Well I am currently sat on the train home from London after the most recent FA Medical Society (@FAMS_SE) meeting. This quarters topic was the case study of a femur fracture within a professional footballer. An injury that we may go our whole careers in sports medicine without encountering, but one that I took a lot from with lessons that are transferable to every day practice. I will attempt to put down some of the key points that resonated with me during the talk, and points that I believe are applicable to everyone.
Figure One: Introduction Slide
- The differences between a high energy trauma and a low energy trauma
The first section of this evenings talk was led by Peter Bates who is a leading trauma surgeon who performed the surgical procedure on the player in the case study. He was keen to highlight the differences between low and high energy traumas. As sports medicine practitioners we are very used to dealing with low energy trauma-related injuries on a daily practice. However one of the major differences between the two is that low energy will not have associated soft tissue damage to the area, and so if a surgeon is able to successfully plate the fracture then there will be a relatively positive outcome with a quick rehabilitation process. However when we enter into the realms of a high energy trauma where there has been rapid velocities involved, as in the case of a road traffic accident then there is going to be a number of differences;
- Multiple injury sites
- Associated soft tissue damage
- High risk of complications such as infection
- Severe psychological effects associated with reliving the incident that in some cases has lead to near death experiences
- Slower recovery time
Although we may very rarely see this type of injury I believe that it is important to see in simple terms what we could expect and so have an early understanding of the potential issues that may face us as clinicians if we were to be presented with a high trauma injury.
- Revisiting the bone healing process
Although the actual incidence of femur fractures in elite sport is luckily very small, it was very useful to be reminded of the principles of bone healing and the effect that we can have upon this process. We will all see players with tibia and fibula fractures throughout the course of our season, and so I will just go through some of the theory discussed this evening.
It is important to firstly state that following surgical procedures it is also important to follow the guidance of the surgeon and allow appropriate time in the initial stages following surgery for healing to occur. This was a clear message from both surgeons who spoke this evening as they reinforced the risk of metal work failure if the patient is pushed too hard too soon. But once we have come through this “at risk” period it is important to apply some dynamic axial loading if we are to promote satisfactory bone healing. This goes back to the prinicples of osteogenesis. I have included a reference at the bottom of this blog for a paper by Burr et al. (2002) discussing the effect of mechanical stress on bones. It is an interesting read, but one that I wont review in this blog as that is beyond the scope of what I am looking to do. But within the paper they do suggest that to optimize bone response we should look to utilise short periods of loading and provide recovery time between bouts. This is something that Ed made reference to in Alter G running prescription with an initial workload of 10 seconds on:50 seconds off. This was probably something that I had not considered in my own rehabilitation cases in the past, and will definitely look into further.
- Look at this player, and this injury and set appropriate functional goals
Figure Two: Rehabilitation Phases
One thing that I really enjoyed this evening was listening to Edward Richmond (1st Team Physiotherapist, Crystal Palace FC) and how he broke down the rehabilitation process and programming in this complex rehabilitation case. One of the clear things that came out of the talk was that as a department they had sat down and gone through the key issues that both the surgeons and the literature highlight as expected issues with this form of injury. Examples of these are;
- Gait abnormalities
- Hip abductor weakness
- Quads weakness
Having highlighted these potential issues before beginning the rehabilitation process they were able to program in modalities and exercises aimed at limiting the risk of these issues developing. This just really highlighted the importance of having a plan to work towards. Yes the injury will never rehabilitate on a smooth upward curve, but if we have a clear plan and philosophy to work towards with goal orientated outcomes, rather than time related goals then we give the player a much better chance of this happening!
Figure Three: Take Home Messages From Edward Richmond
A really good evening of learning and clinical reflection from everyone @FAMS_SE and one that I have definitely taken a lot from in terms of challenge my own practice and processes.
I am already looking forward to the next, and final meeting of the season in April.
Burr et al. (2002). Effects of biomechanical stress on bones in animals.
Sikka (2015). Femur Fractures in Professional Athletes: A Case Series.