibers are partially torn. A grade 3 sprain occurs when the ligament has been completely torn.
In athletes, each knee ligament has its own treatment, healing and return to play time frame.
- Anterior cruciate ligament tears almost always need surgery and recovery time is measured in many months.
- Posterior cruciate ligaments may not need surgery but rehabilitation may take 3 months or more to return range of motion, stability and strength. For those with a PCL tear who undergo surgery, the rehab time may stretch to 9-12 months.
- Medial collateral ligament tears used to be treated with surgery but non operative treatment is found to be more successful. Grade 1 and 2 sprains often heal well enough in 1-2 weeks to allow return to play while a grade 3 sprain may need 6 weeks or longer. While early return to play is allowed, the MCL continued to heal for many more months. Surgery may be required if there is recurrent injury or chronic instability.
- Lateral collateral ligaments tend to heal less well than the MCL and it completely torn, the LCL injury may also involve damage to the posterolateral corner of the knee. This is a group of structures that provide knee stability (and include the fibular collateral ligament, the popliteofibular ligament, the mid-third lateral capsular ligament, the biceps femoris head and the lateral gastrocnemius tendon and the IT band). A grade 3 tears often needs surgery and rehab time that can last a year.
Mr. Messi had an “internal” ligament injury that does not need surgery and will heal in 7-8 weeks. The medial collateral ligament fits that description but the clincher is that the medical collateral ligament has fibers that are both external (outside of) and internal to the joint. While it is a thick band of tissue that covers the whole of the m3edial or inner side of the knee, there are many layers that are outside of the knee joint and others that are internal to the joint. That division is based upon the capsule that is the boundary of the joint itself.
Medical commentary by proxy can be harrowing but sometimes, understanding anatomy, injury patterns and treatment options can uncover the mysteries that are contained in press releases and twitter feeds. And at the end of the day Ben Roethlisberger and Lionel Messi are related by MCL sprain.
This entry was tagged ACL, knee, LCL, MCL, medial collateral ligament, Messi, PCL, Roethlisberger, sprain
Dr. Wedro weighs in
“The difference between doctors who look after mere mortals and those who look after elite athletes may have to do with how many tests they can order, regardless of the cost.”