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Procedure (Boot Removal in suspected fracture)

post #1 of 73
10/29/06 at 6:52pm
Thread Starter 
Question, you bring an accident victim into the aid room that you know has a comound fracture of the fibula.

Do you remove the boot before the emergency vehical transports him, or do you just stablize the leg and let the emergency room attending personel do it?
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post #2 of 73
10/29/06 at 7:34pm
Quote:
Originally Posted by Lars View Post
Question, you bring an accident victim into the aid room that you know has a comound fracture of the fibula.

Do you remove the boot before the emergency vehical transports him, or do you just stablize the leg and let the emergency room attending personel do it?
Our local ski area management procedures is to expose by removing the boot before transport to the hospital because we are better trained in removing ski and snowboard boots then hospital personnel.
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post #3 of 73
10/29/06 at 7:50pm
We are over 1 hr transport time to the ER. We do not remove the boot unless we can't establish CSMs.
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post #4 of 73
10/29/06 at 8:45pm
With long transport times in question, removing the boot is probally a GOOD IDEA to prevent issues with swelling in the boot.
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post #5 of 73
10/30/06 at 4:36am
Thread Starter 
It's been about five years since I patrolled so maybe our policy has changed. If moderate bleeding was involved, it was our policy to leave the boot on for fear of doing more vascular damage. Transportation time from our resort was about a half hour. Mercy flight is about a ten minute ride.

I'd like to hear from some more patrollers.
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post #6 of 73
10/30/06 at 4:47am
Quote:
Originally Posted by mtbakerskier View Post
With long transport times in question, removing the boot is probally a GOOD IDEA to prevent issues with swelling in the boot.
You are certainly entitled to your opinion. This guideline is from our Medical Director. He runs the local ER. If he says leave it on. We will continue to leave it on.
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post #7 of 73
10/30/06 at 5:30am
Be it in the Patrol room or the ER, I am suprised that they do not have a way to do a few "relief" cuts in the plastic to ease getting the boot off.

I don't mean cutting it off like they do a shirt or pants, just a few snips to soften or remove the tongue in a safe fashion without risking a penetration?

I love my boots .... but I wonder if I love them that much?

It seems that you could use a dremel with a grinder to take off just a bit of plastic?
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post #8 of 73
10/30/06 at 9:00am
We have a device that looks kinda like a caulk gun that you use to open up the boot. That, plus a couple of people make getting the boot off pretty easy.

Oh, and compound fracture = open fracture, they've done away with compound.
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post #9 of 73
10/30/06 at 9:17am
Quote:
Originally Posted by catskills View Post
Our local ski area management procedures is to expose by removing the boot before transport to the hospital because we are better trained in removing ski and snowboard boots then hospital personnel.
ditto, for the same reason.
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post #10 of 73
10/30/06 at 11:40am
I asked SierraJim to post a picture of a tool he uses as an aid to boot fiting at his shop. It is a boot spreader that is basically like a set of long-throw vice grips mounted to a board. A board is placed under the boot, and a set of hooks holds one side of the boot stationary. The vice grip grabs onto the overlap of the boot and provides leverage to open it widely.

Jim didn't have the camera at the shop today, but I hope he will be able to post a picture soon. Anyone else using mechanical advantage to extract boots?
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post #11 of 73
10/30/06 at 6:30pm
If 2 people know how to remove the boot correctly it actually comes off really easy, even easier than when you take off your own boot.
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post #12 of 73
10/30/06 at 7:03pm
Yup, all above is true.

But, why?

What do you gain by removing the boot?

This isn't to create a pissing match it is to provoke some discussion and thought.

As an OEC/EMT level care giver, you get the boot off and then what?

You now have a open fib. FX that is not splinted and you may have created further bleeding and soft tissue damage.

What have you done to improve your patients condition?

The reason I pose this is so I can discuss the viewpoints with our aformentiond medical director.

Thanks in advance.
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post #13 of 73
10/30/06 at 7:13pm
^^^^
I agree, I think you're generally better off leaving it on.
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post #14 of 73
10/30/06 at 8:43pm
Quote:
Originally Posted by Cirquerider View Post
I asked SierraJim to post a picture of a tool he uses as an aid to boot fiting at his shop. It is a boot spreader that is basically like a set of long-throw vice grips mounted to a board. A board is placed under the boot, and a set of hooks holds one side of the boot stationary. The vice grip grabs onto the overlap of the boot and provides leverage to open it widely.

Jim didn't have the camera at the shop today, but I hope he will be able to post a picture soon. Anyone else using mechanical advantage to extract boots?
There's another one I've seen that looks like a caulk gun. It has 2 flat metal hooks that separate the cuff as you pull the trigger.
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post #15 of 73
10/30/06 at 10:35pm
Quote:
Originally Posted by bunion View Post
Yup, all above is true.

But, why?

What do you gain by removing the boot?

This isn't to create a pissing match it is to provoke some discussion and thought.

As an OEC/EMT level care giver, you get the boot off and then what?

You now have a open fib. FX that is not splinted and you may have created further bleeding and soft tissue damage.

What have you done to improve your patients condition?

The reason I pose this is so I can discuss the viewpoints with our aformentiond medical director.

Thanks in advance.
I'm definatly no medical profesional, BUT, I do know that with any injury there is going to be swelling, and leaving the leg in a tight boot is going to not exactly be the most comfortable postion. Properly fited ski boots are very snug even when unbuckled. Add to that significant swelling durring long transfer times and you are going to have more issues. Swelling inside a ski boot is going to cause additional and preventable injuries. Most likely taking off the ski boot properly is not going to further damage the injury. Plus you will then beable to bandage the wound and provide direct pressue to stop any bleeding. Secondly you will also beable to better splint the injury.

Another way to think about it is, do you leave your ski boots on for the drive home from the moutnain? How much better do you feel when you take the boots off at the end of the day?

If I was the patient there is no way in hell I would want my boots left on, once I was in the aid room.
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post #16 of 73
10/31/06 at 4:48am
Thread Starter 
There will be no pissing match. It's just a topic Ibrought up for discussion by all the patrollers here,mainly because there are different proceedures in different patrol rooms.

Back to the issue. I agree with bunion here. There is way more risk removing the boot to make the patient more comfortable than to leave it on. Even with help,taking a boot off a leg that is damaged by an open fracture is way to risky. The risk to the soft tissue and veins and arteries is way more than just to make the person more comfortable and ease swelling. At the very worst, they cut the boot off at the emergency room. So you're out a boot.At least you didn't cut an artery and have the patient bleed out. This very discussion was made on the slopes of Copper when it happened to my Son a few years ago. I happened to be part of that conversation before they transported him. It was their decision. Taking the bootoff after being stabelized and sedated in an emergency room was the right decision. As a patroller, I wouldn't want the extra liability of causing further damage by taking a boot off.
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post #17 of 73
10/31/06 at 5:16am

how would you know that the fracture is open(compound) in a ski boot?

wouldnt that be rather rare for a fibula? just thinking about it makes me glad i have kryptons
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post #18 of 73
10/31/06 at 6:27am
Our protocol is to remove the boot. We were told during training that the reason was that the hospital would cut the boot off, so we would save the boot by removing it. There is probably more involved in determinig the protocol, but that was what we were told.

If done correctly, the boot can be removed with little if any further damage, although it is painful. With the boot off cms can be better assessed. In addition, the splint will be more effective during when moving the patient, since there will not be a 5 lb weight at the end of it.

It would seem to me that the ER would use a cast saw to cut off the boot.
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post #19 of 73
10/31/06 at 7:39am

not a cast "saw"

a cast cutter is a vibrating disc designed "cut" plaster and not skin, so it probably wont cut a boot. and why cut something that opens?
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post #20 of 73
10/31/06 at 8:43am
I was told that the ER does not mess with boot removal. They just cut the boot off. It came from a reliable source.

Quote:
Originally Posted by duke walker View Post
a cast cutter is a vibrating disc designed "cut" plaster and not skin, so it probably wont cut a boot. and why cut something that opens?
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post #21 of 73
10/31/06 at 9:52am
If the fracture site is such that I can control bleeding and stabilize with the boot on---I would choose that approach.
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post #22 of 73
10/31/06 at 10:25am
I patrolled one place where the medical director stated our protocol was boot removal in all lower leg injuries. The reason was improved monitoring of circulation. If circulation is compromised we would call airlife. (Ambulance could be an hour).

A friend on patrol told me he broke his leg twice and if anyone tried to take his boot off, he'd have killed them. Many patrollers did not follow the protocol.

We practiced gentle boot removal in teams of two, and were pretty good at it, but I still told friends, if they have good CMS, feel free to refuse the boot removal.

Now I'm at a place where it is our discretion, and rarely done. My policy is if there is no CMS, take it off and make one attempt to realign and establish circulation.
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post #23 of 73
10/31/06 at 12:47pm
Thread Starter 
Quote:
Originally Posted by duke walker View Post
wouldnt that be rather rare for a fibula? just thinking about it makes me glad i have kryptons
In this case the fracture was above the boot(where they usually are)

In the case of my Son, an open fracture and wound above the boot was visible and quite a bit of bleeding was present. Both bones were broken, fibula and tibia. This was visible at the accident scene. We got his leg immobilized and got him in the sled. By the time we got him to the bottom and in the Patrol room the pain was excruciating, even for an 18year old. They left the boot on and transported him to the medical center just a few blocks away. They never even discussed taking the boot off until he was xrayed, sedated and a local was given. Only then did they take the boot off. I squeezed his hand while two nurses took the boot off. His leg was virtually dangling above the boot, no way to stablize the leg. Would you want a couple patrollers trying to get your boot off with your leg like that? I wouldn't. I think the guys at Copper were fantastic. Kudos to their Patrollers that day. Those guys know what they are doing.

What I've learned here is that Ski Patrols at different Resorts treat accident victims differently. What is done at one place is done differently at another. I'm not sure anymore which way is the right way. I can understand if you know a circulation problem might exist, then taking the boot off before transport might be necessary. I still think I might leave that up to the ambulance eemt's to decide.
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post #24 of 73
10/31/06 at 2:08pm
Lars

Thanks for the additional info. I was wondering how a person could have a major break to the fibula and not break the tibia.

As for the question of "take it off" or not"? It all depends on many variables, especially, how bad is the break and how soon will the patient be seen by more advanced care.

As usual, the patrollers applied the emergency care principals properly and did the right thing.

Definatly a serious injury. How is he doing now?
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post #25 of 73
10/31/06 at 2:16pm
Thread Starter 
Was transported to Vail and the Stedman Hawkins Clinic where the performed surgery that night. Put a titanium rod and screws below his knee and above the ankle. He was up and putting weight on it in four weeks.

He was right back at the terrain park the next year. He doesn't have that competitive spirit anymore and doesn't go for such big air anymore but he still slides the rails.

For those of you wondering how he broke his leg. He was sliding the big railin the Copper Terrain Park. He was trying to perform a 180 on the rail when one ski slipped off the rail and under the slide bar. At the time of the accident, there was just upright supports with no fence inbetween, his ski caught an upright and it torque snapped his leg above the boot.

Now all rails have a solid fence underneath instead of uprights.
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post #26 of 73
10/31/06 at 4:22pm
Does it depend on the boot?
I can't imagine getting my old Koflach race boots off with a broken tib and fib without ripping the foot off my leg. I would take the crossmaxs off though.
Let's see that boot spreader! I could use one if I ever get the urge to ski in the old race boots again.
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post #27 of 73
10/31/06 at 5:23pm
Quote:
Originally Posted by Lars View Post
In this case the fracture was above the boot(where they usually are)

In the case of my Son, an open fracture and wound above the boot was visible and quite a bit of bleeding was present. Both bones were broken, fibula and tibia. This was visible at the accident scene. We got his leg immobilized and got him in the sled. By the time we got him to the bottom and in the Patrol room the pain was excruciating, even for an 18year old. They left the boot on and transported him to the medical center just a few blocks away.
Lars I am sure under those conditions everyone here would have handled it the same way by leaving the boot on. The key was the medical center was a few blocks away.
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post #28 of 73
10/31/06 at 8:33pm
Boot spreader,
Well, I remember where I saw it, my shop has on to make it easier to access the inside of the boot for grinding, etc. We have talked about getting one for the first aid room, here's a similar one...
http://www.webxites.com/shopping.asp...itemdetail.asp
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post #29 of 73
11/2/06 at 9:42pm
In Ontario we leave the boot on unless we can't control bleeding. It's an excellent splint.
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post #30 of 73
11/3/06 at 7:33am
Leave the boot on & stay away from the boot spreader,unless the bleeding is severe and out of control.Up here in the Great White North plastic can become brittle in the cold.Imagine the damage and pain that could occur if the boot broke,and the spreader slipped.Then you'd have a triage situation on your hands,as the injured person would probably do damage to anyone close enough to reach.PREVENT FURTHER INJURY!!
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