By Jeff Daniels EBS Medical Columnist

The ski and snowboard season of 2017-2018 is getting off to an unusual start. The snow and cold before opening day has petered out, and now we are praying for a good dump to get us up to par compared to previous years. It certainly seems to be keeping the crowds away, but we know that by Christmas, good snow or bad, things will be hopping at the Medical Clinic of Big Sky.

We did get a couple of bad knee injuries recently, one of which completely fooled me because the mechanism of injury was hard to decipher. A young man was skiing in the terrain park and decided to slide down a rail. At about the middle of the rail, he decided to do an about-face, but his skis did not follow the rest of his body and he ended up doing a split on the rail.

He did not feel a pop, although he was sure that his left knee twisted. The rail gave him a vertical gash in his left shin, and left him with a painfully swollen knee. He was able to ski down to the clinic, where we sutured the leg wound. We started to examine the knee but couldn’t come to a conclusion or a specific diagnosis. I did leave out one test that I wish I would have done, and that is looking for a sag of the lower bone, the tibia, off the upper bone, the femur. This is the opposite movement of what would be seen in an ACL (anterior cruciate ligament) injury. It indicates a tear of the posterior cruciate ligament, or PCL, which is an injury that I’ve seen once or twice on this mountain over the last 24 years. I’ve diagnosed thousands of ACL injuries in that same period.

I was suspicious enough for some injury, so I sent him down for an MRI that afternoon, and it showed a complete tear of the PCL off of its attachment on the femur. This will end his season and necessitate surgery.

I’ll have to add this mechanism of injury—a split on a terrain park rail—to my list of ways to really screw up a knee. It wouldn’t happen in snowboards, where any kind of knee injury is much less common than in skiing. And I’ll always look for that sag.

The other nasty knee injury occurred in a very tall man from South Dakota who was skiing down the Bowl. He ejected from his skis and fell forward. He thought that the ski then came back and struck him in the shin. He needed a sled ride down to the clinic, but was hoping that we wouldn’t find further injury.

I put my hands on his painful swollen right knee and decided to get an X-ray for what I knew would not turn out to be a bruised shin. The first X-ray showed a crack across his tibia, and subsequent images showed that the crack traveled all the way up to his knee joint, making this a tibial plateau fracture of the worst kind, and our first of the ski season. Surgery for this is usually done within a week.

Having had his right knee and leg shattered in a previous ski accident, as well as a broken hip in a third ski accident, he seemed resigned to his fate. His son drove him back to South Dakota that day. He said he would be back next year!

Be prepared for some changes at the clinic. I’ll write about them in my next column.

Dr. Jeff Daniels was the recipient of the 2015 Chamber of Commerce Chet Huntley Lifetime Achievement Award and has been practicing medicine in Big Sky since 1994, when he and his family moved here from New York City. A unique program he implements has attracted more than 800 medical students and young doctors to train with the Medical Clinic of Big Sky.