Lower Leg Injuries Research Articles

Intrinsic factors associated with medial tibial stress syndrome in athletes: A large case-control study

Background. Medial tibial stress syndrome (MTSS) is the most common lower-leg injury in athletes, and is thought to be caused by bony overload. To prevent MTSS, both pathophysiological and aetiological factors specific to MTSS need to be identified. The intrinsic risk factors that contribute to the development of MTSS are still uncertain. Objective. To determine the intrinsic risk factors of MTSS by sampling a large population of athletic MTSS patients and controls. Methods. Athletes with MTSS and control subjects were medically examined in terms of range of motion of the leg joints (hip abduction, adduction, internal and external range of motion; ankle plantar and dorsal flexion; hallux extension and flexion; subtalar inversion and eversion), measures of over-pronation and maximal calf girth. Results. Ninety-seven subjects agreed to participate in the study: 48 MTSS patients and 49 active controls. The following variables were considered: gender, age, body mass index (BMI), hip abduction, hip adduction, internal and external hip range of rotation, ankle plantar and dorsal flexion, hallux flexion and extension, subtalar inversion and eversion, maximal calf girth, standing foot angle and navicular drop test. In multivariate logistic regression analysis, hip abduction (odds ratio (OR) 0.82; 95% confidence interval (CI) 0.72 - 0.94), ankle plantar flexion (OR 0.73; 95% CI 0.61 - 0.87) and subtalar inversion (OR 1.24; 95% CI 1.10 - 1.41) were significantly associated with MTSS. The Nagelkerke R 2 for this model was 0.76, indicating that 76% of the variance in the presence of MTSS could be explained by these variables. Conclusion. Decreased hip abduction, decreased ankle plantar flexion and an increased subtalar inversion could be considered risk factors for MTSS.

The thickness of the anterior compartment does not indicate compartment syndrome in acutely traumatised legs?

BackgroundThe study was conducted to achieve early detection of increased compartment pressure by comparing the changes between the thickness and pressure within the musculofascial compartments after lower leg injury. MethodsWe included cases of a lower-leg fracture between January and December 2007. Bilateral lower leg compartment pressure and thickness were measured before the surgery and post-anaesthesia, and the surgery was performed within 12h after the initial trauma. The intracompartment pressure (ICP) was measured with a Wick catheter pressure monitor. The thickness (width) of the anterior compartment of lower leg was measured using ultrasound. ResultsAll data were measured within 4–6h of the injury. The average thickness in injured legs versus uninjured was 30mm (15–46mm) versus 20.4mm (13–30mm), P<0.001. The average intracompartment pressure (ICP) in injured leg versus uninjured was 45.3mmHg (26–80mmHg) versus 17.5mmHg (15–20mmHg), P<0.001. The thickness and ICP were significantly increased for injured lower legs compared to the uninjured legs, but the increase in ICP did not show a significant relationship with the change in thickness of the injured lower leg. ConclusionIn this study, the results of ICP and thickness changes of injury lower leg compared with uninjured leg revealed no statistically significant correlation. Some injuries showed a high ICP with only mild changes in thickness, while some showed a high ICP with significant changes. Although ultrasound has many advantages for the evaluation of soft tissue changes after trauma, this study revealed that thickness changes are not a predicable parameter for determining pressure on the acute fracture of lower leg.

DEVELOPMENT AND VALIDATION OF EEVC WG17 LOWER LEGFORM FE MODEL FOR PEDESTRIAN SAFETY

Vehicle-pedestrian collisions had claimed the lives of many in the world roads yearly. Among the types of injury that may occur in a vehicle-pedestrian collision, lower extremity injur ies have the highest account. These alarming statis tic has encouraged joining effort from researchers, car manufacturers and the governm ent to find solutions in reducing the risk of vulne rable road users. The car bumper structure design plays a crucial role in cus hioning the impact on the pedestrian leg during a cThe European Enhanced Vehicle-Safety Committee (EEVC) has develo ped test methods to evaluate severity of the lower leg injury, upper leg injury and head impact injury in a vehicle-pedestrian simu lated collision. Since lower extremity injury are m ost common, undivided attention should be paid on the lower legform to bumper test. The maximum bending angle, maximum shearing displa cement and maximum tibia acceleration are among the three injury crite rion determined for lower legform to bumper test. B efore the lower legform to bumper test can be perform the lower legform has to be certified statically and dynamically. The advancement of computerization had supported th e usage of Finite Element Method(FEM) in simulating real life scenarios for analysis. Irregular geometries are now discretized and solved numerically. Finite Element Analysis(FEA ) has proven to reduce time and cost significantly therefore the author took ad vantaged of this tool and simulated a lower legform to bumper collision. This paper presents in detail the static and dynamic certifica tion of the Finite Element (FE) legform model using the HyperWorks software. The static results for both bending and shearing has to be within the EEVC/WG17 limits and the internal en ergy at 15o shall be 100±7J. The maximum bending angle shall not be less than 6. 2o and not more than 8.2o, the maximum shearing dis placement shall not be less than 3.5mm and not more than 6mm, and the maximum u pper tibia acceleration shall not be less than 120g and not more than 250g in the dynamic certification test.

ANALYSIS OF PEAK PRESSURE, MAXIMAL FORCE, AND CONTACT AREA CHANGES DURING WALKING AND RUNNING WITH CONVENTIONAL AND SHOCK-ABSORBING INSOLES IN THE COMBAT BOOTS OF THE CZECH ARMY

The aim of this study was to determine changes of peak pressure, maximal force, and contact area in five foot regions with two different insoles during walking and running, thereby obtaining data contributing to optimization of footwear and reduction of lower leg injury.Twenty-six male soldiers participated in the study. Peak pressure, maximal force, and contact area were measured in five foot regions (lateral and medial heel, midfoot, lateral and medial forefoot, big toe, and toes 2, 3, 4, and 5) with two different insoles (conventional vs. custom molded shock-absorbing insoles) during a walking speed of 5 km/h and running speeds of 8 and 12 km/h using the Pedar-X tensometric system (Novel, St. Paul, MN). Measurements revealed that the shock-absorbing insoles significantly (p &lt; 0.05) attenuated the peak pressures in heel and forefoot region and increased the contact area in the midfoot region which indicates a successful redistribution of forces that arise during the contact phase in walking and running. Shock-absorbing insoles hence may contribute to better plantar pressure distribution during walking and running, and effectively prevent lower leg injuries.

A retrospective survey on injuries in Croatian football/soccer referees

BackgroundInjury among soccer referees is rarely studied, especially with regard to differences in the quality level of the refereeing. Additionally, we have found no study that has reported injury occurrence during official physical fitness testing for soccer referees. The aim of this study was to investigate the frequency, type and consequences of match-related and fitness-testing related injuries among soccer referees of different competitive levels.MethodsWe studied 342 soccer referees (all males; mean age 32.9 ± 5.02 years). The study was retrospective, and a self-administered questionnaire was used. In the first phase of the study, the questionnaire was tested for its reliability and applicability. The questionnaire included morphological/anthropometric data, refereeing variables, and musculoskeletal disorders together with the consequences.ResultsThe sample comprised 157 main referees (MR; mean age 31.4 ± 4.9 years) and 185 assistant referees (AR; mean age 34.1 ± 5.1 years) divided into: international level (Union of European Football Associations-UEFA) referees (N = 18; 6 MRs; 12 ARs) ; 1st (N = 78; 31 MRs; 47 ARs), 2nd (N = 91; 45 MRs; 46 ARs); or 3rd national level referees (N = 155; 75 MRs; 80 ARs). In total, 29% (95%CI: 0.23–0.37) of the MRs and 30% (95%CI: 0.22–0.36) of the ARs had experienced an injury during the previous year, while 13% (95%CI: 0.05–0.14) of the MRs, and 19% (95%CI: 0.14–0.25) of the ARs suffered from an injury that occurred during fitness testing. There was an obvious increase in injury severity as the refereeing advanced at the national level, but the UEFA referees were the least injured of all referees. The results showed a relatively high prevalence of injuries to the upper leg (i.e., quadriceps and hamstrings) during physical fitness testing for all but the UEFA referees. During game refereeing, the ankles and lower legs were the most commonly injured regions. The MRs primarily injured their ankles. The ARs experienced lower leg and lower back disorders. However, the overall injury rate was equal for both groups, with 5.29 (95%CI: 2.23–8.30) and 4.58 (95%CI: 2.63–6.54) injuries per 1000 hours of refereeing for MRs and ARs, respectively.ConclusionIn addition to the reported risk of injury during soccer games, physical fitness testing should be classified as a risk for injury among soccer referees. Special attention should be given to (I) lower leg injuries during games and (II) upper leg injuries during physical fitness tests. A higher physical fitness level and a qualitative approach to training are recognized as protective factors against injury. Subsequent studies should investigate the specific predictors of injuries among referees.

Outcomes of IED Foot and Ankle Blast Injuries

Improvements in protection and medical treatments have resulted in increasing numbers of modern-warfare casualties surviving with complex lower-extremity injuries. To our knowledge, there has been no prior analysis of foot and ankle blast injuries as a result of improvised explosive devices (IEDs). The aims of this study were to report the pattern of injury and determine which factors are associated with a poor clinical outcome. U.K. service personnel who had sustained lower leg injuries following an under-vehicle explosion from January 2006 to December 2008 were identified with the use of a prospective trauma registry. Patient demographics, injury severity, the nature of the lower leg injury, and the type of clinical management were recorded. Clinical end points were determined by (1) the need for amputation and (2) ongoing clinical symptoms. Sixty-three U.K. service personnel (eighty-nine injured limbs) with lower leg injuries from an explosion were identified. Fifty-one percent of the casualties sustained multisegmental injuries to the foot and ankle. Twenty-six legs (29%) required amputation, with six of them amputated because of chronic pain eighteen months following injury. Regression analysis revealed that hindfoot injuries, open fractures, and vascular injuries were independent predictors of amputation. At the time of final follow-up, sixty-six (74%) of the injured limbs had persisting symptoms related to the injury, and only nine (14%) of the service members were fit to return to their preinjury duties. This study demonstrates that foot and ankle injuries from IEDs are associated with a high amputation rate and frequently with a poor clinical outcome. Although not life-threatening, they remain a source of long-term morbidity in an active population.

Brokeback Mountain: Spinal Injuries in Mountain Casualties in Snowdonia

Our emergency department (ED) receives casualties from Snowdonia National Park and surrounding areas. Suspected spinal injuries are common in mountain casualties and pose handling challenges for rescue personnel. The pattern and severity of spinal injuries occurring among UK mountain casualties has not been well studied. Therefore, we wished to establish the incidence and pattern of spinal injuries in mountain casualties presenting to our hospital. Cases with spinal fractures were identified from our database of mountain casualties brought to our ED January 2004 to December 2011 after contact with mountain rescue teams or Royal Air Force Search and Rescue helicopter, or both. Radiological reports and images were reviewed to establish vertebral level and type of injury. Of 789 mountain casualties during the study period, 636 (80%) were injured rather than ill, although 196 had only isolated lower leg injuries. Fifty-one cases had confirmed spinal fractures, including 8 fatalities (17.4% of the 46 trauma fatalities). Most of the spinal fractures (44 of 51) had fallen from a height greater than standing; 20 were direct and 24 were tumbling falls. Most were rock climbing or hill walking at the time of incident. Forty-three of 394 nonisolated ankle trauma casualties (11%) had spinal fractures, but only 7 of 43 were unstable: the unstable fracture rate in casualties found alive was 1.8%. Only 1 survivor sustained spinal cord damage, compared with 5 of 8 fatalities (56%); T12 and L1 together accounted for 43% of spinal fractures. Spinal fractures are quite common in mountain casualties in North Wales. However, only 1.8% of casualties still alive when help arrived had unstable spinal fractures, and only 1 casualty sustained spinal cord injury. Direct falls (eg, rock climbing) produce a similar injury pattern as for urban fallers, but falls of a tumbling nature were associated with a higher rate of cervical and thoracic injury and a greater mortality among fallers with spinal injuries.

FASS is a Better Predictor of Poor Outcome in Lower Limb Blast Injury Than AIS

Due to the absence of clinical blast data, automotive injury data using the abbreviated injury score (AIS) has been extrapolated to define current North Atlantic Treaty Organisation (NATO) injury thresholds for anti-vehicle mine tests. We hypothesized that AIS, being a marker of fatality rather than disability, would be a worse predictor of poor clinical outcome compared with the lower limb-specific foot and ankle severity score (FASS). Using a prospectively collected trauma database, we identified UK Service Personnel sustaining lower leg injuries from under-vehicle explosions from January 2006 to December 2008. A full review of all medical documentation was performed to determine patient demographics and the severity of lower leg injury, as assessed by AIS and FASS. Clinical endpoints were defined as (1) need for amputation or (2) poor clinical outcome (defined as amputation or ongoing clinical problems). Statistical models were developed to explore the relationship between the scoring systems and clinical endpoints. Sixty-three UK casualties (89 limbs) were identified with a lower limb injury after under-vehicle explosion. The mean age of the casualty was 26.0 years. At 33.6 months follow-up, 29.1% (26 of 89) required an amputation and 74.6% (67 of 89) having a poor clinical outcome. Only 9 (14%) casualties were deemed medically fit to return to full military duty. Receiver operating characteristic analysis revealed that both AIS = 2 and FASS = 4 could predict the risk of amputation, with FASS = 4 demonstrating greater specificity (43% vs. 20%) and greater positive predictive value (72% vs. 34%). In predicting poor clinical outcome, FASS was significantly superior to AIS. Probit analysis revealed that a relationship could not be developed between AIS and the probability of a poor clinical outcome. Our study clearly demonstrates that AIS is not a predictor of long-term clinical outcome and that FASS would be a better quantitative measure of lower limb injury severity.

Isolated fracture of the fibular shaft due to alpine skiing; a specific injury

Although musculoskeletal injuries of lower leg due to alpine skiing is well known and widely reported, an acute isolated fibula fracture as a specific ski injury has not been reported in the relevant literature. Herein, we present a case of isolated fibula fracture which is missed at initial admission, and discuss the mechanism of injury and relationship with alpine skiing equipment.

Free flap transplantation combined with skin grafting and vacuum sealing drainage for repair of circumferential or sub-circumferential soft-tissue wounds of the lower leg

BackgroundThis study is aimed at evaluating the operation techniques and clinical significance of free flap transplantation combined with skin grafting and vacuum sealing drainage (VSD) in repairing severe traumatic extensive circumferential or semi-circumferential soft-tissue defects of the lower leg.Material/MethodsThirty patients with severe lower leg injuries were treated by free flap transplantation combined with skin grafting and VSD from January 2008 to June 2011. The size of the wounds ranged from 23×8 cm to 44×28 cm and all affected more 70% of the low leg circumferential area. Wounds were complicated by exposure, necrosis, or infection of deep tissues. The wounds were first debrided and covered by VSD. When the condition of the wound had improved (5 to 7 days later), free flaps were harvested to reconstruct damaged tissue and skin grafts and VSD was used to cover granulation tissues around the transplanted flap.ResultsGranulation tissues developed and the area requiring flap cover decreased in all 30 patients after debridement and VSD. In 28 of 30 cases, the transplanted flaps grew well without complication. Peripheral necrosis was observed in only 2 cases, which required a second debridement and skin graft. Ten wound areas covered by grafts were left with scattered peripheral wounds, which healed with the help of 1 more skin graft or dressing change. Morphological appearance and functional recovery were satisfactory in all 30 cases.ConclusionsInitial debridement and the temporary VSD cover followed after several days by free flap transplantation combined with skin grafting and VSD protection is a reliable treatment regimen for traumatic large circumferential or sub-circumferential soft tissue wounds of the lower leg with deep tissue exposure.

Clinical Microwave Tomographic Imaging of the Calcaneus: A First-in-Human Case Study of Two Subjects

We have acquired 2-D and 3-D microwave tomographic images of the calcaneus bones of two patients to assess correlation of the microwave properties with X-ray density measures. The two volunteers were selected because each had one leg immobilized for at least six weeks during recovery from a lower leg injury. A soft-prior regularization technique was incorporated with the microwave imaging to quantitatively assess the bulk dielectric properties within the bone region. Good correlation was observed between both permittivity and conductivity and the computed tomography-derived density measures. These results represent the first clinical examples of microwave images of the calcaneus and some of the first 3-D tomographic images of any anatomical site in the living human.

Rates of Knee Injury in the U.S. Active Duty Army, 2000–2005

We sought to summarize knee injuries (KI) in the U.S. Active Duty Army (ADA) in terms of absolute numbers, examine current rate trends, and identify ADA who were at increased risk for experiencing a KI. We used the Total Army Injury and Health Outcomes Database (TAIHOD) to compute unadjusted and adjusted rates of KI, categorized by the Barell Matrix, within the ADA for the years 2000-2005. During this period, 21 to 25 per 1,000 ADA suffered from KI. The highest yearly rates were observed for knee dislocation and sprains/strains (31 per 1,000 ADA). In ADA with a history of a KI (within 2 years), rates increased nearly tenfold. Elevated KI rates were also seen in ADA with prior upper or lower leg injuries, those > 30 years of age, and those with a category IV Armed Forces Qualification Test score (lowest admissible in Army). ADA KI rates remained fairly stable throughout the study period. Relative to other ADA Soldiers, those with prior knee, upper leg, or lower leg injuries are at increased risk for subsequent KI.

A lower leg injury not to be overlooked

A 62 year old woman, previously fit and well, was admitted to the emergency department after a high speed road traffic crash. She was extricated from the overturned car by the emergency services, immobilised, and transferred to the resuscitation room. Full advanced trauma life support assessment was performed; her vital signs were stable; and her only injury was a swollen, deformed, and painful left lower limb. There were no overlying skin wounds, and there was no neurovascular deficit to the left foot. The emergency department staff were concerned she might have had an ankle fracture, and she underwent standard radiographs of her left ankle, one of which is below (see figure⇓).

Urgentní pedální bypass jako součást řešení rozsáhlého traumatu bérce

Urgentní pedální bypass jako součást řešení rozsáhlého traumatu bérce

Venous thromboembolism in emergency department patients with rigid immobilization for lower leg injury: Incidence and risk factors

To determine the incidence and risk factors for symptomatic venous thromboembolism (VTE) in adults who are discharged from the ED with rigid immobilization for lower limb injury. Eligible patients presenting between 1 December 2008 and 31 December 2010 were identified retrospectively from the Southern Health ED (Monash Medical Centre, Dandenong Hospital, Casey Hospital, all located in Melbourne, Australia) information system. Age, sex, diagnosis, type of splint and other defined potential VTE risk factors were recorded. VTE was confirmed from archived diagnostic imaging or hospital re-attendance records. Patients presenting between 1 October 2010 and 31 December 2010 were contacted to detect VTE diagnosed and treated outside of Southern Health. VTE incidence is reported, and comparison of risk factors performed. VTE was initially confirmed in 33 of 1231 patients (2.7%, 95% confidence interval 1.9-3.7). VTE was reported by 3 of 174 in the contacted subgroup (1.7%, 0.4-4.6). Applying this 'missed rate' to the whole sample, the estimated VTE incidence is between 3.1% and 7.1%. Multivariate risk factor analysis found VTE risk to increase with age and a diagnosis of Achilles tendon rupture. The estimated VTE incidence was between 3% and 7% in this ED population with age and diagnosis of Achilles tendon rupture increasing risk. Prospective research to more accurately determine incidence, severity and risk stratification is required before firm recommendations on the likely risk versus benefit profile of thromboprophylaxis can be made for this population.

Behaviour of high bumper vehicles in pedestrian scenarios with full finite element human models

The European pedestrian regulations (formerly Directive 2003/102 and currently Regulation 2009/631 and recently modified by Commission Regulation [EU] No. 2011/459) have always approached the protection of lower extremities in pedestrian accidents with tests in the front part of the vehicle using rigid impactors. This approach offers a lot of advantage regarding the repeatability, robustness and reproducibility that these tests need but on the contrary decouple the injury occurrence through the different body areas. It is widely supported to approach pedestrian head protection and lower extremities protection in separate tests; however, there is not such consensus in decoupling pedestrian lower leg injuries from the upper leg injuries, especially in the case of high bumper vehicles. The objective of this paper is to look into the details of this close dependence through a set of simulations with THUMS 50th percentile male pedestrian finite element human model impacted by a wide set of high bumper vehicles. The analysis of both the kinematics and the injury occurrence in these scenarios has shown the strong coupling between the upper and lower leg injuries for this vehicle fleet, requiring therefore assessing both type of injuries at the same time.

Postischemic Lower Extremity Wounds Treated with and without Negative Pressure Dressing

Background: Vacuum-assisted dressing is a noninvasive closure system of the wound, which makes localized and controlled negative pressure. Its mechanical tension reduces edema, stimulates granulation tissue formation and angiogenesis, and prepares the wound bed for closure. In this study, a patient has been presented, who suffered from serious lower extremity wounds due to arterial emboli, one of her wounds has been treated with vacuum-assisted dressing and the other with conventional dressing to evaluate the efficacy of vacuum-assisted dressing in acute ischemic wounds. Methods: A 65-year-old female patient was admitted to the emergency clinic, due to complaint of severe pain in her right lower extremity which suggested an acute arterial occlusion. She immediately underwent an embolectomy operation; however, a few days later, severe ischemia on the leg and foot became appearant. All of the necrosis was sharply debrided under sterile conditions in the operating room, and then lower leg wound was covered with vacuum-assisted dressing, also calcaneal wound was dressed with silver sulphadiazine. Results: Eighteen days after the first dressing with negative pressure, distal leg wound became ready for closure, whereas, enough granulation tissue over the calcaneal area developed merely thirty-four days later. Calcaneal wound closed spontaneously within fifty-three days. Conclusions: When dealing with this experience, using the negative pressure dressing in patient with severe lower limb wounds following arterial emboli, accelerates wound healing by means of developing the granulation tissue, and rapidly prepares the wound for closure, so it may reduce the risk of amputation.

Evaluation of the Biofidelity of the HIII and MIL-Lx Lower Leg Surrogates Under Axial Impact Loading

Objective: Lower leg injury risk is commonly assessed using an anthropomorphic test device (ATD). The current standard leg (the HIII) has been shown to have low biofidelity due to its geometry and material properties. A new surrogate (the MIL-Lx) was developed to address these issues, specifically for anti-vehicular mine blast scenarios but with potential applications to high-force crashes in the automotive industry. Before it is adopted for use, the MIL-Lx must be evaluated under impact loading to ensure that it represents the natural lower leg response. Methods: Axial impact loads were applied to both the HIII and the MIL-Lx at impact velocities of 2 to 7 m/s using a pneumatic impacting device. Testing was also conducted with the foot removed from both surrogates to enable comparison with previous tests of isolated cadaveric tibias at noninjurious and injurious (i.e., fracture) levels. To evaluate the effect of a boot on load attenuation, the HIII was impacted with and without a hiking boot. Results: Forces in the MIL-Lx were between 25 and 100 percent of those in the HIII (depending on impact conditions). The use of a boot reduced the peak force by approximately 65 percent at the highest impact velocities. The MIL-Lx fit the data from noninjurious cadaveric tibia tests with R2 = 0.83. Conclusions: The MIL-Lx is a new surrogate that represents the response of the natural tibia under axial impact loading better than the HIII. The inclusion of a boot has a significant effect on loads in the leg and may influence injury assessment results. The MIL-Lx will be a useful tool for predicting lower leg injury risk over a wide range of impact velocities.

A54 Functional outcome after orif versus external fixation in type-C distal radius fractures

and populations. No HIT was reported in 826 patients with lower extremity injuries requiring immobilisation. Conclusions: Only a few studies have reported on the incidence of HIT in trauma patients who receive prophylactic LMWH. In the heterogenous populations of the available studies, the incidence of HIT appears to be very low (0.36%) and comparable to other patient populations. There is hardly any literature on the incidence of HIT in patients with isolated lower leg injuries receiving LMWH, but incidence appears very low. Monitoring of platelet count could be considered in hospitalised patients with a high risk for development of HIT. A pre-test scoring system may identify these patients.

Analysis of Lower Leg Injury of Occupant in Frontal Crash Tests Based on China NCAP Protocol

With the popularization of passenger vehicle safety devices such as safety belt, airbag and so on, the chance that occupant’s upper limbs were injured seriously was decreased significantly in frontal impact. However, the injury of occupant’s lower limbs became more and more severe, especially on lower leg injury. 37 groups of test data of China NCAP crash tests including full-frontal rigid crash and 40% offset deformable barrier crash were investigated in this paper, and lower leg injury distributing characteristic of drivers and passengers in these two kinds of crash configurations were obtained. Finally the effect rules of characteristic parameters on lower leg injury were summarized.