fractured, broken, or cracked

Sunday, December 25, 2016


Adam Schefter ‏‪@AdamSchefter

Fractured fibula for Marcus Mariota.

Broken fibula for Derek Carr.



Words matter when it comes to medicine. Patients and their families potentially can get confused when different terms are used to describe the same situation. This is especially true when reporters, people who write for a living, use interchangeable words and readers might presume one injury is worse than another. With the above tweet, ESPN’s Mr. Schefter sows those seeds of confusion.

Fracture, broken and cracked all mean the same thing…the integrity of a bone has been disrupted. One term does not imply a more serious injury. You can’t be a little bit broken, fractured or cracked. However, fractures may be more or less serious than others. Some need surgery while some, with time can heal on their own.


It is important to know that the fibula is a strut bone in the shin that runs from the knee to the ankle. While it is an important structure, it is not part of the bones that make up the knee joint (femur and tibia) or the two that make up the ankle joint (tibia and talus).Fibula fractrues are often associated with tibia fractures but isolated injuries to the fibula do occur. When they do, the fractures are not all treated the same. For the isolated fibula injury, it’s like real estate; it’s all about location.

fibula head

Fibular head fractures usually occur because of a direct blow or a twisting injury and non-displaced fractures are often treated with supportive care: weight bearing as tolerated, ice and pain medications. Fractures that are displaced, meaning that the two ends don’t align well, may need an orthopedic specialist to consider surgery. The big deal with this injury is the peroneal nerve. It wraps around the fibular head and if it is damaged, the muscles it controls can stop working, leading to foot drop.

midshaft fibula

Mid-shaft fibular fractures are relatively uncommon, but are usually due to a direct blow. Unless the bone is shattered or significantly displaced (not aligned), the treatment is time.

distal fibula

The distal fibula has a bony protuberance or bulge that is called the lateral malleolus. Ligaments that attach to it help stabilize the ankle. Fractures of the lateral malleolus or the distal part of the fibula may need surgery to maintain ankle stability.

The big thing to remember about fibula fractures has to do with anatomy. The tibia, fibula, knee and ankle form a ring. If there is a twisting injury, there are usually two injuries to be found because it’s hard to twist a ring and break it in only one place. Think of twisting a pretzel and snapping only one curve. For the certified athletic trainer on the field or the doctor in the ER or office, finding an isolated fibula fracture leads to looking for another injury before accepting “just” one injury. And that second injury may be torn a ligament in the knee or ankle that may be more important than the obvious broken bone.

Based on news releases, Derek Carr’s broken fibula may be distal and it required surgery. The location of Marcus Mariota’s fracture hasn’t been released just yet. It’s a reminder that the word broken did not determine injury severity or the need for surgery. It was just a word.

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agony of defeat…tib fib fractures

Sunday, August 7, 2016

The public seems to have a morbid curiosity about trauma. While major injury makes us turn way and not want to look when an athlete gets hurt, it’s that same injury that gets millions of view on Twitter and YouTube. Tib-fib fractures seem to be immensely fascinating, given the long term popularity of Joe Theismann’s broken, injured while playing for the Redskins in 1985.

French gymnast, Samir Ait Said, suffered the same injury during the vault in Rio. A collective groan could be heard in the arena, as could the snap of the bones…and the clicks making him trend on Twitter.

tibfib fracture

  • The initial injury may seem gruesome, but it is the potential complications that may be even worse. This is especially true for tibia and fibula fractures, similar to Thiesmann’s and Said’s. The skin overlying the shin is very thin and with the force of the injury, it is not uncommon for the overlying skin to be cut, torn, lacerated…choose a word. The old term “compound” has been replaced with “open” which describes the fact that the inside of the bone is now exposed to the outside world and the risk of bone infection increases dramatically.
  • The muscles that surround the tibia and fibula are encased in four tight compartments and with an injury like a broken leg, bleeding and swelling can increase the pressure within one, many or all of the compartments. If the pressure inside a compartment increases higher than venous pressure, blood cannot flow back to the heart and swelling starts to occur, increasing the pressure even further. If the pressure is not released by fileting open the compartment, muscle and nerve tissue dies and badness ensues. Up to 10 percent of midshaft tibia fractures may have an associated compartment injury.
  • Other complications that can occur in the next few days include nerve damage, (the peroneal nerve is often the target when the fibular head is damaged and leads to foot drop), skin sloughing because of poor blood supply to the front of the shin, and leg amputation if the fracture repair is delayed. Because both bones are broken, the leg is unstable and can flop around if not immobilized. This can stretch or tear the arteries that are heading to the ankle and foot causing loss of blood supply, a bad thing. Knee dislocations are associated with artery injury and often, the diagnosis may be initially missed because the knee often relocates before it is evaluated by medical personnel.
  • And long term, non-union of the fracture may occur. The tibia is the most common bone to refuse to heal, leading to repeated surgeries. It’s all about get blood supply to the area of injury, so that the body can deliver the building blocks needed to reconstruct the bone. This is a design flaw of the body that leads to poor blood supply and poor healing. Unfortunately, it’s not the only place where the body was not engineered to supply blood to broken bones. Scaphoid fractures in the wrist are another example.

BBC Gets It Right

While Mr. Said lay on the ground, attended by trainers and doctors, the internet started to exploit the injury, giving those who have a fascination with pain and suffering the opportunity to watch replays of the injury. Twitter, YouTube,Facebook and numerous news websites posted videos and photos of the injury. While NBC’s website displays a warning about graphic images, perhaps BBC understands that most people do not want to be “entertained” by such misery. Their reporting ends with the following:

“Highlights footage and photos of the injury are too graphic to be shown on the BBC Sport website.”

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