words and anatomy matter

Monday, October 7, 2013

“They took an X-ray a little bit lower [of Joeckel’s leg]. They didn’t see it,” Bradley said. “They went up and took a little higher X-ray and saw it.” –  espn.com

When a pro athlete gets injured, the minions of medicine descend and to make certain that a diagnosis is not missed. According to Gus Bradley, coach of the Jacksonville Jaguars, it took a couple sets of x-rays to find the break in his star lineman’s leg. For Luke Joeckel, the good news is that the injury was identified; the bad news is that his leg is broken, may need surgery and is season ending. Press releases describe the break as a high ankle fracture but that term isn’t quite appropriate. It’s a tib-fib fracture and while semantics are important, understanding the injury helps predict potential complications.

The tibia and fibula are the two bones found in the shin and connect the knee and ankle. It’s difficult to break just one bone in the pair. They make a circle with the knee and ankle joints, and just like it’s difficult to break a pretzel in just one spot, it is also hard to break the bony circle in just one place. For that reason, it’s important to examine the joint above and the joint below any injury, to look for that second fracture. Depending upon the mechanism and twisting motion placed on the leg, when the tibia breaks near the ankle, the fibula may break near the ankle, in the midshaft or high up by the knee at the fibular head.


Now why it’s important to sort out ankle versus tib-fib fractures. Ankle fractures can involve the bony outcroppings of the tibia and fibula called the malleoli (single=malleolus). Ligaments attach to them to provide stability to the ankle joint. The lateral malleolus on the outside of the ankle and at the bottom of the fibula has three ligaments while the medial malleolus of the tibia on the inner aspect of the ankle has one thick band of tissue called the deltoid ligament. If the fibula’s lateral malleolus is fractured (remember that fracture, break crack all mean the same thing), it is important to check the stability of the deltoid ligament because if it is damaged, the ankle can dislocate. If the tibia’s medial maleolus is fractured, the associated injury may be high up at the knee with a fibular head fracture. This is the can’t miss injury since the peroneal nerve wraps around the fibular head and can be damaged, causing foot drop and the inability to pick up the toes to be able to walk normally.

Tibia and fibula shaft fractures may or may not need surgery, but many treatment options exist. There may be non-operative casting or an operation can be performed to have rods placed through the shaft of the tibia or have plates screwed in across the fracture site to hold it in place. The can’t miss complications aren’t necessarily related to the bone but to the skin and muscles. The skin across the front of the tibia is very thin and has the potential to be torn when the fracture occurs, or break down in the days afterward. The skin acts as a barrier protecting the inside of the body from infection and if the skin is compromised, the bone itself runs the risk of infection. Osteomyelitis is a bad thing and can take months and many operations to resolve (see Rob Gronkowski). The other potential disaster that haunts tib-fib fractures is compartment syndrome. The muscles of the lower leg are encased in tight sheaths and should the broken bones cause swelling or bleeding into a compartment, the pressure inside can rise dramatically and prevent blood from flowing to the muscles. Muscles without blood die and compartment syndrome is a true emergency, where the orthopedic surgeon filets open the leg to allow room for the swelling. It’s like cutting into the casing of a hot dog and watching the insides expand when released.

The good news for the pro athlete is that injuries tend to be diagnosed correctly. The good news also extends to the general public in that not only are injuries diagnosed correctly, but that potential complications are also anticipated. Using the right words to describe a fracture helps the family or emergency doctor explain the injury, not only to patient but also perhaps to an orthopedic doctor who may not be able to see the x-rays. The advice that an orthopod can give depends upon the ability to visualize the injury based upon the words used, not only in deciding what treatment might be appropriate but also what disasters to expect and to avoid. It works like an insurance policy. Teach the patient and family about compartment syndrome and it will never happen. Forget just once and that may be the time that it occurs. Anatomy matters and so do words.

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