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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not all collapsed lungs are punctured

Tuesday, November 15, 2016

It seems that Rob Gronkowski of the New England Patriots is teaching us about medicine, one injured body part at a time. This week it’s about the pneumothorax he sustained after a hard tackle and there is a reminder that the press tries hard but sometimes needs help getting the medical terminology just right. Gronkowski has been reported to have either a collapsed lung, a punctured lung, or both. But while all punctured lungs will result in a pneumothorax, not every pneumothorax is due to a punctured lung.

 

pleura

Normal Anatomy

pneumothorax

Right Lung Pneumothorax

Let’s start with normal anatomy. We breathe like a bellows. The ribs swing out and the diaphragm, the muscle separating the chest and abdomen pushes down allowing air to be inhaled and sucked through the mouth and trachea into the lungs. Exhaling reverses the process. The lungs have to slide along the inside of the rib cage to inflate and deflate and for this to happen, both the lung and the ribs have a slippery lining called the pleura. The two are stuck together by negative pressure and should the seal between the two linings break, part of the lung can fall away from the chest wall and collapse. This is a pneumothorax (pneumo=air + thorax= chest) or air in the chest where it doesn’t belong.

Most often a pneumothorax happens spontaneously, when a bleb or weakened portion of lung leaks and breaks the negative pressure seal. It can happen in tall thin young people or in people with end stage COPD whose lungs are more fragile. A pneumothorax can also happen due to trauma and the jagged edge of a broken rib can damage lung tissue causing a leak. This is the punctured lung scenario that was reported to have happened to Mr. Gronkowski, though the broken rib idea wasn’t mentioned. Punctured lungs can also happen because of penetrating trauma like from a gunshot or stab wound and they have their own issues and complications.

The diagnosis is usually made by chest x-ray. In trauma, like Mr. Gronkowski, the x-ray is meant to look for the complications of the chest wall injury, including pneumothorax and pulmonary contusion, or bruising of the lung. Specific ribs x-rays tend not to be taken since it doesn’t really matter whether the ribs are bruised or broken…it’s all about what’s happening underneath. And for the doc, underneath may also include the upper abdomen, since the ribs protect the organs just below the diaphragm including the liver and spleen.

pneumothorax 2

Arrows show the collapsed lung edge pulled away from the ribs

The treatment of a pneumothorax depends upon how much of the lung has collapsed and whether the patient can tolerate the loss of lung function. If the percentage is small and the patient is doing well, delivering enough oxygen to their blood and not complaining of significant shortness of breath, watchful waiting may be the treatment of choice and the body will absorb the air and the lung will re-expand on its own.

If the pneumothorax is too large or if the patient is not doing well, the air in the pleural space between the two linings can be removed, either one time with a needle or by placing a tube into that space and sucking the air out under negative pressure causing the lung to expand. The tube may be left in place for a day or two to allow the lung to heal and the situation to settle down. Some people need operations to repair the weak areas of the lung to prevent repeat events and sometimes the damaged lung area is purposefully irritated so that it will scar down and adhere to the chest wall to prevent further collapse.

Not all collapsed lungs are easy to treat; they can be recurrent and treatment failures happen. There are also life threatening complications, including tension pneumothorax where the damaged lung tissue does not seal off and enough air flows into the pleural space to cause the heart to shift and prevent it from beating properly.

Since it appears that Mr. Gornkowski’s pneumothorax was small, the treatment was watchful waiting and if repeat x-rays show that the air has been reabsorbed, the ability to return to play will depend upon how much pain he has from his chest wall. Bruised ribs hurt and it can be tough to take a deep breath, and twist and turn. For mere mortals, chest wall pain can last a few weeks and can make routine daily activities tough to accomplish. For pro athletes, playing through pain is an expectation, as long as damage won’t result from ignoring the body’s message to rest.  And here is where the athlete and the doc share the same credo…first do no harm.

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