Dave Burne / Final Year Medical Student / Hull York Medical School
Being a medical student is a tricky business. You are bombarded with so much information – how do you really know what is important? Well, when you bend your knee 90 degrees the wrong way to avoid drowning, you soon find out. This happened to Dave Burne, a final year medical student with a passion for kayaking. Since travelling to British Columbia aged 16 with his brother Tim, Dave had completed first descents in Sri Lanka, Siberia, Tajikistan, and even Outer Mongolia. In this article, Dave tells us about an incident on a river in Scotland, weaving the details of his accident with the orthopaedic issues involved. As any good ED doc will tell you – mechanism is everything.
Just before midday on 26 November, I found myself trapped underwater unable to escape from my kayak having just paddled a waterfall in Scotland. I didn’t realize it at the time, but I had been unconscious almost three minutes. What I did realize was the little pocket of air that had formed in front of my face allowing me vital breaths wouldn’t last forever, and thus my options were hyperextending my knee 90° in an effort to escape, or drowning. I took the former.
Worryingly, I can only remember around 30 seconds of this incident. As it turns out, I was being filmed as I went over the drop. When I got pinned the camera got dropped but kept running. Listening back to it, it is nearly 3 minutes before shouting indicates I’ve washed free. Around 2½ minutes unconscious underwater is a worrying statistic – I’m a lucky guy! In the 30 seconds I can remember, movement was very difficult as I had the force of a powerful jet of water forcing my body into my deck. I was also very aware of the importance of not losing the air pocket that had formed around my helmet, so I didn’t try too hard to dislodge myself from the position I was in. It was only when my helmet (and elbow pad) was ripped off me that I started getting really concerned that the air pocket might collapse. It was at this point I pulled my deck and tried to exit.
Unfortunately with the water forcing my body forward I couldn’t get much purchase to free myself. I managed to get my left knee up, but I couldn’t work my right leg free. Realizing I didn’t have much of an option left I started to push myself forward, hoping my right leg would follow. As my body started to pivot over my knee and it started to hyperextend I had second thoughts, so pulled myself back in the boat, and took a couple of seconds to re-assess the situation. Perhaps it wasn’t the best reassessment I’ve ever made, but perhaps (since I’m here writing this report) it was? With the story of Chris ‘Magic Knees’ Wheeler (dislocated both knees in a similar accident decades ago) flicking through my mind, I pushed myself into the flow and watched as my knee bent 90° the wrong way over the cockpit before letting me loose.
The question everyone always asks is never ‘how’s the knee?’ but rather, ‘how much did it hurt?!’. Well, not as much as bending your knee 90° the wrong way should do – partly because I was concussed, but mainly because adrenaline is an impressively strong analgesic.
Despite knowing I’d done some major damage after watching it bend in supernatural ways, the automatic thing was to lie on my back and kick with both legs. Bad move. Not surprisingly my right leg was uncooperative and just flopped around feebly. I made it to the side where I was pulled out of the river and the first aid commenced.
The View From the Bank by Tim Burne
I drop the camera and try to get to the base of the fall as fast as I can, wading up the eddy to avoid having to delicately traverse the sheer cliff separating me from the base of the fall.
He’s pinned horizontally pointing downstream on the slab at the bottom of the drop. But we can’t see him. I can’t see anything but a constant stream of green water relentlessly pummeling into a fountain of seething white where Dave must surely be.
The three on the right bank are down at the base of the fall before me and have already started throwing ropes at the slab at the base of the drop, in the hope that something will snag.
Three ropes later and we try a change of tack – live-bait – attaching one of us to a line, jumping in and seeing what we can grab. It’s a risky strategy, but we’re running out of options. Unfortunately the smallest member of the group. Beth, ends up getting attached to the line. There is no chance she’d even be able to jump to where we think Dave is pinned, let alone grab anything.
I shout for a line to be thrown across the river to me so we can pull it taut and try to sink it underneath Dave by pulling it upstream. In the rush the first two or three throws of rapidly coiled throwlines tangle and don’t make it across. Without my line I am helpless on the far bank and kicking myself for my stupidity. Whilst the bags are being re-coiled I try to wade out further into the fall, lose my grip and fall into the water. Swimming back up the eddy takes yet more time. Finally getting a line over the river we spend what seems like ages trying to sink it under the fast flowing current. We have no luck at all, it skips over the surface.
Getting desperate I try to clip myself onto the line to attempt a live bait rescue. I’m wearing a new BA and the cows-tail is on the opposite side to where I expect it to be. I search for it and search for it, but in the intense stress of the situation I can’t find it and assume it’s not there.
A shout comes from the other bank. I look downstream to see Dave’s boat resurfacing upside down. I can see he’s not in there, but one guy dives in immediately in case Dave is still trapped inside. My immediate thought is that he’s still in the fall, but I scan the river downstream and some movement catches my eye. He’s hard to see, as despite a red BA, all that is showing above the dark water is his black cag and dark hair, but it’s Dave, minus his helmet, lying on his back, weakly swimming towards the bank.
I jump into the water (goodness knows what happened to the live bait line), swim over to him and he tells me that he’s dislocated his knee or broken his leg.
ABCD – As I was talking and sure that I had not inhaled any water, the AB part was well covered. The bump to the head which left me unconscious had turned the events from early in the morning into a dream-like state, but aside from that I was alert, orientated, and could easily explain what had just happened.
Something was obviously wrong with my knee but there was no pooling of blood in my dry trousers and importantly I always had feeling in my feet – gladly there was no gross neurovascular damage.
Next up was to both stabilize my dislocated knee and to check for any pooling of blood. While I was busy gazing at my knee, my kayaking buddies were finding suitable sticks to splint my leg, which they then tied in place with rope. A good dose of painkillers was also appreciated (keeping note of what and how much I had taken).
It was important to keep me warm (a group shelter or ‘kisu’ was handy for this) until the helicopter arrived. In this time I was regularly checking I could feel and move my toes, and ensuring there was no open fracture. The popliteal artery and tibial nerve & common peroneal (aka fibular) nerves are all vulnerable to damage with a knee injury, so if there was any loss of feeling in my foot things would have been much more severe.
In the helicopter, because I was fully conscious and had feeling and movement in my toes, the air medic decided against cutting into my dry trousers to examine the damage and kept me strapped in the stretcher. Analgesia continued in the form of entonox (50% N2O and 50% O2). They used the SAMPLE acronym to hand me over: Signs and Symptoms, Allergies, Medication (how long for? has it been taken recently?), Past medical history, Last oral intake (in case urgent anaesthetic/operation is required) /Event history (what was the mechanism of injury / lead up to the episode).
In the Emergency Department
X-rays were taken in the ED, but only an avulsion fracture was picked up suggesting ligament damage (the ligaments themselves, being soft tissue, are not shown on x-ray). While waiting for an MRI scan to see the extent of the damage, I had an open cast applied (to allow for swelling) and the leg was rested, iced and elevated.
The rotational and hyperextension injury suffered whilst my body pivoted forwards and clockwise around a lower leg still stuck in the kayak led to rupture of the anterior and lateral collateral ligaments. The MRI showed a split medial meniscus, torn posterior cruciate ligament, an avulsed popliteal insertion and torn joint capsule. In chronic cases (because it has capacity to heal) posterior cruciate damage can be difficult to detect on MRI scans, however in acute ruptures such as mine the diagnosis was clear.
There was not a lot of swelling in the knee. This was because the ruptured joint capsule allowed fluid to drain down into the leg as opposed to swelling the knee. Though this put me at increased risk of compartment syndrome which can complicate such injuries – fortunately it was not a problem in this case.
The surgeon decided to go about the operation in two stages:
Operation #1 / Clean things up (and see the full extent of the damage), repair the lateral collateral ligament in the posterior lateral corner (which had been avulsed from the femur taking a chip of bone with it), and reform the joint capsule. It was not possible to perform this arthroscopically because the joint capsule had also torn so any water pumped into the joint (required to ‘inflate’ the joint to allow an easier view) would simply have leaked out down my leg into the surrounding soft tissue.
Between the surgeries, my knee was constantly in a brace to keep it stable. For the first few months (and for some time after each operation) this was a Posterior Tibial Support Brace with extra thick padding under the lower leg to push my tibia forward (to protect the vulnerable posterior cruciate) and keep the knee in the natural position by preventing it sagging posteriorly.
Operation #2 / Once the first operation had settled, a second arthroscopic operation repaired the ACL, PCL, and the popliteal insertion. This could have been done with synthetic tendons, donor tendons or my own tendons taken from elsewhere. While using my own tendons had the possibility of leaving the ‘good’ leg weaker, it was thought to offer the best chance of long term repair. The tendons the surgeon used were strips from the semitendinosis and gracialis of both legs. To massively oversimplify things, these were folded over, threaded through a tunnel drilled in the bone, then screwed into bone.
In the time from the initial injury to the first operation, the vascular supply to the lateral collateral ligament had diminished, meaning the initial repair was not as strong as hoped. This lead to a third operation to replace the ligament with a synthetic ‘LARS Ligament’.
Since then, I’ve been doing a whole load physio. Both trying to get as much flexion in the knee (very painful!) and building up the strength and robustness of the joint. Much of the stability of the knee joint comes from the muscles, so these physio exercises have also increased the muscle bulk in my impressively/depressingly wasted quads and calf muscles.
Two months after a PCL repair the leg brace can be removed and short distances can be walked. Twelve months after the second surgery most non-contact sports should be able to be played to the past standard. Contact sports can be played after a longer period, but is the risk worth it?
Long Term / I should be able to go back to effectively full fitness. My knee will ultimately be slightly weaker and more prone to damage should unnatural forces be put on it again. There will be a decrease in the amount of flexion I can achieve (I’m aiming for around 120°), and it is likely I will get arthritis in my right knee in my early 50s. But that’s ages away… I can worry about that one later! (Not as far away as you think Dave – Editor.)
Six months of attending university in a knee brace and crutches ensured I didn’t have to repeat the year. I’ve had some excellent support from HYMS and more importantly, fellow students. My placement partner, Emily Moore, has been my chauffeur for much of this time both driving to the hospital and pushing me round in my wheelchair. Having this to rely on has been such a bonus (cheers mate!).
With a bit of forward planning and forewarning of medical and nursing staff there has been very little problem with getting round the sessions. It helped that I could use the wheelchair for longer distances, but after six months I was nimble enough on crutches to manoeuvre around small wards without getting in the way. The NHS staff have been very accepting of the situation, the only real difference is that I’ve been asked for ID far more than before.
What about the head game? For an active guy who enjoys the outdoors, moving around on crutches can be frustrating, that’s for sure. The loss of independence takes longer to adapt to. Big tasks are usually easier than the small ones, for example when you’re in a rush and leave your keys upstairs… devastating!
However, I am well aware how fortunate I am that this is just a transient episode in life. I’ve never been the kind of person to over analyse things – to a large extent, what will be will be. I’ve lost friends and acquaintances in kayaking who were wither unconscious in the water, or unable to exit their boats. To have both of those things happen and come away with a largely repairable injury is, realistically, something to be very grateful about.
What have I learnt?
Be prepared / If you have the equipment, take it with you! I was fortunate to be with a well-prepared group, meaning that calling in the rescue was much quicker and more comfortable than it likely would have been otherwise.
Personal kit / Bright colours help you get seen. Don’t dress like a ninja.
Location / Knowledge of where you are and a map of the location is essential. Helicopters, Mountain Rescue, Ambulances won’t stand much of a chance if you are too vague.
Mobile phone / Carry one, especially if away from civilization. If we hadn’t got one with us (we had two, but one got wet and died), it would have taken much longer to summon outside assistance. It might be worth pointing out here that it is possible to text 999, but your phone needs to be registered with the service first.
Don’t give up / On any casualty in any situation, unless your life or safety is at risk.
The popliteal artery and tibial nerve & the common peroneal nerves are very vulnerable to damage with a knee injury. Peroneal (aka fibular) nerve damage can cause foot drop.
The damage inflicted can often be deducted by taking a good history of the mechanism of action.
If the joint capsule is torn, the damaged area may not be as swollen as expected – but watch out for compartment syndrome.
The medial meniscus is less mobile than the lateral meniscus because it is connected to the joint capsule and to the medial collateral ligament and so is more likely to suffer injury.
Avulsions are all that may be picked up on an X-Ray if there is ligament damage
Autografts have a better long term prognosis than allografts.
A year on from the accident, Dave’s knee was just about strong enough to search some out first descents in Borneo following his elective. See more at www.kayakborneo.co.uk. To learn more about river rescue, have a look at these excellent videos from whitewater guru Jim Coffey.