In my write up on the Ankle Fracture I briefly touched on the terrible injury suffered by Tyrone Prothro. What makes his injury different is that he broke both the Tibia and Fibula as well as having a compound fracture and a subsequent infection.

It is possible to have an ankle fracture component to this injury. I believe that is the type of injury that Tyrone Prothro had, but I have not been able to confirm that or any of the devices used in the treatment of his injury. It is not far off to say that he probably had an intramedullary rod (IM Rod) as well as plates and screws to stabilize his multiple fractures. In the case of a sever open injury it is common practice to delay the primary fixation procedure to let the surrounding tissue "relax" to let the swelling subside in order to aid in the closure of the open wound.

The x-ray below is a closed injury

Distal Fibular Fracture

The fibula is the smaller bone that runs parallel to the Tibia. It only carries about 10% of your body weight. The fibula usually fractures at the same time as the tibia. When only the fibula fractures, it is usually because of a direct blow to the side of the leg or an extreme sideways bend at the ankle or knee. The Fibula is important because it provides extra stability and support to the Tibia. When both the Tibia and Fibula are broken the Fibula, when brought out to length, actually helps reduce the Tibia fracture and keeps the leg from shortening during the healing process.

This type of injury is usually treated non-operatively or closed but there are some things to watch out for.

Indication for Closed Treatment:

- chief indication of closed treatment is enough overlap to initiate early wt bearing; at least 50% cortical overlap at the fracture site.

- more than 50% initial fracture displacement will significantly increase risk of loss of reduction and non-union, due to instability of fracture.

- unstable fractures of tibia/fibula may be treated by closed reduction & casting, however, malunion may occur. - initial shortening of more than 2 cm is a contra-indication for casting, since this amount of shortening would be expected with weight bearing (despite the success of the initial reduction); OM Bostman et. al. JBJS 68-B (3) 1986. p 462-466.

Prognosis for Fracture Healing:

- more than 50% cortical comminution or displacement more than 50% are significant risk factors for non-union. - With a stable fracture the average time for union is 4 to 5 months, with a range of 2 to 14 months. - 1-2 % refracture and 1-2 % require surgical bone grafting for union. - nonunion occurs in 2-5%, malalignment occurs in 3% to 8%, and shortening of more than 1 cm occurs in as many as 10% of patients.

Treatment Information from Wheeless' Textbook of Orthopaedics

Louisville’s Michael Bush also suffered a lower extremity injury in the first game of last season. His was a closed injury of the tibia that required a surgical procedure to repair his fractured Tibia.

The Surgical Technique

Bush’s injury required an IM Rod to reduce and stabilize his fracture. This requires a small incision to be made just below the knee-cap where a thin guide wire is placed within the Tibial canal to help guide the rod and also aid in reducing the fracture back into place. A reaming device is then placed over the thin guide wire, under power and the direct visualization of a fluoroscope, to ensure that canal is sequentially reamed to the proper diameter and the proper depth. Not doing this can lead to further damage as the IM Rod can potentially burst the fracture site leading to more comminution.

Once the IM Rod is placed within the canal a targeting jig is then attached to the rod and screws are then place at the top of the rod to atbilize it at the top of the tibia. The targeting jig is removed and the distal screws are place using the free-hand technique under the direct visualization of a fluoroscope. Once all the screws are placed the incisions are irrigated and sutured closed. This procedure can take form 30 min to 90 minutes depending on the severity of the fracture.

Bush required a second surgery probably for bone grafting due to a delayed union of the fracture. Once healing was achieved he more than likely had a third surgery to remove all of the hardware once he was fully healed. Once the hardware is removed further healing is needed to allow the screw holes to fill in and heal as these are a stress riser and could lead to a re-injury if they are not fully healed.

The x-ray on the left is the anterior/posterior view of the injury. The center x-ray is the medial/lateral view of the injury. The x-ray on the right is anterior/posterior view of the repaired fracture. The plate on the fibula is placed at the discretion of the surgeon based on the fracture pattern or the stability of the reduction.

On a side note the reduction of the tibia looks be a little too rotated for my liking, but I’m not the guy who is putting in the rod so it isn’t my call. This will probably heal but non-union of distal tibia fractures is higher than those fractures in the shaft or proximal tibia.