Dr. Mudd's Diagnosis

[STS Lincolnite]

In my 20+ years experience working with athletic injuries (many fibular fractures, sprained ankles, etc.), the description of Booth's leg would be expected following a fibular fracture given his circumstances. I would note that generally speaking, the amount swelling and ecchymosis (bruising) are not always representative of the severity of the initial injury. As Laurie and Dr. Greene stated, the amount of swelling and bruising could have been partially related to many secondary tissue injuries resulting from movement - but if Mudd's splint did it's job there shouldn't have been that much movement at the fracture site.

There is one other thing, however, that I think would be a major contributor to this type of local swelling and bruising. These post injury signs are very commonly seen after injury when people keep their leg in what we call a dependent position (leg lower than the level of the heart). As Rick alluded to, one of the first treatments we would typically implement after this type of injury would be elevation of the injured extremity above the level of the heart. This allows for the various chemical mediators and resultant swelling and bleeding to be evacuated from the immediate area - relieving pain and allowing greater function. When not elevated, all the post injury "junk" is just sort of trapped in the area while continuing to accumulate. This would certainly result in significant swelling, bruising, and often times a sort of rigidity (do to the swelling taking up any tissue slack). It is unlikely that Booth spent much time while on the run with his leg elevated above the level of his heart. Immediately after his injury, he spent long hours in the saddle with his legs obviously down. Even when he was hiding out for days he may have been laying down, but probably did not have his leg above the level of his heart. He then spent even more time in the saddle or otherwise seated. I have treated some sub-acute, relatively minor injuries (fibular fractures, sprains) that looked absolutely horrific, but when appropriate treatment (simple elevation along with ice and some simple range of motion exercises to activate sort of a "muscle pump") is applied they are vastly improved in appearance, pain levels, and function in as quickly as hours and certainly in a day or two.

I don't think it likely that Booth had an infection of any type if the skin was not broken (I tend to go with the autopsy report, not the newspaper account). In an infected limb you may see bruising (but not necessarily). If infected, you would see swelling along with the hallmark signs of infection which are redness and streaking. The descriptions do describe ecchymosis but I don't recall any mention of redness or streaking (though my memory may not serve me here). In an open wound, Laurie is absolutely correct, there would certainly be an odor associated with an infection, but I have seen a number of instances of infection (for example in a surgically closed incision) that do not have any odor.

As far as Mudd feeling or manipulating the leg to identify a fibular fracture, it doesn't typically take much for this type of injury. A simple compression of the lower leg will elicit pain, movement, and the described "crepitation". This is due to the creation of what we call a "false joint" at the fracture site. Such a test takes maybe 20 seconds if that. I have correctly identified several of these fracures in my career.

John, I think you are right when you stated that Mudd may have just misspoken if he said fractured tibia. Those two bones should be easy to distinguish for a physician. I suppose there is also the chance he was intentionally being deceptive and trying to put forward the idea that the man he treated had a broken tibia not fibula. So if Booth was caught he could say the man he treated had a broken tibia so it couldn't have been Booth. That probably would've worked better if he had gotten rid of Booth's boot.

Sorry, that post got kind of long - didn't intend it to be so.