the unlucky break

For anyone who has paid any attention to this year’s NCAA basketball tournament or the news period, a gruesome injury was witnessed by the nation on Sunday. Louisville guard Kevin Ware suffered a compound fracture of his tibia, the larger of the two bones in the lower leg. As television viewers watched the game a sudden stop in play came followed by players and spectators alike turning away from the court in horror.

On a seemingly routine play, Ware came down from an attempted shot block and fell to the ground as his right tibia broke and protruded through the anterior portion of his leg. Ware stated that he did not realize the injury had occurred at first until he attempted to lift his leg up. After being transported to a local hospital, Ware underwent a two hour surgery where surgeons reset the tibia, inserted a metal rod, and closed the puncture wound according to the Louisville Courier-Journal. The University of Louisville released a statement saying that there is currently no timetable for his recovery but it is sure to be a lengthy one. Although this is a very gruesome injury, many others (see Joe Theismann and Michael Bush) have recovered fully from this injury.

The lower leg is composed of two bones, the tibia and the fibula. The tibia is a weight-bearing bone while the fibula strictly acts as an attachment point for a variety of soft tissue structures. Fractures of the tibia are normally a result of a high velocity force such as a car accident. In the sports realm tibia fractures are normally seen from direct impacts such as Joe Theismann and Michael Bush’s injuries. The cause of Ware’s fracture is still up to speculation and may never have a clear answer. A variety of surgeon’s have commented that Ware may have had a preexisting stress fracture of the tibia, which is a chronic weakening of the bone, that would have predisposed the player to a full fracture. Currently there have been no comments from the Louisville sports medicine staff on this thought. Stress fracture or no stress fracture, a fracture such as this one can be possible with the ‘perfect’ moment of weight-bearing, torsion, and deceleration.

Initial treatment for a tibial fracture is to stabilize the area and activate the emergency action plan. In the case of a compound fracture, when the bone has protruded through the skin, the health care professional should attempt to cover the injury and keep the patient’s attention off of the injury to help prevent shock. While stabilizing the leg another should check the pulses in the foot to ensure circulation has not been cut off. If a vacuum splint is available and the first-aider is trained in it’s use, the fracture may be splinted prior to the arrival of EMS. The first responder’s main responsibility until the arrival of EMS is to stabilize above and below the fracture, using universal precautions due to the open wound, monitor vitals, and attempt to prevent and treat signs and symptoms of shock.

Due to the open wound created from a compound fracture, the first order of business for emergency personnel is to fight infection. Possibly as soon as the ambulance ride an intravenous antibiotic will be began. After the initial assessment of the fracture the wound will be irrigated to remove any larger particles that may have made their way into the puncture site. Until surgery is performed the wound is covered with a sterile dressing and splinted. Debridement of the site should occur as soon as possible in the operating room to bring the open wound to as close as possible to a normal surgical wound. The current preferred method of surgically treating a compound fracture is intramedullary nailing. After reducing the fracture a rod is placed in the tibia through incisions made at the knee and the ankle. Once the rod is in place intramedullary nails are placed at each end of the tibia to ensure proper placement during healing. After complete healing has occurred these nails may be removed at the patient’s request. Casting is typically no longer used for a fracture that is displaced this much because it does not provide a rigid enough splint.

Unfortunately recovery time for this injury is lengthy. Realistically a bone will take 12 months to heal fully. Initial treatment consists of rest, ice, compression, and elevation. The puncture site and incisions made for surgery will need to be cleaned routinely to prevent infection. Range of motion exercises may be begun soon after surgery to prevent potential loss of motion. Due to the rupture of soft tissue caused by the protruding bone, strengthening exercises should be begun as soon as possible under the care of a physical therapist or athletic trainer. Some surgeons may decide to splint or cast the leg after the surgery while others will not. Those who are casted or splinted will lose muscle strength during the immobilization period and should begin strengthening as soon as possible after having it removed. Frequent follow ups with the surgeon should be had after the surgery to monitor healing and potential infections. When weight-bearing is allowed by the surgeon the patient will begin with partial weight-bearing with the use of crutches or a walker. Typically recovery time for a compound tibial fracture is 6-12+ months depending on the individual.

Complications that may occur from this injury are sharp fragments of the tibia cutting or tearing adjacent muscles, nerves, or blood vessels. Recovery time will be increased with each of these conditions. In some cases acute compartment syndrome may occur which is a condition when excessive swelling in one of the lower leg compartments cuts off blood flow to the portion of the leg distal to the injury. Chronic Pain Syndrome (CPS) occurs most often with these injuries. This condition should be anticipated and treated early before it becomes a chronic issue. CPS may not present itself to the patient until months or years following the initial injury.

Although it is a lengthy and early on painful recovery, the prognosis for open tibial fractures is good. In the majority of cases, such as Michael Bush, athletes are able to return to their respective sport and have a long and healthy career.



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