Edi Albert / Associate Professor, Remote and Polar Medicine / University of Tasmania
In the final instalment of his series of articles on snowsports injuries, Dr Edi Albert picks out a miscellany of tips, tricks and potential pitfalls garnered from his eight winters working at Perisher Ski Resort (the largest in the southern hemisphere) and coordinating a multi-disciplinary Masters programme in Remote and Polar Health at the University of Tasmania.
Alpine sports injuries are generally not unique to snowsports (perhaps with the exception of the fractured lateral process of the talus in snowboarders). However, there are some patterns and fairly common injuries that might be expected to those new to the game. Hopefully the following snippets will serve as a springboard for your success.
Own the Bier’s Block
Lesson 1 / Develop a consistent, safe approach to “own” your Bier’s block. Set the timer to 20 minutes, blow up BOTH cuffs and leave them up, use a low dose of 1% lidocaine (10ml or 1.5mg/kg.), don’t worry about exsanguination of the limb, and watch your patient throughout.
I borrowed the idea for this title unashamedly from the folks at Life In The Fast Lane.
The Bier’s block (IVRA or intravenous regional anaesthesia) seems to be one of those things that’s loved in one department and shunned in another. Used appropriately it is an excellent means of achieving anaesthesia – usually in the upper limb for reduction of fractures, but also in the lower limb if you have an appropriately sized cuff. In essence, a Bier’s block involves the intravascular injection of local anaesthetic into a limb distal to a tourniquet that is set above the systolic pressure.
The huge advantage of a Bier’s block is that you can develop a safe technique that works reliably in the hectic, uncontrolled environment of the ski clinic. In particular, you don’t have a precious staff member tied up watching a patient whilst they recover from their procedural sedation.
Use it predominantly for wrist fractures and elbow fracture/dislocations, but also for manipulation of fracture/dislocations at the ankle.
Lesson 2 / Learn to use your clinical acumen in conjunction with evidence based guidelines.
There’s no doubt about it, head injuries can be tricky: I mean we’re talking about taking responsibility for somebody else’s brain and, by extension, their life. But that doesn’t mean ignoring your clinical judgement, slavishly following the NICE guidelines on head injury and insisting on a CT each and every time. Indeed, when you might see half a dozen a head injuries each day and have a limited ambulance capacity, clinical skills become absolutely essential.
The history from ski-patrol, accompanying friends and relatives can be a double edged sword: don’t take what they say at face value. Dig a bit deeper, in particular with regard to loss of consciousness (LOC). The length of LOC is often exaggerated. An LOC of 15 minutes that happened only half an hour ago just isn’t consistent with an alert and oriented patient whose only complaint is a bit of a sore neck. Trust your intuition.
One phenomenon we see quite commonly is goldfish bowling. Remember Dory from finding Nemo? The patient has usually had some transient LOC (probably) and has a modest amount of amnesia. They are often laughing and joking, though some have enough insight to feel concerned about being in a medical clinic with no knowledge of how they got there. They ask the same questions over and over again. It can be quite amusing to start with but soon wears thin. Get a piece of paper and write down the answers to all their questions for them to read. These patients (even if they meet NICE criteria for CT) always seem to recover.
There is increasing concern and research evidence related to concussion in contact sports, so get a sports history from the patient and advise them accordingly. Of course, skiing and boarding aren’t contact sports until you fall over.
Lesson 3 / Learn to use the NEXUS Rules to clear necks clinically where possible
What I’ve written for heads also applies to necks. The NEXUS Rules have been validated for pre-hospital use and should be your first port of call. Their inherent issue is that you can always argue that there has been a significant mechanism of injury (MOI) and thus shy away from using the rules. However, in those for whom you have a genuine clinical concern it always seems possible to find something that’s not quite right on the plain x-rays (with no radiologist around to advise). With no onsite CT or not enough ambulances to evacuate the patients, the NEXUS Rules are the solution. They have been validated in pre-hospital settings involving young fit trauma victims engaged in outdoor sports. They work, so use them unless you have a really good reason not to. Good reasons include a polytrauma patient who looks like they have been hit by a car, or a patient with a head injury and a reduced level of consciousness.
You can always go back and reassess a patient once they have settled down a bit. It’s amazing how a bit of time and a calm demeanour can make symptoms go away.
What about cervical collars in those for whom you have genuine concerns? Well, this isn’t the place for a review of the topic but the dogmatic use of full spinal immobilisation and application of hard collars is very much being challenged. Have look at Bledsoe’s article or this review in the Journal of Neurotrauma if this is a surprise to you.
Anterior Wedge Compression Fractures
Lesson 4 / Beware the patient who has landed hard on their back and been winded. They probably have a wedge compression fracture even if they have no posterior midline tenderness.
Personally, I’m a bit of a coward approaching fifty, so only go into the terrain parks designed for ten year-olds. It works for me and I don’t get injured. However, not everyone is like me and we see a lot of people (usually males) who have landed hard on their backs or flat onto their skis or boards. The former can have thoracic spine fractures: those that scorpion get their fractures at the thoracolumbar junction and those that land hard on their feet can get lumbar spine fractures or even fractures at multiple levels.
We are taught to roll the patient and examine them for spinal tenderness, and of course that is worth doing. But, some anterior wedge compression fractures present without posterior mid-line tenderness, particularly those in the thoracic spine. Patients have generally been winded and their pain may be retrosternal rather than in their back (remember how visceral pain is quite non-specific).
Femoral Shaft and Neck of Femur Fractures
Lesson 5 / Learn to perform a fascia iliaca block. It’s much better than large doses of yucky opiates.
In “normal” medicine the #NOF is almost always seen in the elderly female who has tripped over the edge of a rug, hurrying to get to the toilet in the middle of the night. However, in alpine sports medicine, high energy injuries mean that you will see fractures femoral necks and shafts in the young and athletic. For either injury your “go to” analgesia should be the fascia iliaca block. This block can safely be done with ultrasound guidance, or using reliable landmarks and a “two pops” technique. Use a large volume (30-40ml ideally) and be patient.
For femoral shaft fractures newer and cheaper lightweight traction splints (for example, the CT-6) have replaced the older heavier ones and are ideal for pre-hospital use.
Your one-stop shop for snowsports injury and injury prevention is Mike Langran’s Ski-Injury.com. It covers many of these topics in much more detail.
Photos: Author’s own plus Wikimedia Commons. You can contact Edi by email: firstname.lastname@example.org.