tibial plateau fracture

Monday, October 9, 2017

It’s difficult to understand why bad things happen to good people. It goes without saying that the Texans’ J.J. Watt is beloved in his adopted home of Houston. It is also true that his broken leg, a tibial plateau fracture, will call into question whether he will play again in the NFL.

His response on Twitter to his situation?

“I can’t sugar coat it, I am devastated. All I want to do is be out there on that field for my teammates and this city. I’m sorry.”

This from the man who raised tens of millions of dollars for the Houston hurricane relief efforts and who has played and been recognized as the best defensive player in the league. but the demon of injuries is blind to ability to play and a tibila plateau fracture is a big deal.

Broken bones are not all created equally. It’s all about location. The tibia (shin bone) connects to the femur to form the knee, and to the talus to form the ankle joint. Fractures that involve the joint surface have the potential to not heal appropriately and cause long term problems like arthritis, stiffness and loss of range of motion. This is especially true for the tibial plateau.

The top of the tibia, has two shallow surfaces lined with cartilage that allow space for the femoral condyles to slide and allow the knee joint to flex (bend) and extend (straighten). It takes a lot of force to fracture the tibial plateau and in addition to the trauma, there needs to be some bad luck involved, where the knee is just in the right position, so that the force drives the tibia into the femur and shatters that once smooth surface. Most often, these injuries occur in car wrecks or falls from height where a load is placed on an extended leg and all the force is transmitted into the knee.

Anatomy is important in understanding injury patterns. The top of the tibia is expensive real estate. There is a medial and a lateral tibial plateau, both covered with a meniscus or cartilage, and between the two is the intercondylar notch where the ACL (anterior cruciate ligament) and PCL (posterior cruciate ligament) attach. Because the knee is designed to be held in slight valgus, the medial tibial plateau tends to have thicker bone that that makes is less prone to injury than the lateral tibial plateau.

When the tibial plateau is forced into the femoral condyle the bone collapses and the surface where the cartilage sits, may or may not get crushed. The pain is immediate, the swelling occurs quickly and trying to walk on the injury may or may not be possible, depending on the severity of the break. X-rays can show the general injury, but they are only 2D images and the body is three dimensional. CT may be needed to look at the surface of the plateau and understand the extent of damage…and if there is concern that there are ligaments involved, an MRI might also be needed.

When it comes a decision about surgery, it’s all about making certain that the joint surface lines up properly. If there is any step off, inflammation will occur with each step taken as the femoral condyle rubs against the uneven surface. The long-term complications include pain, knee stiffness and arthritis, but other problems might arise, including malunion (failure of the bone to heal) or collapse of the fracture, so that the knee joint has no bone beneath for support.

The bottom line for Mr. Watt is that a tibia plateau fracture is a bad thing that happened to a good person. Depending upon the extent of the injury, his recovery and return to play might span a spectrum that runs months to never. The goal for all patients is to return them to the level of function that they had enjoyed prior to the injury. Unfortunately, most patients aren’t best in class NFL defensive lineman.

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hip dislocation

Monday, September 22, 2014

Bo knew football. Bo knew baseball. Bo knew hip dislocation. Now Dennis Pitta knows what Bo knew…hip dislocation leads to badness. For the second time in two years, Mr. Pitta, the Baltimore Ravens tight end, dislocated his hip and required surgery to repair the damage. A year ago, the hip injury occurred while being tackled. This time, he twisted on the field and went down in a heap without being touched, the hip popping out of joint without significant trauma.

In 1991, Bo Jackson, then of the Oakland Raiders, was tackled in a playoff game and felt his hip pop out of joint. Even with having the dislocation reduced, or having it put back into place immediately, and even with surgery and rehabilitation, he developed avascular necrosis of the femoral head (the ball of the hip joint). This is a common complication of hip dislocation that occurs because of hip has been poorly structurally engineered. Some of the blood supply to the femoral head comes from arteries that have to travel across the joint from the acetabulum (the socket of the hip joint) to the femoral head. When the hip dislocates, that blood supply is lost and the potential exists that the femoral head will not get enough oxygen and nutrients from other arteries to survive. This is called avascular necrosis (a=without + vascular=blood vessels +necrosis=death) and it damage the femoral head no matter how good the treatment is or how fast the hip is repaired. Mr. Jackson underwent hip replacement surgery and was able to return for a brief time to baseball but soon his career was over.

hip xray 1

For Mr. Pitta, surgery and rehabilitation for his first hip dislocation went well and he was able to return to play football late in the season. Dislocation number two raises questions about the potential for him to return a second time.

The hip is a strong structure and it takes a significant amount of force to cause a dislocation. Aside from the bony protection of the acetabulum and the five large ligaments that help stabilize the hip joint, the angle that the femoral head enters the acetabulum provides even more stability. Most often, hips are dislocated in car wrecks, where the dashboard is driven into the knee of the driver or front seat passenger. By sitting with a bent knee the direction of the force drives the femoral neck through the back of the acetabulum, breaking that bone.

Aside from avascular necrosis and arthritis, which are long term complications, the big risk in the acute situation is damage to the sciatic nerve, the large nerve that leaves the back and runs through the buttock, behind the hip, to supply the leg. When the hip dislocates posteriorly or toward the back, it can damage the nerve in a variety of ways, from having generalized swelling inflame the nerve to specific damage done because of bony fragments injure the nerve.

Mr. Pitta required surgery again to repair the injuries and time will tell whether he will escape the complications that can plague hip dislocations. Most certainly, his second hip dislocation occurred because the structures that held his hip in place, the muscles, tendons ligaments and joint capsule had loosened. He had the bad luck to have his injury witnessed by an audience of thousands in the stadium and millions more in the television audience, but the injury could have just as likely happened in a parking lot, twisting to get out of a car or playing in the backyard with his family.

Dennis Pitta now knows what Bo knows. 20 years of medical progress still cannot guarantee perfect healing. Injury and trauma have a way of humbling those in the medical profession. Even with the best care, the body cannot always be put back together like it was before. There are complications that cannot be prevented. There are injuries that cannot be completely rehabilitated. Sometimes badness happens.


Xray image attribution: www.wikiradiology.com



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