Bone bruises of the tibia have been extensively studied using MRI
technology. It is now verified that bone bruising is a common injury
accompanying meniscal, ligamentous, and other injuries.3,4,6 This case
study presents bone bruising that occurred throughout the tibia along
with an occult fracture of the lower tibia and fibula. There was also
bruising of the fibula to a lesser degree. Significant lymph tissue
involvement caused secondary problems with edema, as well as pain.
This paper will look at lymph involvement secondary to bone bruising
and the relationship between the two.
The subject underwent open reduction and internal fixation following
a fall from a mountain bike. Correction of bony alignment and fixation
of the tibia was provided by a rod secured by four screws. The fibula
was not corrected. (See Figures 1 and 2).
Figure 1
Figure 2
The subject presented for treatment 4 weeks
after the surgery. Initial assessment indicated a significant loss
of normal ankle range of
movement into dorsi-flexion of about 20 degrees less than a 90 degree
angle. (See Figure 3) There was also a loss of plantar-flexion of
about 20 degrees. Subtalar mobility was normal.
Figure 3
Pitting edema of the left leg below the
knee caused the following circumference measurements:
|
Left leg |
Right leg |
10 cm. below fibular head |
38 ½ cm. |
36 ½ cm. |
20 cm. below fibular head |
29 cm. |
27 cm. |
Myofascial mapping and tissue
motility palpation, as developed by Sharon Weiselfish-Giammatteo,8 were
used to assess for bone bruises and lymph system dysfunction. Both
were found
to be
positive in this subject.
It has been shown that the incidence of bone bruise, in cases of knee
ligamentous injury, is about 80%.3 This is in a case where force is
transferred from soft tissue into bone, following a vector consistent
with the mechanism of injury. Therefore it is reasonable to assume
that the prevalence of bone bruise in bone surrounding a fracture site,
where force is transmitted directly through bony tissue, is at least
80% or even higher, likely 100%. Thus it is paramount to consider that,
when treating for fracture, one should also be treating bone bruising.
Bone bruise histology consists of micro-fractures of cancellous bone
as well as edema and bleeding in the bone marrow. Necrosis was also
found in the bone marrow because of "protrusion of fragments
of hyaline cartilage mixed with highly fragmented bony trabecules."6 Ward
et al., in their study of diffusion changes to post traumatic bone
marrow, found that marrow injury where trabecular damage was present,
allowed "increased movement or diffusion of interstitial water
relative to normal marrow. The magnitude of diffusion change appears
to reflect the severity of marrow injury."7 This change to homeostasis
in the lower leg environment and the disruption of normal osmotic fluid
transfer accounts for the high incidence of venous and lymph related
swelling and edema after trauma.
In one case study of a maxillary fracture, it was found that chronic
eye lymphedema was related to both lymph tissue occlusion and congestion,
as well as removal of lymph nodes and vessels at the time of surgery.1
This begs the question; how much further damage is caused to the lymph
tissue of the lower leg at the time of the open reduction and internal
fixation procedure? The surgery, although necessary for proper bone
healing and alignment, may not be without some cost, in the form of
further soft tissue damage that then has to heal. Also, it has been
shown that there is a biochemical response of the body to the hardware
itself that causes an inflammatory response.5 Therefore, the other
factor of utmost importance in the treatment of fracture is the treatment
of edema: that is, the treatment of the lymph and the skin.
The subject was treated with manual therapy techniques for bone bruising,
lymph congestion, and skin motility.8 These techniques are the original
work of Sharon Weiselfish-Giammatteo and have been clinically shown
to be highly effective in the management of bony and soft tissue healing.
The subject was also placed on a home program of contrast bathing,
leg elevation, Neuro-fascial Process (self treatment technique devised
by Weiselfish-Giammatteo), treadmill walking, and a specific exercise
program, called Conscious Movement.2
The subject made excellent progress with these treatments. She received
13 treatments in total and now has full ankle mobility. (See Figure
4) She has returned to work and regular daily functions and pain levels
have significantly decreased. She reports that, if she follows her
home program, she has no pain at all.
Figure 4
Leg circumference measurements are as follows:
|
Left leg |
Right leg |
10 cm. below fibular head |
36 ½ cm. |
36 ½ cm. |
20 cm. below fibular head |
27 cm. |
27 cm. |
It is evident from this case study that
treatment of soft tissue, especially lymph, as well as treatment of
bone bruises is essential for proper
healing after fracture. It is apparent that the management of the
post-fracture patient requires thinking beyond the fixation of the
fracture and the usual exercise regimes to restore function, and
that effective treatment involves hands on treatment of all affected
tissue, in a holistic manner, in order for complete healing to occur.
The use of integrative manual therapy techniques proved to be the factor
that ensured proper healing and pain resolution, in an efficient and
timely manner.
Correspondence:
Tanya Crowell, PT
tcrowell@allstream.net
References
1. Akoz T.,et al. Persistent lower eyelid lymphedema after Le Fort
III maxillary fracture (letter) Plast Reconstr Surg,
1998, Mar.
2. Conscious Movement; a program that incorporates 10 principles
of exercise therapy; copyright 2000,
T. Crowell and F. Bach.
3. Johnson, Darren, etal.; Articular cartilage changes seen with
magnetic resonance imaging-detected bone bruises associated with
acute anterior
cruciate ligament rupture Am J Sports Med 1998,
vol. 26, no.3.
4. Miller, Mark, et al.; The natural history of bone bruises; a prospective
study of magnetic resonance imaging-detected trabecular microfractures
in patients with isolated medial collateral ligament injuries Am
J Sports Med 1998, vol.26 no.1.
5. Pape, H.C., et al.; Biochemical changes after trauma and skeletal
surgery of the lower extremity: quantification of the operative burden.
Crit Care Med 2000, Oct 28(10):3441–8.
6. Rangger, Christoph, et al.; Bone bruises of the knee; histology
and cryosection in 5 cases Acta Orthop Scand 1998;
69(3): 219–294.
7. Ward, R., et al.; Analysis of diffusion changes in post-traumatic
bone marrow using navigator-corrected diffusion gradients. Am
J Roentgenol 2000 Mar; 174(3): 731–4.
8. Weiselfish-Giammatteo, S.; Dialogues in Contemporary Rehabilitation
Course Material: Integrative Diagnostics, Myofascial Mapping, Cranial
Therapy Series, The Lymphatic System.
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