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Lower leg

Fractures of the lower leg occur most frequently in alpine skiers but also in crosscountry skiers, riders and participants in contact sports such as American football, soccer, rugby, and ice hockey.In alpine skiing, the injury occurs most frequently in young skiers and there is no difference in incidence
by sex. Snow conditions are an important consideration in tibial fractures: on icy or hard-packed surfaces the incidence of tibial fractures is much lower than on powder snow. A contributory factor may be the failure of the ski binding to release.Tibial fractures are relatively unusual in crosscountry skiing but
they do occur. Soccer fractures can occur when the lower leg is kicked by an opponent while the foot is loaded. Rugby tackles or an opponent tripping over an outstretched leg may also cause fractures. Lower leg fractures are not uncommon in motor sports.

Fractures of the tibia and fibula
The tibia and fibula may fracture simultaneously or separately. As a rule the injury is more serious if both bones are affected, particularly if the broken ends penetrate the skin causing a compound fracture.

Symptoms and diagnosis
– Intense, instantaneous pain is felt in the injured area.
– Tenderness and swelling occur over the fracture.
– The athlete is unable to use the injured leg.
– The normal contour and alignment of the lower leg may be altered by displacement of the fractured bones.

When treating fractures it is important to remember that the soft tissues around the injury are also damaged. Guidelines for acute treatment can be found in Chapter 5. The injured athlete should not be given anything
to eat and drink before transportation to hospital in case general anesthesia is required.
The doctor may:
– examine the injured area and nerve function and circulation distal to the injury;
– X-ray the injury;
– realign the bones if necessary and put the leg in a walking boot, a brace, or a plaster cast, which for the first 4–8 weeks should include the foot, the lower leg, and sometimes the thigh up to the groin. The treatment usually lasts for 8–12 weeks or sometimes longer;
– operate if necessary. The bone ends can be fixed with a steel rod or a plate and screws. After surgery,
external support may be applied for 4–12 weeks, but motion of the knee and ankle should be allowed as soon as possible;
– realign the bones and use an external fixation instrument. This allows early range-of-motion training.
Acute compartment rupture may occur and should be treated along with the fracture

Anterior lower leg pain
Anterior lower leg pain is caused by chronic compartment syndromes in the anterior (10–20%) and lateral (1–2%) muscle compartments, peroneal nerve syndromes (20%), muscle hernia (5%) or medial tibial stress syndromes (50%).

Acute anterior compartment syndrome
Acute anterior compartment syndrome can occur as a result of direct impact, such as a kick or a blow, to the tibialis anterior muscle. This is, however, uncommon, as the muscle lies well protected laterally to the tibia Acute bleeding in the anterior compartment of the lower leg can lead to greatly increased pressure which in turn impairs the blood flow of the vessels that pass through the muscle compartment. Of most importance is the artery supplying the anterior part of the dorsum of the foot, which can become completely blocked, causing an acute condition which requires surgery.
Acute anterior compartment syndrome can also be caused by overuse, triggered by the athlete training or competing too intensively, perhaps on a hard surface and without proper preparation.

Symptoms and diagnosis
– A characteristic symptom is acute pain which gradually increases until it becomes impossible to continue running.
– Weakness can occur when the foot is dorsiflexed (bent upwards).
– A sensation of numbness extending down into the foot may be felt.
– Local swelling and tenderness can be present over the tibialis anterior muscle.
– Pain can be triggered when the foot or toes are passively plantar flexed (bent downwards).

The athlete should:

– rest actively;
– cool the injured area.

The doctor may:

– prescribe diuretics;
– prescribe anti-inflammatory medication;
– check the effectiveness of the treatment by measuring the pressure in the muscle compartment;
– operate to divide the fascia if the pressure in the muscle compartment is too high and does not diminish.Treatment should be started early, because the increased pressure can cause permanent damage to muscle
and other soft tissues in the muscle compartment.

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