Ankle Fracture and Recovery

Posted on Apr 3, 2020

I suffered a right ankle fracture on March 16, 2020. This post chronicles the accident and recovery steps and will be updated periodically over the next few months.

The Accident

I was at the Bill Putnam (Fairy Meadows) Hut in British Columbia, Canada on a guided ski trip. On Day 3 of our trip, we traversed the Granite Glacier and did a couple of runs below the SW face of Mt. Colossal. At approximately 3pm we had finished a second skin up to put in the final laps for the day.

Moments after I began my run, I looked down and saw my left boot detach from the toe-piece (I have the original Dynafit Speed Turn bindings) just as I was initiating a left turn. This knocked me off balance and while my body finished the turn my right ski did not, significantly torquing the right foot.

There was a sharp shooting pain in my ankle, along with a clear feeling that the muscles on the inside of the calf had been “warped” across the shin (although that probably can’t really happen, that is what it felt like). As my body was flooding with adrenaline, I was able to get the ski oriented correctly so the immediate force was removed. By this time two of the guides and one of the clients (who is an ER nurse) were near me. I was in pain, but coherent and communicative. We proceeded to remove both skis, check me once for any other injuries and then let me catch my breath while next steps were figured out.

Getting me out

While the ski boot had prevented something ridiculous (like the ankle pointing 180 degrees away from where it should be), and was holding everything together like a splint (and preventing swelling), I was still unable to weigh the right leg without pain. Skiing would be a slow/excruciating/dangerous affair.

The Bill Putnam Hut is only accessible by helicopter in the winter. Given the nature of the terrain back to the hut and the time we had before it got dark, it was unlikely I could ski on my own to the hut, nor was it likely someone would be able to tow me safely. The weather was really good, so getting a helicopter rescue was the best way to ensure everyone’s safety.

Jason (one of the guides) and Inka (the ER nurse) would stay with me and we would try to get to a reasonable landing site, while the other guides would take the rest of the group back to the hut and coordinate the rescue.

I realized the importance of satellite phones and radios on trips like this. Being on a guided trip and in a developed country with good support for recreational activities can often mean the difference between prompt medical attention and some disastrous epic.

Given the slope angle and the conditions of the day, there wasn’t much avalanche danger. It was windy, with temperatures probably around -7C, so staying warm was important. In addition, we were on a glacier, so some basic precautions had to be taken against crevasses. That meant staying on skis, and watching each other.

The Granite Glacier has a large, relatively flat area just south of Colossal. It would involve about a kilometer of gentle skiing. Jason went ahead to prepare a landing site, while Inka assisted me with my slow gliding. I could not initiate S-turns or pizzas. Instead I would do a very gentle ski in one direction, then do an uphill turn, with Inka providing some balance. It probably took 30 minutes to traverse a distance that would usually be done in 5 minutes, but at least we were at a reasonable site. Jason and Brent (the lead guide) had communicated and it seemed like Alpine Helicopters out of Golden would be able to get someone to our location in about an hour.

Jason and Inka worked tirelessly on the landing site. I dressed up in all my layers, a space blanket and a tarp to stay warm.

The helicopter picked me up around 16:15 MDT. There was a pilot and two rescuers from Golden SAR. Since I was conscious and mobile, I didn’t really need any medical assistance that could be provided in the field. I was able to limp/crawl into the heli and settle in. Jason and Inka loaded all my gear into the heli and we set off. Huge thanks to them even though I was unable to see them again!

Everyone had coordinated to get the heli to make a quick stop at the hut, because I would at least need my passport and money once I was back in civilization. Leo had packed all my luggage and had it ready to load. At least I would be a documented patient now…

The helicopter ride out was beautiful and I was feeling pretty calm.

How bad is it?

Once we landed in Golden, one of the rescuers gave me a ride to the Emergency Room (ER), along with my luggage. The thing to remember about SAR is, once you are rescued, you are on your own (unless you are unconscious or something). My friends were eager to come out with me and assist, but given I was feeling fine apart from the leg, I specifically requested them to continue their trip. It was, after all, only 3/7th of the way through an expensive and once-in-a-lifetime trip. I was loaded from the helicopter into a car using a trolley for crates :D I used that time to call Shreya and tell her what had happened, and if she could start looking into how I could get from Golden to Calgary ASAP to get a flight home.

Fractures in the time of COVID19

On the drive over, the SAR guy brought me up to speed on COVID19. When we had left on the trip on March 13, the impact in North America was still low and nobody had started shutting things down. By March 16, Canada had closed down the border and started to institute shelter-at-home in various provinces. Shit was getting real! What a time to break a leg… It was imperative that I get back to the US as soon as possible.

At the hospital they made me wear a mask, then walked me through the admission process and charges. My insurance would cover it later, but I had to pay CAD1050 to be admitted and checked over. Once I was done with that process (I’m still in my ski boots on a wheelchair as all of this is going on), they took me to a bed. The doctor came in after some time and it was time to find out how bad things really were. I had been hoping and praying that it would be just a sprain and I could rest it for a few weeks and then get back to normal.

The first step was getting the ski boot off without taking my foot with it. This was the scariest minute of my entire life. I was terrified that the boot wouldn’t come off, that it would hurt like hell, that they would need to cut something under general anasthesia (the boot, not my foot!). Luckily, it just needed 2 pairs of hands and some support around the ankle to pop the damn thing off. Then there was a minute of watching in horror as the ankle doubled in size. The doctor palpated it and was fairly convinced it was a fracture! Damn!

I was taken for X-rays, where, as soon as I put my foot on the plate, something inside clearly shifted! This was not going to have a good outcome. Since I wasn’t from Canada, they gave me a copy of the X-rays on CD. The doctor came in after a few minutes and confirmed his suspicions. Broken fibula. In addition, due to the rotational force, the fibula had shifted, and the deltoid ligament on the inside of the ankle was damaged. Given my age and activities, his opinion was I should get corrective surgery within the next 2 weeks to ensure everything healed in the correct position. He said he could get me into surgery within 10 days if I decided to stay in Canada, but he could see me wanting to get home at a time like this. For sure! More details about the fracture later.

For now, the doctor splinted it up, wrote a prescription for Tylenol+Codeine to help with the pain and sent me on my way. The nurse came in with crutches and a few pills to start me off until I could get to a pharmacy. Cost of crutches in Canada - CAD27. I don’t want to know the ridiculous markup in the US. The hospital was kind enough to call a cab for me, and I found a nearby inn that had a ground floor room and no stairs.

That night in the motel room was a little difficult. I was just learning crutches, I was tired and I was alone. I had to repack all my luggage to fit on a plane. I only really had protein bars for dinner and breakfast as I wasn’t in the mood to even order in. It was pretty trivial to get a direct flight from SFO-YYC for the next day. The tricky part was getting to Calgary. With the ski resorts shut down all the Golden bus operators were cutting back their operations. A private shuttle company was charging me CAD850! Fortunately Abhinav found GetTransfer and a driver from Calgary was willing to do the round trip for CAD300. Phew!

March 17, 2020 was uncomfortable but uneventful. The cab and the flight were on schedule and there were no problems at immigration. Sitting in an airplane, with the leg below the heart was really uncomfortable. I was glad it was only a 2.5 hour flight. Shreya and Abhinav picked me up on the other end and I finally experienced some relief after 24 hours of constant stress.

The goodness of people

I just want to take a moment to call out everyone who helped a bunch in getting me home safely. All the guides (Jason, Vicky, Brent) at Peak Stratagem, and the rest of the people in the ski group who helped get me and all my stuff rescued. Alpine Helicopters and Golden SAR. Leo, Yelly, Lita, Becca and Phil who coordinated afterwords to return the rental car and grab my skis from the hotel and bring them home. All the hospital staff. Both the cab drivers who helped load and unload my luggage since I couldn’t do anything. The guy at the Prestige Inn who wheeled my luggage around, and was able to find me a spare shoe in the lost-and-found. The wheelchair assistants at YYC and SFO. The flight attendants. They all made sure that I was taken care of and didn’t need to attempt any dangerous manuevers with a broken leg.

Shreya and Abhinav are of course, in a league of their own. They will be taking care of me for the next several months.

Surgery in the time of COVID19

I was able to get appointments at UCSF and California Pacific Orthopaedics within 3 days of the injury. Because the Bay Area had started prepping early for COVID19, all elective surgeries and appointments had been cancelled, so even with a skeleton crew, they were still looking at new patients with urgent needs. Since ankle fractures had bad long-term outcomes if not treated soon, they are urgent, and both the initial visit and any surgeries would proceed as usual. Thank god!

In addition, either due to luck or due to acting early, SF has (so far) avoided the horrors of New York. I don’t think I could have gotten assistance immediately if I was in New York right now.

Both doctors supported the Canadian doctor’s recommendation of surgery, so it was a no-brainer. Cal Pacific was able to give a surgery date of March 26, so we went with them. On March 23, they decided to renege because “the patient had travelled to another country and needs to self isolate for 14 days”. This was such total crap at a time when New York was going crazy while Canada had had barely any cases. WTF American supremacy!? Fortunately UCSF didn’t have any such restrictions and were able to get me a slot on March 31.

Most of the pain from the original injury subsided after 4-5 days. I weaned off of Tylenol and got comfortable with crutches and was able to go a few blocks away to the park. I couldn’t weigh the leg, but apart from that, there wasn’t much I needed to do except keep it elevated to keep the swelling down.

Technical details about the fracture

I have a Weber type-B fracture of the lateral malleolus, which is the part of the fibula that forms a bump on the outside of the ankle. The tibia, fibula and the talus bone form what is called the ankle mortise, where all three bones fit perfectly and are cradled by a bunch of ligaments that hold everything in a stable position. The deltoid ligament is one of those important ligaments and is present on the inside of the ankle. The twisting force, the fibular fracture and the deltoid ligament damage means my ankle has moved into an unstable configuration. To avoid several complications, including early osteo-arthritis, it is crucial to put all the bones back into the correct places. Even a few millimeters makes a difference in wear and tear over the long term. This is why surgery is recommended.

You can see my X-ray.

The procedure is called ORIF - Open Reduction Internal Fixation. An incision is made near the fibula (open), the broken piece is aligned in the right place (reduction), a plate and screws are used to secure the piece in this position (fixation) and everything is closed up. The screws and plates are only necessary until the bone heals. I don’t think it makes my ankle stronger by leaving it in. In any case, I can choose to leave them in permanently, or have another surgery in a few months to take them out (that one is a lot less painful and involved). I’ll leave them in unless it starts to bother me.

On the medial (inner) side of the ankle, another incision is made to reattach the ligament to the bone. This is done with a bioabsorbable suture that will disappear in a few months.

Post-surgery

I had my surgery on March 31, 2020. I was put to sleep around 7am and woke up around 9:30. I was discharged around 10:30 once they verified my vitals. I received a nerve block at the knee that would hide the pain for the first several hours. This meant the first day after surgery went OK. The doctors recommended I start on Oxycodone (a strong narcotic) that evening as the nerve block can wear off between 12-24 hours after injection and you do not want to play catch-up after the pain already starts. My nerve block wore off around 7am the next morning. Even with 10mg of Oxycodone entering my body every 4 hours, the next 3-4 hours were just agony! This was the worst pain of my life, and at least 2x worse than the original fracture. Everything below the knee was burning and thumping. I was crying with pain. Talking to my parents on FaceTime helped a bit.

Day 3 onwards was much better. By April 2, I was on just Tylenol every 6 hours and as of today, I haven’t taken that either. I will probably take one just before sleeping to help me sleep.

My sutures and splint will be removed on April 16, after which I can hopefully start some basic movements of the ankle and physical therapy. There is no weight bearing until at least 4 weeks after the surgery. After that I’ve to learn to walk all over again. The doctor expects I’ll be walking normally in 3 months and able to resume all activities in 6 months. I have my fingers crossed!

Recovery in a time of COVID19

About the only silver lining I have going for me is that I’m shutdown while everything else is shutdown. Pretty minimal FOMO here. (Once they heard I was hurt) The ski resorts decided to shut down. Communities are encouraging backcountry skiers not to ski. Most parks are closed. The Broken Arrow Skyrace for this year is cancelled. So I won’t be missing any events. We are work-from-home at least till the end of May, so I don’t have to worry about commuting. I do have to rebuild my leg and recover all of my previous fitness. It will be a long journey, but I’m hoping to be back to running and skiing next year. Of course, it still sucks that in an alternate universe I would have two legs and be at home, which is a better place than this universe, but I don’t get to pick now.

Update: May 2, 2020

It is now just over a month since surgery. The splint and stitches were removed 2 weeks after surgery. There aren’t any complications yet and the foot is healing well. I am still non-weight bearing till May 12, when the 6 week mark X-rays will be taken to see if the bone is healed. At that point the doctor will decide when and how to start weighing it.

When I went to the hospital for splint removal, I also had a chance to look at my post-op X-rays. There is a fibular plate attached by 4 screws on the lateral side, and one more screw going more posterior and diagonal that directly holds the 2 pieces of bone together. In addition, something like TightRope fixation was performed to keep the ankle mortise reduced and held in place. This basically means the drilled a hole all the way through my tibia and fibula. A high-strength Dyneema (UHMWPE) wire was passed through this hole, tightened and then held in place by buttons on both sides. This keeps the bones in the correct position as the fibula heals, and ideally will preserve my ankle for a long time. I think my biggest fear at this point is getting early arthritis from incorrect healing, so I’m looking forward to the final X-rays.

Right after removal any swinging motions would cause pain, but the past 4 weeks have led to dramatic improvements. There is still a decent amount of swelling, but I have about 50-60% of ankle ROM back, and I don’t have to baby the foot any more, even when it is out of the boot. That is, I can lay it down on hard surfaces and I’m getting close to be able to sit cross legged (of course without getting the foot completely under my body).

Showering has generally been the most annoying part, so I’ve procrastinated on it, particularly since we aren’t leaving the home or meeting anybody. I basically didn’t shower from the day of the surgery until after they removed the sprint, which was a straight 14 days! That beats my previous streak of 12 on the John Muir Trail! After that I’ve showered roughly ever 4-5 days, getting more “rough” on the ankle as I gain confidence in it.

Update: June 9, 2020

The 6 weeks after surgery are pretty monotonous as you are in this holding pattern where the leg is healing but you aren’t supposed to do anything with it. Even my internal sense of identity had changed. A couple of times I had dreams where I’d be on crutches even in the dream! On May 12, I had X-rays first. Astonishlingly it was the X-ray technician who made me stand on the injured leg for the first time, even before the doctor saw me! This was scary as I was holding on to this rickety handle while my leg was radiographed from various angles. They want to do this to get an AP stressed view which exhibits syndesmotic injuries that may not be visible without weight. Then I saw the doctor who was happy with the results and cleared me to start walking as I was comfortable. I still had to keep the boot on for 2 weeks any time I was walking, but I could take it off when sleeping or sitting. That was a big deal! I could finally sleep on my stomach or side.

Luckily I had a PT appointment scheduled right after, so we could get to work figuring out how much weight I could put on that foot while being comfortable (20kg). The goal then was to crutch along, touching that foot and trying to load it to a comfortable level. I was to do this for a week. By the time a week rolled around, I was actually ready to start putting most of my weight on it, but didn’t know that. Crutches, due to their height, kinda restrict how much you can weight the leg, while still using crutches. So I wasn’t really able to weight it comfortably. So the PT gave me hiking poles instead, and voila, I was able to walk!

Week 2 was about weaning off the crutches. About 3-4 days in, I was down to one crutch and then the next day I was walking without assistance. It was still awkward with the boot because you can’t do any of the rotational motions you usually would.

Once you start weighing the leg, progress is pretty fast. I walked into the PT’s office after 2 weeks ready to kick off the boot if he was OK with it. Which he was! So we went for a stroll around the office and then I went home in normal shoes! That was such a great day! The PT had recommended I keep the boot on 50% of the day for a couple of days, but I was done with that ugly and smelly thing. I loved this new me, even though the leg would get tired pretty quick. I loved being able to shower without the rigmarole of keeping the boot dry. The inability to quickly change pants. The inability to just walk and go somewhere without first spending 30s putting the boot on.

These weeks also involved a LOT of exfoliation from the injured foot. After being in various splints and casts and boots and socks for 2 months, it was finally allowed to see the sun, and be dry and shed all the skin it hadn’t been able to shed. I’d spend time in the shower just scrubbing a bunch of dead skin off, and then spend some time outside the shower doing the same. Within a few days the foot was looking pink and healthy instead of the sickly dark brown. That was another psychological boost.

I’m getting pretty close to the good leg in terms of range-of-motion for plantar flexion and eversion. Just a couple of degrees off. Dorsiflexion is still difficult, partially because of swelling, but it has been improving every day. Inversion is also reasonable enough.

For the past week the primary restriction on walking normally has actually been the Achilles tendon, which needs to stretch more, and the heel bone, which is irritated most of the time. Wearing shoes definitely makes it easier to walk. Uphills are easiest, where I don’t even limp. Downhills are fine as long as they are even. Descending stairs is the trickiest as my knee doesn’t extend beyond my toes yet. I’ve been able to ramp up to ~2mi confortably and am learning to deal with terrain.

In terms of gaining strength, I’m cleared to do squats and glute bridges and anything else that is non-impact and uses only bodyweight. The goal is to get neuromuscular strength and coordination back. The first target is being able to single-legged balance effortlessly on that leg. Squats are still weird because of lack of dorsiflexion. I end up biasing the good leg towards the very bottom.

There is still significant swelling by the end of the day, but nothing that is too painful. In fact I’ve only iced it a couple of times over the last month. The ankle has really started feeling “mine” when I wake up in the mornings. Not much stiffness. Good proprioception.

Generally, progress has been really good. The surgery wound is completely healed. I feel this pinching right below the steel plate sometimes, but I’m not sure if that is just soft tissue that is still healing, or the plate is actually poking something. I should know in a few weeks. The deltoid ligament is also sensitive after a long walk, and will probably remain so for a good few months, as it heals pretty slowly.

I have another post-op X-ray this week (4 weeks after the previous one and 10 weeks after surgery). This is to make sure the walking hasn’t upset anything and healing is still on track.