when a broken leg isn’t so bad

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.

fibula-fxap

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.

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