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A ‘boot top’ fracture is an injury to the lower leg caused by high impact trauma. They are often associated with skiing due to wearing tightly secured boots that come up to the mid-shaft calf. Sarah’s boot top fractured occurred in exactly that way.
The tibia is the main, weight bearing bone of the lower leg and when broken, the fibula that runs alongside the tibia, is generally broken as well because the force of the break is transmitted along the interosseous membrane of the fibula. Fractures of the tibia can also involve the tibial plateau, tibial tubercle, tibial eminence, proximal tibia, tibial shaft, and tibial plafond.
The diagnosis of a tibia and fibula fracture is determined by clinical examination and imaging resources.
The clinical examination includes questions such as what events were leading up to the injury and symptoms that are present to the patient. The physician should initially examine the patient for oedema (swelling), ecchymosis (bruising), and the point of tenderness. Further investigation for a patient medical history and and any secondary injuries or complaints are also determined at this time.
After a history and initial set of observations having been recorded, the physician will then inspect the injury more closely. During further examination an assessment will be made of the nerve and blood supply by visually inspecting and palpating the extremities. The physician will make note of any temperature drops (due to a lack of blood to limb) or altered or lack of sensation which may point to further complications
Once the clinical examination is complete, X-Rays and sometimes CT scans of the knee, tibia and fibula and ankle are taken to determine the exact location and severity of the fracture. Special procedures including temperature tests are used to assess blood supply to the injured leg [this bit sounds interesting, what’s a temp test? or do you mean just palpating the leg for warm or cold to touch?].
A fracture to the tibia and fibula can cause multiple injuries such as bone damage and soft tissue damage. Some of the symptoms include pain on the weight bearing leg, bruising of the injured area, tenderness around the knee and limited bending of the knee and/or ankle due to bleeding within the joint, possible deformity around the knee, pale and/or cool foot due to poor blood supply and numbness or an unusual sensation around the foot which indicates possible nerve injury or excessive swelling within the leg.
In the journal ‘Tibial non-union: a review of current practice’, Moulder et al. (2008) state that the aim of treatment is to achieve a functional limb and to minimise physical, social and psychological morbidity.
Correct identification and management of injuries such as a tibia and fibula fracture is important to ensure that the limb functioning such as strength, motion and stability is fully restored and also lessen the risk of arthritis. The soft tissues surrounding the tibia and fibula such as skin, muscle, nerves, etc may also be injured at the time of the impact. Due to the possibility of soft tissue damage, an orthopaedic surgeon would also look for signs around the fracture and include this in the management plans for the fracture. In order for adequate healing, both the fracture and the surrounding soft tissue damage should be treated at the same time, with or without surgery. Tindall, A. (2005) states that the trick to good treatment is to ensure the bone heals in the correct position.
If there is an open wound and the skin is broken there is great concern that the fracture may be exposed to bacteria that might cause infection. In these circumstances, early surgical treatment is required to cleanse the fracture surfaces and soft tissue surrounding the injury to prevent infection.
Occasionally soft tissue swelling may be so severe that it inhibits blood supply to both the leg and foot, a condition referred to as compartment syndrome. This condition requires emergency surgery called a fasciotomy, where vertical incisions are made to release the skin and muscle coverings. Once swelling has gone down and the soft tissues recover in days or weeks to come, the incisions are closed.
If a cast or splint isn’t possible because of the nature of the injury, an ‘external fixator’ may be considered where pins are inserted above and below the joint. The pins help to stabilise the knee joint and support the limb so that the soft tissues have the chance to recover. Soon after an accident the injured skin and soft tissuesare easily harmed by surgery and should be treated with care.
In other cases unlike Sarah’s, non-surgical treatment may be considered and in result be very beneficial. Non-surgical treatment includes external devices such as braces and casts that restrict motion of the injured leg and inhibit weight bearing. After a period of time, limited knee movement and weight bearing is accepted to encourage optimum recovery.
As confirmed in ‘Systematic review shows lowered risk of non-union after reamed nailing in patients with closed tibial shaft fractures’ by Lam et al. (2010) “Tibial fractures are one of the most common trauma cases that require surgical treatment to ensure satisfactory healing.” Several devices may be considered if surgical treatment is required. In Sarah’s case, surgical treatment was required with the application of pins and an internal fixator was elected. This provides support until the bone is strong enough to weight bear again. Furthermore, internal fixation enables individuals to return to full function quicker and reduces the likelihood of improper healing from occurring.
Other forms of internal fixation include rods and plates. A rod or plate may be used to stabilise an intact fracture of the upper one fourth of the tibia and fibula. A tibia fracture that doesn’t extend into the knee can be treated by either a rod or a plate as shown in the diagram above to the right.
Plates are commonly used for fractures that do extend into the knee joint such as the one in the diagram to the right. The plate is secured with screws to the external side of the bone which is also shown in the diagram. If the fracture does extend into the knee, the bone may depress and therefore lifting the bone fragments is required to restore joint function. Lifting the fragments creates a defect or hole which then needs to be filled so that the joint doesn’t collapse. A bone graft is optimal however; synthetic materials that promote bone healing can also be used. Failure to lift the depressed bone may lead to conditions such as arthritis and instability. For further stabilisation of the fractured area, a plate with screws is applied.
For the treatment of an open fracture, thorough irrigation under pressure is required initially which is then followed by surgical removal of any dead tissue that is surrounding the injury. Incisions are made longitudinally down the lower leg and pins or rods are then placed in the hollow centre of the bone that usually contains marrow. Incisions caused by surgery may be closed with sutures and finally bone grafting may be completed either early or late in the course of the treatment. Once surgical treatment is complete, medication such as analgesics for pain relief, antibiotics for infection control and calcium supplements for bone strengthening can be incorporated to enhance the recovery process with minimal pain for the individual. Furthermore, for open fractures, a tetanus shot is advised.
Alternatively, external fixation can be used such as casts and splints to support the bone from the outside of the body. This form is elected when the soft tissue around the injury is so poor that the use of a plate or rod might threaten the injury further.
Recovery and Rehabilitation:
Shortly after treatment, whether it’s surgical or not, the recovery phase begins. It is imperative for the patient to follow all instructions of the surgeon, such as the amount of knee movement allowed, weight bearing recommendations, the use of braces and any other recommendations that are given in order to obtain full recovery of the bone and surrounding tissues. Because the tibia is a weight bearing bone, long term injuries commonly occur. These injuries such as long term arthritis and loss of knee movement are important to prevent as they prove to be very unfavourable to the patient.
The length of rehabilitation will be determined by how severe the fracture is, the type of fracture and the exact location of the fracture evident by X-Rays and other scans and the way in which the fracture is stabilised either surgically or non-surgically and finally the length of immobilisation.
The overall goal of rehabilitation is to decrease pain in the individual and to restore full functioning of the limb, including full motion, proprioception (the ability to sense the position, location and orientation of the limb) and the strength and endurance of all adjacent joints. Furthermore, maintaining independence in everyday activities is a high priority in order to stay motivated and not become depressed doubtful of a recovery.
In conjunction with painkillers and other medications that promote correct healing, heat and cold packs can be used to control the pain and oedema of the limb.
After surgical treatment Sarah will be unable to weight bear on the injured leg and will therefore have to use crutches or a wheel chair to get around to enable the healing process. After 6-8 weeks of non-weight bearing activities, the rehabilitation process will begin. Sarah may progress to using one crutch which limits weight bearing to a minimal amount but at the same time helps the leg by getting it used to a little bit of weight with the support when required. Once her leg gains strength, there is minimal pain and both Sarah and the surgeon are confident with the result of recovery she may then progress to no support at all unless her pain returns. If external fixation such as a cast, or internal fixation such as rods were used for support they can then be removed. Once it is removed the individual should immediately commence activities such as strength exercises, range of motion exercises and exercises specifically for proprioception recommended by an expert in the field. Exercise frequency and intensity should not be altered at all until full function is achieved and it is highly important to ensure there is no overload until the bone has regained full strength. Complete recovery of the fracture site can take anywhere between 6 to 16 weeks whereas the ability of the bone to sustain a heavy load may take up to a year. The resumption of heavy work and sports should be guided by the treating physician.
The role of exercise in the management of this injury:
To ensure fitness and a healthy lifestyle is maintained, exercise is extremely important in the management of a tibia and fibula fracture. It would be advised by any expert that warming up extensively before undertaking any exercise is vital to ensure there is no further damage done to the current injury.
Although the injury is to the lower leg, it is extremely important that Sarah maintains strength, flexibility and aerobic endurance to other parts of her body during the rehabilitation phase. In order for full recovery and for Sarah to be able to squat in the future, Sarah should also consider light stretching on a daily basis to ensure all of the muscles required for supporting the squatting action are prepared and are at optimal length.
As stated in the case study, 23 year old Sarah can currently run, walk and climb stairs with no pain. However she cannot squat without pain in the lateral compartment of her leg and without stiffness and pain in her ankle. It would be advised that Sarah continues walking and running on a regular basis and slowly incorporates small shallow squats amoungst her daily activity. It would be advised to ignore her boyfriend’s advice of not squatting at all as squatting is an essential part of her job if she becomes a paramedic and will need to be performed on a regular basis.
Using a resistance band, Sarah can build up her strength in her ankle and the surrounding muscles. She can do this by pulling her leg towards herself against the resistance of the band. During her first few weeks of any exercise, including practicing her squats, Sarah could wear a brace on her ankle for extra support.
Beginner level aerobics may assist in the squatting motion as the landing from bounces and small jumps will encourage muscles of the lower leg to engage and therefore strengthen which will further assist her squatting motion.
Any exercises recommended by her physio should be continued along with some non-weight bearing activities such as swimming to encourage movement such as flexion and extension of the lower leg. This helps to relieve pressure on the bones but at the same time continues to build up muscular strength. Furthermore, non-weight bearing activities such as swimming and other activities such as aerobics can also help with Sarah’s aerobic fitness which would have diminished whilst she was in the recovery period.
Suggested Exercise Plan for Sarah:
The main aim for Sarah in her recovery process is to ensure that all her muscles and tissues that are surrounding the break of the tibia heal correctly and in a timely manner. In conjunction with that, it is important that the bone heals in the correct alignment which minimises complications in the future.
Sarah should be visiting a physiotherapist to help with the rehabilitation from her broken tibia and fibula who will treat her leg accordingly with massages and assist in making an exercise plan for her to follow. Ideally Sarah should be visiting her physio on a regular basis after 6 weeks of immobilisation for approximately a 6 week period to ensure optimum results. Furthermore, she should not undergo any physical exercise or weight bearing exercises until her physiotherapist approves it.
For every exercise that Sarah completes, she needs to remember to not overload as it may cause further damage. There are important principles that her physio will attend to which are the intensity (weight) of exercise, the volume (sets and reps) of exercise and the frequency (sessions per week) of exercise. If all of these principles are monitored correctly then Sarah won’t overload and therefore shouldn’t do any further damage to her injury.
Sarah’s physio will recommend exercises such as gait training with appropriate devices to promote independent ambulation. It simple terms, gait training is helping an injured person relearn how to walk safely and efficiently. Sarah may progress from a non-weight bearing status such as crutches, up to minimal weight bearing status with one crutch and further onto no crutches unless she’s experiencing pain or expecting to do a lot of walking.
A rehabilitation specialist will evaluate Sarah’s abnormalities in her gait and employ such treatments such as strengthening and balance training to improve her stability and body perception as they are important in her lifestyle. In order to walk again without assistance, Sarah will need adequate sensation in her lower leg, musculoskeletal functioning and motor control along with mental assistance.
Hydrotherapy is good for rehabilitation as it promotes movement of the lower leg which will help to gain strength without putting weight on it.
Once Sarah gains little strength in her lower leg and the pain has almost gone, she should move onto doing light exercises such as brisk walking, leg lifts and calf raises. This will help to improve all the muscles in strength and endurance that deteriorated after the injury.
After a period of time, Sarah will be able to walk around quite easily on her leg without any pain and with good stability which means her muscles are working correctly and have gained enough strength to carry her own body weight.
As Sarah is studying to be a paramedic, she is going to need to be able to squat free of pain to assist in lifting the stretcher with a patient on it. At the present time Sarah cannot squat without experiencing an aching pain in her lateral leg and stiffness and pain in her ankle therefore lifting a stretcher with the added weight of a patient on it is going to prove to be very difficult for Sarah. Although Sarah’s boyfriend recommended that she should never squat again, this would mean that Sarah cannot be a paramedic as she would not pass the test required to get into the job. Therefore once Sarah masters the walking without pain, her physio should incorporate exercises to improve her squatting technique, despite what her boyfriend recommended.
Sarah should begin using a physio ball which will assist her core strength and stability which may have began to diminish over the course of her 6 week recovery period. Sarah will be able to do a range of exercises on the physio ball that don’t interfere with the rehabilitation of her lower leg such as sit ups, bridges and oblique stretching, etc. Maintaining her core strength and stability is extremely important to ensure she doesn’t do damage to her lower back or other parts of her body once she returns to her normal day to day activities.
It is recommended that Sarah begins by doing some easy flexibility stretches that focus around the lower leg such as the seated calf stretch. This requires Sarah to sit on the floor with her legs straight out, using a towel placed around the base of her feet which is pulled towards her body in a flexing motion. This stretch is held for 10 seconds, released and then repeated. Sarah could also do some standing calf stretches, performed standing, facing a wall with her hands on the wall. Sarah will place her injured leg back with her foot flat on the floor and her uninjured leg forward with her knee slightly bend . She then needs to lean in towards the wall stretching her calf muscle. Again hold for 10 seconds, release and repeat. Sarah can also incorporate some heal and toe raises, plantar-flexion and dorsi-flexion exercises using a pulley, inversion (inward and upward from body) and eversion (outward and downward from body) exercises again using a pulley, which all promote ankle flexibility.
Step ups and downs are also recommended for initial lower leg strength and then further down the track it is suggested that Sarah begins doing some lunges that will assist in quadriceps strengthening. Hamstring stretches are also beneficial and once these are all accomplished with no pain, she can move onto some shallow squats.
Sarah may like to use a chair or similar object for support for her first few shallow squats to ensure she doesn’t collapse from pain or muscle weakness and when she is confident enough, she should do them without a chair to ensure maximum results are achieved. Her physio should also increase her reps each week before progressing to another exercise.
Once Sarah accomplishes shallow squats without any pain at all, she should move onto some deeper squats or 1 legged squats that will really test her muscular strength and endurance, again using a chair for support if required. Repetitions should again be increased each week for maximal results before progressing to another exercise.
Finally once the deep squats are achievable for Sarah, she should start doing weighted squats as they will correspond closer with squatting with the weight of the stretcher and squats on a wobble board that will assist in balance techniques. Initially this may prove to be quite difficult for Sarah due to the injury she sustained, but once they are achieved Sarah is well and truly on her way to passing the physical test required by Ambulance Victoria to become a paramedic without any compromise. Instead of always increasing the amount of repetitions Sarah performs, for this exercise she can also increase the amount of weight she is using.
Gym work is required for full leg strengthening and endurance and is recommended once the injured area has fully recovered.
It is important that Sarah goes for brisk walks or does some laps at a swimming pool while she is rehabilitating her leg to ensure her aerobic endurance doesn’t diminish while she is focusing on the recovery of her fractured lower leg. Furthermore, upper body strength is going to become quite poor if she forgets to work on that as well. Regular push ups, or weight exercises are recommended and can be commenced early after the injury. It is suitable to start exercises such as dumbbell curls while she is immobilised, as it doesn’t affect the lower leg at all and will prevent loss of upper body strength while she is unable to do everyday activities.
Whilst undertaking all these exercises, it is ideal for Sarah to take calcium supplements that will her bones to strengthen and ensure she is drinking plenty of water for hydration purposes.
Prognosis and Outcome:
A fracture of the tibia is quite serious as it is slow to heal and sometimes doesn’t heal correctly because of the limited blood supply in some areas of the bone. If the fracture is left untreated it can lead to long term arthritis and other complications further down the track. There would be intense amounts of pain in the leg and any physical activity would be virtually impossible in most cases.
In general, the likelihood of perfect and absolute healing of an uncomplicated tibial or fibular fracture is good. However the result or prognosis depends on the location, severity of the fracture, and extent of soft tissue damage, along with the presence of any underlying complications. As stated by Babis, et al. (2009) in ‘Distal tibial fractures treated with hybrid external fixation’, age has no significant impact on the quality or time taken for the healing of a tibia and fibula fracture and leads to no further complications down the track.
The prognosis of an isolated fibula fracture is good as it is a non-weight bearing bone and has minimal complication. In contrast, the tibia that runs alongside the fibula is the most common fracture in the body to remain unhealed due to it being a major weight bearing bone.
Infection is the biggest danger with a tibial fracture. It is most common after high velocity, open injuries with skin necrosis, similar to that of Sarah’s fracture after her skiing accident. However if correct treatment is administered in a timely manner, then the risk of infection is minimised. In conjunction with infection of the bone, joint stiffness and loss or knee motion can also occur.
Furthermore, delayed healing or misalignment of the bone fragments and leg shortening can occur in the case of a serious fracture and if the ankle or knee joints are involved then severe arthritis may occur.
Other complications include complex regional pain syndrome, fat embolism and compartment syndrome which is an injury to the common or deep nerves around the affected area which may result in foot drop and injuries to the popliteal artery.
In the worst case scenario, if there is severe soft tissue damage, neurovascular compromise, popliteal artery injury, compartment syndrome or infection of the soft tissues such as gangrene in the leg then amputation may be necessary.
Return to work restrictions:
After a fracture to the tibia, prolonged standing and walking will be temporarily limited and the individual will be unable to engage in physical activity that requires leg strength and movement.
Furthermore, if the right leg is injured then the individual will be restricted and unable to drive until lower leg strength is improved and the control of the lower leg muscles is regained. This will limit the individual’s ways in which to travel to work.
The injured leg needs to be elevated to help with the reduction of swelling and blood pooling and in some cases this isn’t possible in the work place.
Finally, the individual may be taking pain killers with sedating qualities that may affect dexterity, alertness and cognitive function all in which will result in poor performance at work.
Failure to recover:
If the individual fails to recover in the maximum amount of time then questions are asked to determine why this is the case. Additional assessments are required to see where there can be changes or improvements to ensure adequate recovery in the future.
If Sarah cooperates and follows her surgeon and physiotherapist’s instructions such as no weight bearing activities for 6 weeks and completes her exercises correctly then the likelihood of a full recovery from her fracture is promising.
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