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Doctor’s Note: ‘Boot top’ fractures painful, often require surgery

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By Dr. Jeff Daniels EBS Medical Columnist

One of the most severe injuries on the ski hill is a fracture of both bones in the lower leg, the tibia and fibula, and we treat an average of two or three per month here in Big Sky.

Because of the rigid nature of ski boots and the forces put on the leg by the weight of the ski and boot during a tumbling or twisting fall, the two bones of the lower leg are very vulnerable to breakage.

This injury is sometimes referred to as a “boot top” fracture. Because of the anatomy of this area and possibility of severe swelling, surgery to fix this fracture is considered an emergency and usually done within 24 hours of the injury.

Adults nearly always require surgery but kids, whose bones are softer, don’t experience the same devastating breaks and can often heal just with a cast. Kids’ fractures are usually of a spiral nature, whereas adult fractures are like taking a thick branch and breaking it over your knee. Metal rods, plates and screws are needed to hold everything in place after the ends of the bones are realigned.

A more benign lower leg fracture just involves the fibula, the thin bone on the outside of the leg. It starts at the outer side of the knee and ends at the ankle, and if broken in the middle is somewhat painful. But the leg retains its stability because the much thicker tibia remains intact. Casts and crutches are usually unnecessary if the knee and ankle aren’t injured. This type of break usually occurs by a simple sideways fall, with the top of the boot pressing into the fibula and snapping it.

When we see a tib-fib fracture in the clinic, our first objective is to x-ray the leg, and then stabilize the fracture with the ski boot off. We make sure that the bones have not punctured through the skin, causing what is called an “open” fracture, which is more serious due to the possibility of infection. However, in my 22 years of experience in Big Sky, I’ve seen very few open tib-fib fractures.

Getting the ski boot off might be a challenge and pain medication or sedation is sometimes required. We will never try to cut off a ski boot – we did that once and two hours into the process regretted the decision. The room was full of burnt plastic and we couldn’t cut through the metal cables effectively. It was a mess.

Once the leg is exposed, we wrap it in fast-drying splinting material to hold it steady, because preventing any movement is the best way to control the pain. Nearly all patients are stable enough to get to an orthopedic surgeon in Bozeman in a private vehicle, avoiding an expensive ambulance ride.

Recovery after surgery takes a couple of months. If the knee and ankle joints aren’t involved, full recovery is expected without any long-term problems or effect on athletic ability. Although one might ski a little more cautiously, as would happen after any serious injury. Or you could make skiing down the Big Couloir your proof of recovery.

Dr. Jeff Daniels 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 700 medical students and young doctors to train with the Medical Clinic of Big Sky.

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