RICE & MICE: On femur fractures and icing…

Certain injuries have the ability to spark a fierce debate in regards to rule changes, and it’s usually the severe or gruesome injuries that result in near immediate change. Even though some players had called seamless glass unsafe for years, the head and neck injuries suffered by Max Pacioretty last season was partially responsible for the prompt switch from seamless to non-seamless glass and to look at the padding around the glass in time for the 2011-12 NHL season.

The recent focus on concussions and head injuries have resulted in another alteration of the rule book in regards to boarding calls and hits to the head. So far in the preseason, suspensions have been swift and plentiful. So, it should be no surprise that the injury to Edmonton Oilers defenseman Tyler Fedun this past week has also sparked a debate about touch-up icing in the NHL. Fedun’s career may very well be cut short before it really started.

In a preseason game against the Minnesota Wild, Minny forward Eric Nystrom’s stick blade caught Fedun’s skate and he crashed awkwardly into the end-boards in a race for an icing call. The impact with the wall fractured Fedun’s right femur and he required emergency surgery to repair the fracture. He will miss the entire season. It’s almost identical to the injury suffered by then-Wild defenseman Kurtis Foster, in a race for a puck almost 4 years ago. Foster also had surgery to repair his femur in which he lost a significant amount of blood in an operation that took over 6 hours to complete.

The thigh bone, or femur, is both the longest and strongest bone in the human body and also one of the toughest to break. When the  fracture is close to the hip joint it is referred to as a hip fracture. Fractures of the shaft of the bone, femoral shaft fractures, are often seen as the result of car accidents, but can also result from a direct blow to the leg, gunshot wounds, or falls.

Since the bone is so strong, and is cushioned all around by the very large muscles of the thigh, the amount of force required to break it is usually very large and in most cases these fractures are commonly displaced fractures and cause significant deformity and/or shortening of the leg. Hip fracture or ligament tears in the knee may also coincide with a femoral shaft fracture.

Significant displacement through the muscle and skin (an open fracture) is also not uncommon, again due to the large amount of force required to break it, and these fractures must be treated quickly due to risk of infection. Complications of the fracture include damage to surrounding blood vessels or nerves. Acute compartment syndrome can result, but is usually a rarer complication.

The muscles that surround the femur, as well as the bone itself, have excellent blood supply and can cause significant internal bleeding or hematoma formation. A significant loss of blood is not an unusual complication of this type of fracture. Since these fractures are usually displaced, surgical fixation is done in one of 2 ways.

The first, and more commonly used, is done by inserting a rod, usually made of titanium, through the marrow canal of the femur. The insertion point can be at the top of the bone (hip) or at the bottom of the bone (knee) and then screws are inserted through the bone at both the hip and near the knee to hold the rod in place while healing. Fixation can also be accomplished by use of plates and screws. During this operation, the bone fragments are first repositioned and held together with screws and metal plates attached to the outer surface of the bone. This is not the favored method for most fractures, but are useful for breaks that extend into the hip or knee joints, where metal rod insertion  is not possible. Because the length of bone has to be exposed when using plates, there is a larger scar and higher risk of complication via infection or blood loss.

Complications from surgery to repair a fracture may result in: blood loss, reaction to anesthesia, infection, blood clots and subsequent embolism, delayed healing or non-healing fracture, inability to correctly align bone fragments causing malalignment, irritation of the surrounding tissue from hardware (nails, wires or screws), or fat embolism. A fat embolism is where a piece of bone marrow breaks off and enters the blood stream and travels to the heart or lungs. This can happen as a result of the break itself or from surgery. Most of these fractures take 4-to-6 months to fully heal, however open or complicated fractures take longer.

To give some perspective to the length of recovery, Foster started skating 7 months after his injury, though he missed almost a full calendar year of play. The NHL also modified the Icing rule after the 2007-08 season:

Any contact between opposing players while pursuing the puck on an icing must be for the sole purpose of playing the puck and not for eliminating the opponent from playing the puck. Unnecessary or dangerous contact could result in penalties being assessed to the offending player.

Foster has remained vocal in his efforts to persuade the NHL to re-evaluate the need for touch up icing and in an interview with TSN this past February, said he wanted the rule changed before anyone else had an injury like his. Interestingly enough, almost 4 years after his initial injury and surgery, foster had a procedure in mid-September to remove hardware from the fixation that was causing irritation and inflammation in his leg. The icing issue has been debated at the annual GM meeting and variations of hybrid icing rules have been experimented with at the R&D camp for the past few years.

There have been both minor and major injuries as a result of the current icing rules over the past few years. In 2004, Marco Sturm was trying to beat Adam Foote to the puck on an icing play when Foote grabbed him and rode him into the boards. Sturm crashed into the boards feet first and broke his ankle on the play. Pat Peake shattered his right heel in a playoff game in 1996 while attempting to nullify an icing call. Al MacInnis — then with the Calgary Flames — missed time in the 1992-93 season after dislocating a hip hip in an icing race.

The Flyers have even been touched by this mishap.

In a November, 1981 game at the Aud in Buffalo, Bob Dailey’s career ended when he collided with Sabres forward Tony McKegney on an icing rush and suffered multiple gruesome leg fractures. Three years prior, Joe Watson’s career was put to rest when something similar occurred while he played for the Colorado Rockies.

The NHL is the only professional league that has not adopted a hybrid or no-touch icing rule, and while it sparks a passionate debate, I hope that more severe injuries aren’t on the horizon, should the NHL keep the current icing rules. In 1990, Ludek Cajka suffered a severe spinal-cord injury while playing in the Czech Extraliga when he collided with an opposing player in an icing race. The injury left him paralyzed and in a coma for several weeks before he died. His death prompted the adoption of no-touch icing in that league.

So, do we make changes before more injuries happen, or worse, before someone dies? Do we preserve the game as much as possible and try to resist change? Is the touch-up on icing really an integral part of the game that it must stay? How many times is icing nullified in these plays? What do you think?