Case Report

Tibial Fracture in a Basketball Player: Treatment Dilemmas and Complications

Tim C. Garl, MPH, ATC; Larry Alexander, MS, ATC; Steven K. Ahlfeld, MD; Larry Rink, MD; Brad J. Bomba, Sr, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 6 - JUNE 97

In Brief: A 19-year-old male basketball player suffered a spiral fracture of the tibia with an intact fibula, an uncommon injury in basketball. Treatment options for these injuries include cast immobilization, external fixation, and internal fixation using an intramedullary rod or plates and screws. Numerous complications can occur in these injuries, possibly including interference with healing by the intact fibula. The player was treated with an intramedullary rod, but delayed union ensued. Treatment of the patient's delayed union with closed exchange intramedullary nailing and fibular osteotomy enabled him to return to basketball participation.

Trauma to the lower leg is frequently seen in basketball players and ranks among the most common sports injuries (1). Fractures of the tibia are not uncommon in contact sports, and these injuries account for the majority of healing problems in long-bone fractures in the United States. However, except in skiers, spiral fractures of the tibia with an intact fibula are infrequent. Whether open or closed, this fracture pattern can be associated with complications such as delayed union, nonunion, or malunion.

A review of the literature makes obvious that there are several acceptable options for treating this injury. There is disagreement, however, about the ideal treatment and postoperative management for optimal healing (2,3). This case study describes the care of such a fracture for a patient who was a National Collegiate Athletic Association (NCAA) Division I men's basketball player, and the complications encountered during the recovery, rehabilitation, and ultimate return to participation.

Case Report

A 19-year-old male basketball player competing in the NCAA Basketball Tournament fell to the floor of the court after running and jumping in an attempt to block an opponent's shot. He reported that as he jumped, he heard a "pop" and immediately felt severe pain.

Examination revealed a deformity of the distal portion of the left leg. X-rays of the leg showed a displaced spiral fracture of the tibia with an intact fibula (figure 1). The patient had no symptoms prior to the acute injury, but given his current activity level, an impending tibial stress fracture might have been a factor in this severe injury.

After treatment options were reviewed, a decision was made to perform a closed intramedullary nailing of the fracture. A reamed intramedullary rod with static interlocking screws was inserted to stabilize the fracture. Immediate postoperative x-rays revealed no distraction of the fracture.

Anterior lower leg compartment pressures were monitored for 24 hours postsurgery with no indication of compartment syndrome. After 10 days, the patient's leg was placed in a non-weight-bearing short leg cast. The cast was removed 1 month postsurgery. The patient was then given a short leg boot and partial weight bearing was allowed. At this time he started using electrical bone stimulation. Two months postsurgery he was bearing weight comfortably, and crutches were discontinued. Two-month postoperative x-rays revealed adequate alignment and early healing of the fracture (figure 2). Dynamization was performed 12 weeks postsurgery. The patient began light jogging and easy fundamental basketball drills 4 months postsurgery. By 6 months postsurgery he had progressed sufficiently to begin limited basketball practice. He continued to participate in basketball practice and regained excellent functional ability.

After being involved in a motor vehicle accident 9 months postsurgery, the patient complained of pain in the distal tibial area. X-rays revealed radiolucency at the tip of the intramedullary rod and delayed union (figure 3). At that time a closed exchange intramedullary nailing and a fibular osteotomy were performed.

Within 6 months of the exchange intramedullary nailing, the patient returned to full activity and resumed playing Division I basketball with no disability. X-rays 6 months after exchange nailing revealed a healed tibial fracture with adequate alignment (figure 4). Two years after the fracture the patient was continuing to play basketball with no pain.

Discussion

Sixty-four percent of all tibial fractures involve the middle and lower third of the tibia (4). The majority of tibial fractures are closed (1). Fractures of the tibia and fibula are the most common bony injuries to the lower leg in children (4).

The most common cause of an isolated tibial fracture is torsional force resulting in either a spiral or oblique fracture of the lower third of the bone (4). Spiral fractures have been common in skiers, but this trend is decreasing with greater safety awareness and better equipment (5).

Isolated fractures of the tibia have a significant complication rate (4). These fractures are prone to varus displacement and require careful follow-up (1,4). Comminution, soft-tissue injury, and fracture displacement are often cited as the factors most highly correlated with complications following tibial fractures (1). Common complications include delayed union, nonunion, malunion, posttraumatic osteoporosis, ankle pain, and compartment syndrome. In addition, there is the possibility of interference by the intact fibula with healing of the tibia. (1-3,6,7).

External fixation is most commonly used in comminuted tibial fractures with significant soft-tissue damage. However, it has been found to be biomechanically less stable than internal fixation. Complications of external fixation include malunion, nonunion, loosening of pins, and pin tract infections.

Internal fixation using plates and screws has been reported to have a high success rate (2). Infection appears to be the most significant complication of internal fixation, with studies reporting rates as high as 44% (2). DiPasquale et al (8) found that using an intramedullary rod in tibial fractures permitted excellent stabilization of the fracture. Bostman (9) found that for severely displaced fractures of the shaft of the tibia, open reduction and internal fixation was an acceptable method of treatment.

Timing of weight bearing on the injured leg is an area of disagreement among authors regardless of the method of treatment. In one study (3), increased weight bearing was found to protect patients from severe local osteopenia. However, in a study by Teitz et al (1), all patients who developed a varus malunion had been bearing weight in a cast in the first 4 weeks of treatment. Teitz et al suggested that tibial fractures be kept immobilized and be protected from weight bearing for 1 month.

Because of the risk of fibular interference with tibial healing, some authors suggest that a fibular osteotomy should be performed when a patient has an isolated fracture of the tibia (10,11). However, it has been shown that the osteotomized fibula may heal faster than the tibia; therefore, an acute fibular osteotomy is not recommended (10,12). In this case of delayed tibial union, an exchange intramedullary nailing combined with fibular osteotomy was effective. In some cases of delayed union, exchange nailing alone may be a satisfactory treatment.

A Satisfactory Approach

The literature presents conflicting accounts as to what method of treatment best minimizes the risk of complications in patients who have acute tibial fractures. In the young competitive athlete who has a displaced spiral fracture of the tibia, intramedullary nailing appears to be a rational method of acute treatment.

References

1. Teitz CC, Carter DR, Frankel VH: Problems associated with tibial fractures with intact fibulae. J Bone Joint Surg (Am) 1980;62(5):770-776
2. Gregory P, Sanders R: The management of severe fractures of the lower extremities. Clin Orthop 1995; 318:95-105
3. Tandon SC, Gregson PA, Thomas PB, et al: Reduction of post-traumatic osteoporosis after external fixation of tibial fractures. Injury 1995;26(7):459-462
4. Briggs TW, Orr MM, Lightowler CD: Isolated tibial fractures in children. Injury 1992;23(5):308-310
5. Freeman JR, Weaver JK, Oden RR, et al: Changing patterns in tibial fractures resulting from skiing. Clin Orthop 1987;216:19-23
6. Blick SS, Brumback RJ, Poka A, et al: Compartment syndrome in open tibial fractures. J Bone Joint Surg (Am) 1986;68(9):1348-1353
7. Smith EJ, Ward AJ, Watt I: Post-traumatic osteoporosis and algodystrophy after external fixation of tibial fractures. Injury 1993;24(6):411-415
8. DiPasquale T, Helfet DL, Sanders R: The treatment of open and/or unstable tibial fractures with an unreamed double locked tibial nail. Orthop Trans 1992;16:826
9. Bostman OM: Spiral fractures of the shaft of the tibia. J Bone Joint Surg (Br) 1986;68(3):462-466
10. Fernandez-Palazzi F: Fibular resection in delayed union of tibial fractures. Acta Orthop Scand 1969;40(1):105-118
11. Dehne E, Deffer PA, Hall RM, et al: The natural history of the fractured tibia. Surg Clin North Am 1961;41:(6)1495-1513
12. Lottes JO: Treatment of delayed or nonunion of the tibia by a medullary nail. Clin Orthop 1965;43:111-128

Mr Garl is a basketball trainer at Indiana University in Bloomington. Mr Alexander is a graduate assistant athletic trainer at the University of Oklahoma in Norman. Dr Ahlfeld is orthopedic consultant for the Indiana University basketball team in Bloomington and is in private practice in Indianapolis. Dr Rink and Dr Bomba are team physicians for the Indiana University basketball team in Bloomington and are in private practice in Bloomington. Address correspondence to Tim C. Garl, MPH, ATC, Indiana University, 1001 E 17th St, Bloomington, IN 47408; e-mail to tgarl@indiana.edu.

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