Tibial shaft fractures in football players
© Chang et al; licensee BioMed Central Ltd. 2007
Received: 07 March 2006
Accepted: 13 June 2007
Published: 13 June 2007
Football is officially the most popular sport in the world. In the UK, 10% of the adult population play football at least once a year. Despite this, there are few papers in the literature on tibial diaphyseal fractures in this sporting group. In addition, conflicting views on the nature of this injury exist. The purpose of this paper is to compare our experience of tibial shaft football fractures with the little available literature and identify any similarities and differences.
Methods and Results
A retrospective study of all tibial football fractures that presented to a teaching hospital was undertaken over a 5 year period from 1997 to 2001. There were 244 tibial fractures treated. 24 (9.8%) of these were football related. All patients were male with a mean age of 23 years (range 15 to 29) and shin guards were worn in 95.8% of cases. 11/24 (45.8%) were treated conservatively, 11/24 (45.8%) by Grosse Kemp intramedullary nail and 2/24 (8.3%) with plating. A difference in union times was noted, conservative 19 weeks compared to operative group 23.9 weeks (p < 0.05). Return to activity was also different in the two groups, conservative 27.6 weeks versus operative 23.3 weeks (p < 0.05). The most common fracture pattern was AO Type 42A3 in 14/24 (58.3%). A high number 19/24 (79.2%) were simple transverse or short oblique fractures. There was a low non-union rate 1/24 (4.2%) and absence of any open injury in our series.
Our series compared similarly with the few reports available in the literature. However, a striking finding noted by the authors was a drop in the incidence of tibial shaft football fractures. It is likely that this is a reflection of recent compulsory FIFA regulations on shinguards as well as improvements in the design over the past decade since its introduction.
Football is officially the most popular sport in the world. The Fédération Internationale de Football Association (FIFA) estimates that there are 250 million licensed players in 204 countries with 1% participation at professional level . In the UK, it is estimated that about 10% of the adult population play football at least once a year . It is therefore of considerable importance to the social fabric of society especially in Glasgow where there are two derby teams. Despite this, there are very few good papers in the literature on the epidemiology of tibial shaft fractures in this sporting group [3, 4]. In addition, there are conflicting views in the literature. One study described football-related tibial diaphyseal fractures as low-velocity injuries, and very rarely associated with severe soft tissue damage . Other studies [5, 6], suggest that lower leg fractures in footballers are serious and potentially high-energy injuries. Nevertheless an interesting observation is that studies carried out in the late 80's and early 90's had relatively higher numbers [3, 4], as compared to recent studies where numbers are noted to be relatively lower [5, 6]. This may be a subtle hint of a decrease in the incidence of these fractures.
We herein present our experience over a five year period of tibial shaft football fractures in an attempt to identify similarities and differences with the little available literature on this common sport.
AO/ASIF classification of tibia shaft fractures 
A1 – spiral
A2 – oblique
A3 – transverse
B1 – spiral wedge
B2 – bending wedge
B3 – fragmented wedge
C1 – spiral
C2 – segmental
C3 – irregular
Fracture union was defined as pain-free weight-bearing without support; and bridging callus seen on 2 radiographs taken at 90 degrees to each other. Delayed union and non-union were defined as absence of callus on radiographs at 4 and 6 months respectively .
The independent t-test was used for statistical analysis of the results and a p value of less than 0.05 was considered significant.
In the 5 years period from 1997 to 2001, there were 244 tibial fractures treated. 24 (9.8%) of these were football related. Of these, 3 were professional soccer players and 21 amateurs. All patients were male with a mean age of 23 years (range 15 to 29). The right tibia was fractured in 91.7% (22 patients) and the left in 8.3%. The mechanism of injury in almost all cases, 23/24 (95.8%), involved direct contact. Shinguards were also worn in 95.8% of cases. 14 cases (58.3%) occurred on a weekend whilst 10 cases (41.7%) occurred on a weekday.
Summary of tibial shaft football fractures according to AO type.
Mode of Treatment
11/24 (45.8%) patients were treated conservatively. A standard regimen was followed in the conservative group which consisted of a non-weight bearing above knee plaster for 8 weeks followed by a Sarmiento cast with partial weight bearing until union occurred. The average in-patient time was 2.4 days (range 2–4 days). Mean time to fracture union was 19 weeks (standard deviation 4.05 weeks). The mean length of time taken to return to activity/training was 27.6 weeks (standard deviation 4.54 weeks).
The remaining patients, 13/24 (54.2%), were treated operatively with 11/24 (45.8%), treated with a Grosse Kemp intramedullary nail according to the manufacturer's instructions with primary locking in all cases. The remaining 2 cases were treated with open reduction and internal fixation using a DCP plate and screws (closed 42A1); and interfragmentary screws (43A1) respectively. All patients who underwent intramedullary nailing were allowed partial weight bearing for the first 6 weeks, followed by full weight bearing as tolerated until union. The mean time from admission to fixation was 20.9 hrs (range 3 to 39 hrs). Inpatient time averaged 3.7 days (range 2 to 6 days). Mean time to union was 23.9 weeks (standard deviation 3.99 weeks). Despite this however, the average time to return to training/activity was slightly quicker at 23.3 weeks (standard deviation 6.46 weeks).
Treatments used according to AO fracture type.
AO fracture type
Plate and screws
Summary of complications of tibial shaft football fractures according to treatment method and their outcomes.
Position slipped at day 12
IM nail. Nail was removed at 13 months because of anterior knee pain.
Closed 42A3 (fibula intact)
Position slipped at day 9
Position slipped at day 28
Position slipped at 8
Non-union at 5 months
Underwent bone grafting and plating plus fibulectomy. Subsequently lost to follow-up.
Anterior knee pain
Nail removed at 29 months
Dynamisation at 24 weeks
Anterior knee pain
Nail removed at 24 weeks
IM nail (at 23 hrs)
Admitted to Intensive Care for 2 days then discharged on day 8 post-op. Fracture subsequently united.
Anterior and medial knee pain.
Self-discharged from clinic and lost to follow-up.
Amongst the operatively treated group, anterior knee pain was the most common complication, 3/13 (23.1%). One patient (42B2) whose fixation interval was 23 hours had respiratory complications related to fat embolism that required supportive care and observation in the intensive care unit for 2 days. Dynamisation was carried out in one case that subsequently united at 9 months.
No patients in either group developed compartment syndrome.
Union times were noted to be quicker in the conservative group (p < 0.005). This may be a reflection of the self-selecting bias of those fractures treated by intramedullary nailing. Whilst the majority of fractures in both treatment groups were A2 and A3, of these, the more displaced and hence more severe ones would have been treated by nailing.resulting in the longer healing time. This again is a reflection of the personality of each fracture. On the other hand, return to activity was earlier in the operative group (p < 0.05), a well recognized fact . It facilitates earlier mobilization, hence preservation of muscle mass and prevention of joint stiffness. which would otherwise be present after treatment in a cast.
A striking finding in our study is the much lower incidence of football fractures amongst all tibial shaft fractures 24/244 (9.8%). The Edinburgh study period was from 1988 to 1990 with an incidence of 24.7%  whilst, Leeds looked at the period from 1990 to 1994 and quoted an incidence of 17.6% . This corresponded to an introduction of shinguards by FIFA in 1990 as part of the compulsory basic equipment of a player . Shin guards protect by spreading loads over wider areas of the skin. The force of the initial impact is reduced as peak pressure is dampened down. Over the past decade there have been improvements in shinguards since its introduction. Francisco et al tested 23 commercially available shinguards and found that they reduced force by 11% to 17% and strain by 45% to 51% compared with the unguarded leg . The introduction of shinguards with its design improvements may explain the lower incidence in our most recent of all previous study periods (1997 to 2001). In fact, shinguards were worn in 95.8% of cases which testified to its current widespread usage.
The nature and pattern of tibial shaft football fractures in our series compared similarly with previously published series. One exception noted however, was a decreasing trend in the incidence of tibial football fractures. A possible explanation for this may have been the introduction of shin-pads and improvement in their designs.
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