Edi Albert / Associate Professor, Remote and Polar Medicine / University of Tasmania
In one of our first ever Adventure Medic articles, Queenstown GP Tonya Cruikshank gave us some basic tips on how to respond when first arriving at an accident on the ski fields. Now, in this three part series of articles Edi Albert will look at what happens next. Edi has worked at Perisher Ski Resort (the largest in the southern hemisphere) for the past eight winters. He also co-ordinates a multi-disciplinary Masters programme in Remote and Polar Health at the University of Tasmania.
In his first article, Edi discusses the ‘at risk’ groups, common injury patterns in skiers and snowboarders and injury prevention. Timely stuff, winter is fast closing in on the Northern Hemisphere and soon hopes of fresh snow and blue ice will be all that keep us sane.
You may be the doctor in a group doing some back-country ski touring; you may be the nurse amongst a bunch of friends faced with a swollen knee over breakfast the next morning, or you may be as lucky as me – and get a job in a clinic in a ski resort.
Clearly, a few articles can’t replace hands on experience and training, but can hopefully help with a few key pointers and concepts that aren’t usually found in the first aid manuals or medical text books.
We will start by considering the different patterns of injuries experienced by skiers and boarders and relate these to the mechanism of injury and to some extent the age of the patient. Examination can be difficult out on the slopes, or even in the clinic with a freshly injured patient, so a good history and a good understanding of mechanism can go a long way to help with the diagnosis.
We will then consider assessment and management of knee injuries, shoulder injuries, and also along the way, a selection of other injuries that may pose diagnostic and management pitfalls.
Injury rates and ‘at risk’ groups
Alpine skiing and snowboarding are, despite intermittent media hype, relatively safe sports with injury rates in the region of 3-5 per 1000 days. These are considerably lower than for other “normal” sports such as football and rugby. Patterns of injury vary between different snowsports and should be understood by those involved in their medical treatment. These sports, by their very nature, can involve high velocity, high energy impacts – especially in the terrain parks.
LESSON 1 / Injuries can involve very large forces. Take a good history to understand the mechanism of injury, have a low threshold for x-rays where significant forces are involved, and a high index of suspicion where a “normal” x-ray just doesn’t correlate with your clinical findings.
There are a few groups that have been shown from studies to be at higher risk – children, beginners, and elite competitive athletes. This makes injury prevention strategies and protective equipment particularly important for these groups (see the section on injury prevention).
From my own experience there are two other groups who end up flat on their backs in our clinic:
The first are overweight mothers who have been dragged on to the ski slopes by a keen husband and even keener teenagers. They would have preferred a nice beach holiday, do no regular exercise of any kind, and certainly haven’t thought about preparing for their ski trip. They are often baffled that they are lying injured as they thought they were “just taking it easy”.
LESSON 2 / Beware of the low speed, slow twist knee injury in particular (see article 2 on knee and shoulder injuries) – it’s one of the best ways known to man to bust your ACL
The second ‘at risk’ group are the older skiers. Whilst it is fantastic, and personally very encouraging, to see more and more people still skiing in their sixties, seventies, and even eighties, and whilst they do tend to keep fit, take care, and ski carefully, their bodies are much more vulnerable.
LESSON 3 / “Senior” skiers can do themselves a real mischief with minimal force. Their apparent vigour and vitality is not matched by the integrity of their bones and connective tissue. Have a low threshold for investigation.
Injury patterns in skiers and snowboarders
Look out of the window in the morning and you can almost predict how your working day will unfold: a soft blanket of overnight snow will provide a forgiving medium that makes everyone feel invincible and keep the clinic quiet, that heavy, claggy “porridge” we get in warm, wet, windy Australia is wonderful for destroying knees, and a few days of freeze-thaw conditions will generate a hard surface such that snowboarders with broken wrists turn up in their droves.
From a bio-mechanical and injury perspective, skiing and snowboarding are two quite different sports. Of course both can fall over and bang their heads, both get meaty slices through their limbs from sharp edges, and both can “scorpion” on a jump and end up with a wedge fracture at the thoraco-lumbar junction. But, in general, injury patterns are quite different, so understanding them can guide the clinician towards a quicker diagnosis, with more appropriate imaging, and a lower chance of missing something. What follows is necessarily a generalisation: clinical acumen should allow you to pick up those presentations that don’t follow these generalisations.
Put simply, skiers spend their time on awesome torque inducing over-sized lolly-pop sticks, whereas boarders stand sideways on a tea tray and keep falling over forwards or backwards.
The skier is at risk from anything that interferes with the controlled movement of their skis. Catching an edge, crossing your skis, or having someone else run over the back of one of them can create huge rotational forces from the foot, all the way up the leg. In children and older adults the tibia may give way with spiral boot-top fractures occurring. In older children and adults, the tibia tends to pass the force up the way and it is the knee that suffers: MCL, meniscal, and ACL injuries can occur in isolation or combination.
Assuming the snowboarder has his or her back foot strapped in (which isn’t the case getting on and off lifts) then the knees are fairly protected against over-rotation and you are unlikely to get more than a grade 1 MCL injury.
When snowboarders fall, those that haven’t “learnt how to fall” usually fall forwards onto out-stretched hands – or backwards onto outstretched hands. Injuries then reflect transmission of force – distal radius or scaphoid fractures, fracture dislocations of the elbow or further up into the shoulder (see my next article on knee and shoulder injuries).
LESSON 4 / Always assume the relocated elbow conceals a fracture – even if you can’t see it on X-ray, commonly a coronoid process fracture – so get a CT. The one above is easy to spot on this post-reduction film.
Falling onto the shoulder is a common way to protect the wrists but then puts the snowboarder at risk of shoulder dislocation, ACJ injury, rotator cuff injury, and clavicle fracture.
When skiers fall, they can, like the snowboarder, do a high speed “superman”, but often they are sideways onto the slope and either fall uphill or downhill onto their shoulders. The classic Skier’s Thumb occurs when the thumb is forced back by the presence of the ski stick held in their hands.
LESSON 5 / With a Skier’s Thumb presentation look for a UCL rupture or fracture at the base of the 1st meta-carpal. Stress x-ray views may be appropriate when USS or MRI is not available. To examine the UCL you need to “fix” the 1st MC so it doesn’t move when you wiggle the thumb.
Finally, a word on falling from heights: which is something that both skiers and boarders do quite regularly when they get into the terrain parks and when there is a confidence-competence mismatch. An undershoot on a jump results in an unexpected flat landing on the “knuckle” and an overshoot can result in an unexpected landing way beyond the “sweet spot” with disastrous consequences. Forces start at the heels and then travel up the legs, into the pelvis and on up the spine. Look for fractures in all these places, and anticipate more than one fracture.
LESSON 6 / A man with “groin strain” who can’t weight bear has a fractured pelvis – even if his plain x-rays are normal.
Be physically fit, don’t drink and ski, maintain situational awareness, don’t do that “last” run before lunch or the end of the day, don’t have music blaring through your headphones, don’t drag your girlfriend to the top of a black run on her second day so you can show her how good you are, don’t let your friends teach you or lend you their gear… blah… blah… blah. Good advice seems to fall on deaf ears. This is okay by me of course, otherwise I wouldn’t have a fun job in a ski clinic.
A discussion around injury prevention is bound to focus on helmets and wrist guards. Both are hotly debated and use of both is becoming more common.
If you want to read the science and evidence behind this then head for Mike Langran’s comprehensive ski-injury.com site. The following is just a brief synopsis.
Helmets / Helmets do not make you invincible and probably do not reduce the risk of death. Let’s face it, if you hit a solid object hard enough (which is easy to do on skis) there’s nothing much that a helmet can do. It has been demonstrated that in order to protect the head from a direct impact at (only) 50km/h you would need a helmet 18cm thick that would weigh 5kg! But these sorts of injuries are very rare.
Much more common is falling over backwards and hitting your head, or when somebody pulls down the restraining bar on the chair lift before you’ve got on properly, or when tree skiing and your duck just isn’t quite enough.
Now, are you seriously going to tell me that a nice, colour co-ordinated helmet with built in speakers that can Bluetooth to your phone, keep your head warm, and reduce the morbidity from common incidents isn’t worth having? I’m not worried so much about what I might I do wrong, but what some other idiot might do to me.
Helmets don’t increase the risk of neck injury, they don’t reduce the field of vision, and don’t impair your sense of hearing. They do make sense: especially for those ‘at risk’ groups.
Wrist guards / Wrist guards are designed to prevent wrist fractures in snowboarders. Wrist guards reduce both the incidence and the severity of fracture. Sure, some people do still break their wrists under the guards but these are always less severe than if they had had no guard on. There is still a myth out there that wrist guards transfer the force up the arm – typically that you break your mid forearm at the end of the guard. The research evidence does not support this. You can make a good argument for an experienced boarder not wearing them. You can’t make any sort of rationale argument for beginners and children.
LESSON 7 / If your boyfriend or girlfriend breaks both wrists then it will be quite a while before they can wipe their bottoms again. Which means that you will have to do it. Treasure this opportunity: it’s a wonderful relationship tester! Either that or insist on wrist guards.
LESSON 8 / The golden rule of the ski slopes – always wear waterproof mascara – there’s nothing worse than treating patients whose tears have transformed their faces into something reminiscent of a KISS concert.
Your one-stop shop for snowsports injury and injury prevention is Mike Langran’s www.ski-injury.com. It covers many of these topics in much more detail.
You can contact Edi by email: firstname.lastname@example.org.