Winter Sports Injuries: Diagnostic and Treatment Strategies for Optimizing Clinical Outcomes
Winter Sports Injuries: Diagnostic and Treatment Strategies for Optimizing Clinical Outcomes
Author: Charles Stewart, MD, FACEP, Emergency Physician, Colorado Springs, CO.
Peer Reviewer: Michael Gerardi, MD, FAAP, FACEP, Clinical Assistant Professor of Medicine, New Jersey Medical School; Vice-Chairman, Department of Emergency Medicine, Morristown Memorial Hospital; Director, Pediatric Emergency Medicine, Children’s Medical Center, Morristown, NJ.
Winter months represent unique recreational opportunities for children (of all ages). Each year, children will scamper, trudge, or be hauled upslope just to go faster down slope, and turn around and do it again. Each year downhill skiers make about 50-60 million visits to their favorite slopes. An uncounted number keep to the flat and level on cross-country skis.
The downside to the down slope isn’t just the trudge back up. Commonplace at ski resorts and urban hospitals alike is the practice of "seeking hospital air" (snowboarder jargon for an emergency department visit).
Ski injuries have been well studied. For each 1000 of these skier’s visits, about three will end in an injury serious enough to require immediate medical care. Unfortunately, many will seek medical care only after they have returned home, where practitioners may not be cognizant of the types of injuries sustained or the potential seriousness of these injuries. As many as 40% of these injuries are unreported.
Although snowboarding is only about a decade old, a growing body of information is available to assist the emergency physician in understanding the problems of this fast-growing alpine sport. Snowboarders are probably less likely than skiers to report minor injuries, since the "boarders" expect them.
Less information is available for sled and toboggan injuries. In the largest available study, serious injuries at a major urban hospital occurred twice as frequently from toboggans as from snowboards.1 Emphasizing mechanism of injury, historical features of the accident, and physical examination, this article guides the emergency physician toward specific diagnosis and strategies for definitive management.
— The Editor
Snowboarding Injuries
Snowboarding was invented in 1972 and has grown in popularity at an annual rate of greater than 100% through the 1980s and 1990s. Most snowboarders are well-conditioned males and are an average age of about 21 years. The injured population is significantly younger than that found with skiers.2 Sixty-six percent of snowboarders are 12-21 years old.3 As such, snowboarding injuries are much more common in the pediatric emergency department than the adult ED.
Industry reports estimated in 1997 that only 18% of snowboarders are women, with a dramatic increase expected over the next few years.3 Other surveys agree that the number of female snowboarders is markedly increasing.4 If this increase materializes, then sexual equality will change current demographics of snowboard injuries.
The original snowboards made of wooden boards have evolved into fiberglass bodies, plastic bases, and steel edges and are similar in design to alpine skis. They vary from about 140-190 cm and are about 30-40 cm wide. Most snowboards are symmetric, allowing the snowboarder to travel backward easily. Traditional snowboarders place their left foot forward and face toward the right side of the snowboard. Occasionally, snowboarders will ride in a reverse position (i.e., "goofy-footed").
Snowboard riding techniques are similar to those of surfing and skateboarding. The rider’s weight is primarily over the front foot, and turns are made by shifting weight and swinging the back end of the board around and then setting the edges. Without poles, the arms and hands are used more actively for maintaining balance and may often be dragged along the snow surface for added stability.
The skier is firmly fixed to the board in non-releasable boots and bindings. The front foot is set at 45° to the board, and the rear foot is positioned perpendicular to the board. Bindings (and the boots that go with them) can be divided into two types. The soft type has a high back and uses a soft boot with a rubber sole. Most snowboarders prefer these soft boots. Hard boots provide greater control of the snowboard as well as greater ankle support. A compromise of the increased comfort and maneuvering ability of the soft boot and the increased stability of the hard boot can be found in newer hybrid boots.
The plate type of binding has a steel or plastic base plate and a heel and toe clip that fits hard shell boots or ski boots. The snowboard binding is usually non-releasable, even when used with ski boots. Some newer snowboards are using a releasable front binding with hard boots.
Other safety equipment includes helmets, face guards, forearm guards, and wrist guards. This safety equipment is usually found on racers or freestyle competitors. Recreational snowboarders rarely will use helmets or wristguards.
Snowboarders and skiers have substantially different injury patterns as detailed below. Fortunately, severe injuries are relatively rare but, as with skiers, the most common cause is collision with a tree. Unfortunately, the actual incidence of snowboarding injuries is difficult to measure, since ski lift tickets are not divided by type of device used.
Injuries to snowboarders occur at about twice that of skiing injuries, with 6-10 injuries per 1000 exposure days.6 Nearly 50% of injuries will occur in beginners, as opposed to only 18% of skiers.7 Indeed, nearly 20% of beginners will have an accident on the first day of snowboarding.8
Collision with a stationary object is a much less common mechanism of injury in snowboarding. Snowboarders are often slower than skiers, so collisions are not associated with increased severity of injury.9
The snowboarder has far more falls than the skier. Many falls occur when the snowboarder is attempting a jump or aerial maneuvers. Unfortunately, snowboarders fall backward and are more likely to have buttock contusions and spinal injuries than downhill skiers.10 Aerial maneuvers and subsequent falls are associated with increased risk of injury to the head, chest, spine, face, and abdomen.8,11-13 Falling backward has an increased incidence of head injury compared to falling forward, partly because the snowboarder can protect his or her head with the upper extremities while falling forward.14
There are fewer lower extremity injuries and nearly twice as many upper limb injuries in snowboarders. The absence of ski poles and the fixed position of the feet means that the upper limb receives the full impact of any fall—a mechanism that can produce damage to the shoulder, elbow, wrist, or hand. When jumps and aerial maneuvers are included in the repertoire of snowboarders, upper extremity injury accounts for nearly 75% of snowboarding injuries.9,15,16 Ulnar collateral ligament injuries are far less frequent in snowboarders, since they do not use poles.
The rate of upper extremity fractures is markedly higher in snowboarders, accounting for 38% of injuries in snowboarders and 15% in skiers. Ten percent of all snowboarding injuries will involve a fracture to the distal radius from a fall on the outstretched hand.6 The mechanism of injury is often falling on the outstretched arm, with longitudinal thrust of the radius against the capitellum.17
Wrist guards are very effective in preventing wrist injuries in in-line skaters with similar injury mechanics and might be effective in decreasing snowboarding wrist injuries. Novice snowboarders who do not wear wrist guards should keep their hands clenched, since this decreases the chance of falling on an outstretched palm. Some instructors use ski poles for the first few weeks of lessons to decrease the frequency of early injuries.
Elbow injuries are also quite common in snowboarders and are often extensive, including fractures, posterior dislocations, or both.18 Posterior dislocation of the elbow, combined with coronoid process fracture and simple coronoid fracture, occurs in 60% of elbow injuries to snowboarders. These injuries occur when the snowboarder falls on the outstretched arm in extension with either abduction or hyperflexion of the elbow.18
Shoulder injuries from snowboarding have not been as well discussed in the literature. The rate of shoulder injuries during alpine skiing is about 0.2-0.5 injuries per 1000 skier days. During snowboarding, shoulder injuries account for 8-16% of all injuries and 20-34% of upper extremity injuries.19
Common shoulder injuries included dislocations, rotator cuff strains, acromial-clavicular separations, and clavicle fractures. Dislocations occur when the arm is rotated excessively or from direct loading. A single field attempt at reduction by a qualified medical provider in the field is appropriate. Acromial-clavicular (AC) separations occur exclusively from direct trauma to the AC joint during a fall. The mechanism for clavicle fractures and AC separations is the same. The patient falls on the point of the shoulder. The shoulder is depressed and the clavicle fractures or the AC ligament is torn.
If the lower extremity is injured, the front leg is involved in about 75% of cases.20 Because both feet are fixed to the same board, far fewer torsion injuries to the knee are found. Snowboarders are also less likely to sustain lacerations and boot-top contusions.
Ankle injuries predominate in these lower extremity accidents. A fracture of the lateral process of the talus is now recognized as unique to snowboarding and is sometimes referred to as "snowboarder’s ankle."21 This appears to occur when the patient has dorsiflexion of the ankle and inversion of the hindfoot. Talus fractures do not always respond well to conservative treatment and orthopedic consultation is always indicated. Since this fracture is not common, the emergency physician must be aware that it is not an unusual finding in snowboard injuries and aggressively look for it. A lateral plain film of the ankle, with the ankle held in about 10-20 degrees of inversion, may show this injury better than standard ankle views. If the ankle radiograph is suspicious, then CT of the ankle is indicated.21
In lethal snowboard injuries, the most common cause of death was blunt head injury followed by blunt chest trauma.3 Helmets were not worn by any snowboarder involved in a lethal accident.
The most common non-impact injuries to snowboarders are caused by hyperdorsiflexion of the ankle as the rider falls forward.10 This can cause Achilles tendon and gastrocnemius injuries. The rider is also more likely to sustain hyperplantarflexion foot and inversion and eversion ankle injuries, since these individuals are falling with a soft boot that is rigidly fixed to the board. Hard-shelled boots or inserts as well as ankle supports help to prevent these injuries. The lower extremity injuries associated with these boards and bindings are quite similar to those found in the older style, non-release ski bindings.15,22
Finally, snowboarders are more commonly injured getting off of the chairlift than skiers. This may be because the exit ramps are developed for forward facing skiers rather than snowboarders who ride facing to the side.7
Sledding and Tobogganing
Generally considered to be a benign winter sport, downhill sledding is a common recreational activity for both children and adults.23 Sledders may use commercial sleds, toboggans, or saucers, and makeshift cardboard box sleds or inner tubes can be recruited. A sunny day followed by a cold night may produce a fast course on icy slopes with hard ground. During icy conditions, the rider may have high-velocity impacts with hidden obstacles such as rocks, stumps, and moguls.24 Since less snow is required, the hidden obstacles are much less padded than on a ski slope.
Injury statistics suggest that younger people are at higher risk for injury.25 Poor judgment is commonly implicated in cited injuries. Children will often choose a "quiet" street on a hill for their course. There can be potentially disastrous results if a vehicle is on the street at the wrong time.26
The standard sled can be steered when ridden in the prone position. This is the most common riding position. The rider can also sit upright and control steering with the feet. When the rider is prone, head and facial injuries are more common.27 (See Emerg Med Rep 1995;16:59-70 on facial trauma.)
The most common injuries are lacerations, followed by contusions and strains. Serious injuries occur in as many as 21% of sledding injuries.28 Abdominal injuries result from bumps or after impact with the ground. Impalement injuries due to sledding are uncommon but devastating.29 When the rider sits erect, the spine is more susceptible to hyperflexion injuries.
Unlike skis, toboggans are cumbersome to steer and virtually impossible to brake. Most riders will attempt to brake the toboggan by extending feet onto snow and as would be expected, toboggan injuries often involve the lower extremities. Toboggans and inner tubes are ridden in the seated position, with riders often leaning forward with their back arched. It is thought that this position enhances the likelihood and severity of a spinal injury. More life-threatening injuries have been reported in tubing than in tobogganing.1,25,30
It is possible that these devices can be made somewhat safer for children. Steerable devices, such as sleds and toboggans, are safer than nonsteerable devices, such as saucers, tubes, or cardboard boxes. Sleds with braking devices may be safer than toboggans or improvised devices. Finally, a bicycle helmet may provide impact protection while the sled rider sits in the prone position. In the largest study available on pediatric winter sports injuries, only 1% of injured patients reported using a helmet.1
Downhill Ski Injuries
Demographics. There are between 6 and 10 injuries per 1000 skiers daily. Unfortunately, as many as 40% of injuries are not reported on the slope, and even this figure may be grossly inaccurate. Injury figures provided by a ski patrol reflect only those patients who seek medical care from the patrol, rather than all who eventually require medical care.31,32
There are several reasons for this underreporting. First, many accidents sustained by skiers are simply not reported. Second, younger skiers are often taken elsewhere for minor, and sometimes even major injuries. Finally, many parents will prefer to have their children treated at facilities closer to home, and will simply take them to a medical facility near their residences.
There are other confounding variables. For example, some injuries are not thought to be "that bad" until the following day, when the patient seeks medical care off the slope.
Injury Rates. Given the aforementioned limitations, it is estimated that males have an injury rate of about 4.9 injuries per 1000 days of skiing, whereas the rate for females is 7.9 per 1000.33 Juvenile skiers have at least three times the injury rate of adult skiers, with at least one-third of all injuries occurring among skiers who are younger than 16 years of age.34,35 The highest rate of head and neck injuries is reported in the 11- to 13-year age group.36
Experience and athletic proficiency appear to be major factors in reducing the risk of injury associated with skiing. For example, similar to snowboarders, entry-level skiers have 2-3 times the injury rate observed in more experienced skiers.6 Not only is the novice more likely to sustain injury, but he or she is more likely to cause injury to another skier.37 When asked to identify the reason for their injuries, one-third of all skiers injured felt that they were going too fast for their expertise and/or the condition of the slopes.
Slope Conditions. Environmental conditions on the slope play a major role in ski-related injuries. As might be expected, powder snow is associated with the lowest frequency of injuries. Skis are more likely to get entrapped in heavy, wet snow, and twisting knee and ankle injuries are more likely to occur. In contrast, during icy conditions, upper-extremity injuries are more likely to occur because skis slide out from under the skier. In these accidents, the skier may fall on the face, shoulders, and upper body in the process of trying to break a fall.
Groomed powder-covered slopes create a higher incidence of injuries than ungroomed slopes, but skilled skiers use ungroomed slopes more frequently than beginners.38
Skier fatigue. Time of day also plays a role. For example, more injuries occur in the afternoon (between 1 p.m. and 4 p.m.) when skiers are tired and hungry (or have consumed alcoholic beverages for lunch).39 The last run of the day is typically the most dangerous and the time when most accidents occur. Not only is the skier fatigued at this point, but there is often a frenzy to get in "just one more run" before the slopes close for the day. For prevention, parents should recognize children’s physical limits and not allow them to ski when exhausted. Many slopes now offer "downloading" where a skier can use the chairlift down the slope instead of skiing if he or she feels tired.
Alcohol. Although alcohol is considered an "adult" problem, as any experienced emergency physician knows, the adolescent can find a way to procure intoxicating beverages despite abundant laws prohibiting this behavior.
Injuries are reported at a higher rate and tend to be more serious when alcohol consumption prevents the skier from being able to concentrate on the mechanics of skiing.40,41 Alcohol promotes fluid losses by diuresis and heat loss is accentuated by alcohol induced peripheral vasodilation. These effects of alcohol make intoxicated skiers more prone to cold and dehydration. All ski slopes sell alcoholic beverages, so it is impossible to accurately estimate the contribution of this factor.
Prevention: Protective Equipment and Safety
As might be expected, the design of skiing equipment has a dramatic effect on ski-related trauma.
Boots. The contemporary ski boot consists of a high, hard plastic outer shell coupled to a soft inner liner. The plastic outer shell is designed to transmit foot and leg forces to the ski in order to increase control over the ski. The liner is a thick sock-like bootie that surrounds the foot with a moldable form. The body heat molds the liner around the foot so that the bony parts of the foot are protected from the hard outer shell. Padding is provided for the anterior shin with a wide, thick foam tongue on the boot liner. Forces from the skis are transmitted through the boots and are applied at the mid-third of the tibia.
Because the ankle and foot are reinforced, there are fewer ankle and foot injuries. Over the past 25 years, the incidence of tibial and fibular fractures has been reduced by 72% and 43%, respectively, because of improvements in boot design.35 Low boots similar to old style downhill boots are often used with cross-country skis, particularly in Telemark skiing (a downhill variant of cross-country skiing). These boots allow the stresses of a fall to be absorbed by the relatively weak ligaments of the ankle and lower portion of the tibia and fibula. Ankle movement is freer and rotation abduction of the leg can occur about the ankle. This can result in both ankle injuries and mid-distal-third tibia fractures.
Bindings. Of all of the factors that determine whether the skier will still be skiing at the end of the day, the type and appropriate function of the bindings are most significant. Bindings have two competing functions. First, they must rigidly attach the skier’s foot to the ski. Second, they must release this attachment under any stress that could injure the skier. Current dual-mode bindings release in two different directions: toe rotation and heel lift. This protects the skier from most rotation-based injuries. When combined with high-topped boots, the ankle is almost completely protected.
Unfortunately, the knee then becomes the main shock absorber in trauma to the lower extremity. The knee is quite vulnerable to this trauma for the following reasons: Rotational forces that used to cause ankle injuries are transferred to the knee by the high boots as described above. Forces that are not protected by the dual-mode binding can cause injury to the knee. (Upward release at the toe would decrease some of these injuries.) Criteria for protection of the tibia from injury are based on cadaver studies on fractures of the tibial plateau. Unfortunately, this protection does not extend to the ligaments of the knee. Finally, the binding may fail to protect the patient in deep and wet snow conditions.42,43
Probably the most significant failing of the bindings occurs before they are put on, when the skier adjusts the tightness. If the binding is too tight, then it will not release under forces that will fracture or seriously damage the knee. Failure of the release mechanism accounts for 44% of downhill injuries and 70% of lower leg fractures and serious knee injuries.44 This may be due to either improper maintenance or improper adjustment of the bindings.35,45
Helmets. There are little data on the effectiveness of ski helmets in prevention of ski deaths. A group of researchers in the Department of Industrial and Manufacturing Engineering at Rochester Institute of Technology estimated that helmets could prevent 60-80% of head injuries caused by skiing. Helmets for children have been advised in the popular literature, and recent celebrity deaths have increased use on the slopes. Since all sanctioned competition requires all skiers to use helmets, and has for many years, there isn’t a comparison between helmeted competitive skiers and non-helmeted controls.
Mechanisms and Categories of Injury
From a practical perspective, skiing accidents involving all ages can be grouped into two main categories: collisions and falls. In addition, skiers may also develop "overuse" injuries of muscles, ligaments, and joints. (See Table 1.)
| Table 1. Incidence of Selected Injuries Due to Downhill Skiing | |
| Injury | Incidence |
| Sprains, strains | 45% |
| Cold injury | 20% |
| Lacerations, abrasions | 11.5% |
| Fractures | 9.5% |
| Contusions | 5% |
| Dislocations | 3% |
| Adapted from: Foster CR, Garrick JG, Steadman JR, et al. | |
| When skier turns tumbler. Pat Care 1987;21:24-44. | |
Collisions. Collisions account for only 5% of all injuries sustained on the slopes but for more than 67% of all admissions. In particular, high-speed collisions with immovable objects such as trees, buildings, support towers, or even snow-grooming machines can cause massive blunt trauma and impalement injuries.46,47 In the typical fatal ski crash, the skier strikes a hard object and dies of head injury.48,49
The nature of collision injuries is not predictable and varies widely depending on the part of the body involved and the speed. Impact at as little as 20 miles per hour can be fatal.50 In 1995, there were 6500 known skiing head injuries in the United States, including 3315 concussions and 451 concussions that required hospitalization.51 According to the National Safety Council, there were 36 skiing deaths in the 1996-1997 ski season. During 1996, there were 716 boating deaths and 800 bicyclist deaths.52 Major skiing injuries in children included injuries to the head in nearly 80% of cases.53 (See section on helmets.)
Falls and Lower-Extremity Injuries. More than 87% of all reported ski injuries are caused by a fall.54 Fortunately for emergency care providers, injury patterns resulting from ski-related falls are predictable, well-studied, and permit a systematic approach to patient evaluation and management. The most common injuries, in order of occurrence, are: thumb injuries, knee injuries, lacerations of the face and head, leg contusions, shoulder injuries, ankle sprains, tibia fractures, knee contusions, and dislocations of the shoulder.
Strapping a ski onto the foot produces an increased lever arm and, in turn, "enhances" the chances of an injury with any given fall. If the tip of the ski becomes fixed in deep snow or is lodged against a tree, the resultant forces can be enormous and cause massive musculoskeletal damage. In these accidents, as the skier falls or rotates, the increased lever arm of the ski-foot-leg combination will exceed the tensile strength of the human musculoskeletal system. The clinical result can range from muscle strains and tears to ligament injuries and compound fractures.
Recognizing the mechanics predisposing to such injuries, ski equipment manufacturers have invested millions of dollars in order to develop ski bindings that will release before muscles, ligaments, or bones tear or break. In fact, when properly fitted, affixed, and adjusted, these bindings can prevent a great deal of injury.
From a clinical perspective, torsion and twisting forces associated with falls generally produce injury in several well-defined and predictable patterns. In the lower extremity, for example, there are four such patterns: external rotation, internal rotation, forward falls, and backward falls. The first three patterns commonly produce injury, whereas the fourth is a less frequent mechanism of injury.
External Rotation. External rotation ("catching an inside edge"), which usually is associated with ankle abduction, is the most frequent mechanism of injury. In these cases, the inside edge of one of the skis is fixed in place. As the skier continues forward, his or her body weight shifts to the other ski and the "caught" leg is externally rotated and abducted. These forces may fracture the lateral malleolus, cause spiral fractures of the tibia and fibula, or produce ankle sprains and knee sprains.
Internal Rotation. Internal rotation ("catching an outside edge") injuries occur in exactly the opposite manner from that described for external rotation injuries. The skier, who is usually a novice, will catch the outside edge of the ski during a turn or when the skis cross. The internal rotation forces that result can produce an ankle sprain of the anterior talofibular ligament, a medial malleolus fracture, or a tibial fracture.
Forward Fall. Forward falls most often occur when the skier digs a tip of the ski into the snow and continues in forward motion as the ski stops. The lower leg angulates over the boot top as the skier’s forward momentum is terminated abruptly by the ski, which remains wedged in the snow. If the binding fails to "give," the musculoskeletal system will be disrupted and produce one of three injuries: boot-top fractures, Achilles tendon ruptures, or dislocation of the peroneal tendon. If the skier extends the arms to protect the face, upper-extremity injuries also may occur.
Backward Falls. Backward falls are commonly encountered when the skier slips while getting off of the ski lift. A less common mechanism is found when the skier allows the skies to get away from them or a novice skier sits down to stop. These falls tend to cause wrist fractures, buttocks contusions, coccyx injuries, ankle sprains, and anterior cruciate ligament (ACL) tears and strains. Less commonly, head injuries occur when the skier falls backwards.
Overuse Injuries
Overuse syndromes are probably the most common type of injury sustained by skiers and the least reported. These injuries are common and, because they are usually minor in severity, are often ignored by both novice and experienced skiers. Since symptoms associated with overuse injuries usually do not declare themselves until the following day, estimates on their incidence are grossly inaccurate. The most common overuse injuries are characterized by muscle discomfort and pain in the quadriceps femoris, the gastrocnemius, and the paravertebral muscles of the back (see Emerg Med Rep 1995;16:129-140 on back pain). Aggressive use of ski poles may also lead to triceps tendinitis.
Another overuse syndrome is the pressure injury to the foot. Pressure injuries to the foot occur when the skier is wearing boots that are either too small or buckled too tightly. Even with integral padding, the pressure of tight-fitting boots may decrease distal circulation and exacerbate cold-mediated injuries. Because anesthesia of the area may accompany this type of injury, the skier may not notice the problem until the boots are removed and the pressure is relieved. Subungual hematomas (skier’s toes) and injuries to the bony prominences are common signs of direct pressure trauma. In extreme cases, anesthesia may persist due to pressure-mediated peroneal nerve palsy.
The younger patient is less likely than the adult to suffer from debilitating overuse syndromes. Treatment of overuse injuries in children includes strengthening exercises, nonsteroidal anti-inflammatory drugs (NSAIDs), and application of ice. Rest and elevation until healing occurs are appropriate therapeutic maneuvers. Although frequency, duration, and intensity of exercise should be reduced, cessation of activity usually is not necessary. In most cases, the child will limit his or her activity. Unfortunately, convincing a parent who has booked a "once-in-a-lifetime" vacation to have their child avoid skiing may be difficult. Recovery is relatively quick in the usual case.
Specific Injuries of the Leg, Foot, and Ankle
Midfoot Sprains. Midfoot sprains occur when the skier digs a ski tip into the snow. The resulting hyperflexion of the foot can cause pain over the dorsum of the foot as well as swelling and tenderness. Midfoot sprains are more common with poor-fitting boots and when skiers have loosened their boot buckles.
Ankle Sprains. Contrary to what many clinicians may think, ankle sprains have become relatively uncommon injuries in downhill skiing since the introduction of high-padded boots. Overall, they now represent less than 1% of all ski injuries.32,55,56 However, when older boots and less effective release mechanisms were in common use, ankle injuries (see Emerg Med Rep 1995;16:39-48 on ankle injuries) accounted for more than 25% of all ski-related injuries.32,57
Prevention-oriented measures should be emphasized to the patient. To minimize the likelihood of injury, the buckle over the ankle joint should be fastened first. It should also be the tightest in order to keep the heel seated during downhill maneuvers.17 All other buckles can be fastened for comfort. It should be stressed that even the best ski boot available does not protect the ankle completely from severe rotational forces. Fortunately, however, dual-mode bindings release easily with rotational stress and protect the ankle from these potentially destructive forces.
Most ankle sprains associated with properly adjusted boots occur when the skier catches the inside edge of the ski and both abducts and externally rotates the ankle. Anatomically, the talus is forced against the lateral malleolus and stretches the anterior talofibular ligament. If the ligament is disrupted, an unstable ankle injury may result. Treatment depends on the severity of the sprain. Grade I sprains are treated with rest, ice to the area, compression dressings, and elevation (RICE). Weight-bearing may be resumed when pain is no longer present.
Grade II and III sprains may show evidence of instability. If the patient complains of pain without weight-bearing and has severe swelling, suspect a grade II sprain. A grade III sprain rep-resents complete ligamentous disruption, which requires fixation with plaster and, in some cases, may even necessitate surgical repair. Patients with either grade II or grade III sprains are treated with ankle immobilization and should be referred to an orthopedic surgeon for further treatment.
Lateral Malleolus Fracture. In the setting of ski-related trauma, the lateral malleolus fracture is often produced by a forward fall, particularly if the fall is combined with external rotation. The most serious injuries occur when the skier catches a ski tip and falls forward and rotates the ankle during forward movement. Most of these orthopedic injuries are isolated lateral malleolar fractures, although medial malleolus and comminuted fractures may also be seen. Not uncommonly, tibiofibular ligament sprains are be associated with the injury, and occasionally, the neck of the talus may be fractured rather than the medial malleolus. Since these fractures are easy to miss, care should be taken to look for them.
On physical examination, lateral malleolar fractures present with the usual swelling, pain, and tenderness on palpation of the fracture site. Ecchymosis may or may not be present. Deformity should suggest a displaced and unstable fracture. Fractures of the neck of the talus are characterized by tenderness on both sides of the ankle, in a location anterior to the medial and lateral malleolus.
Diagnosis of a fracture of the ankle is best made with appropriate radiographs. If a fracture of the neck of the talus is suspected, ask for a tangential view of the neck of the talus. This view is taken with the foot placed flat on the film. Treatment requires appropriate immobilization in a long leg splint, ice, elevation of the extremity, and orthopedic referral.
Achilles Tendon Rupture. This injury occurs when the young skier runs into a mogul or other object and the skis stop while the skier continues in forward motion. This produces a forward fall, which is accompanied by marked dorsiflexion of the ankle. The patient may note a tearing or popping sound as the tendon rips. This injury is primarily a problem of adult males.
Following the accident, the patient may be able to walk, have little or no pain, and be able to plantar flex the foot despite a tear of the Achilles tendon. On physical examination, however, the patient will have tenderness and swelling along the tendon sheath, with a palpable defect present about 2-3 cm proximal to the calcaneus. In some cases, the patient will have an obvious foot drop and will be unable to plantar flex the foot. Thompson’s test of the calf, which may demonstrate disruption of the Achilles tendon, is performed on a sitting patient with legs in a dangling position. When the middle third of the calf is squeezed, the foot should plantar flex. If there is no plantar flexion, suspect an Achilles tendon tear.
If an Achilles tendon tear is strongly suspected, the patient should be immobilized in a long leg splint and referred to an orthopedic surgeon. Partial tears can be treated with immobilization alone but still require evaluation by an orthopedic surgeon.
Peroneal Tendon Rupture. Although dislocation of the peroneal tendon is considered a rare injury in a typical orthopedic practice, it is considered one of the more common ski-related ankle injuries.58 Moreover, peroneal tendon rupture or dislocation is also one of the most underreported and over-looked skiing injuries.59 Dislocation can occur when the skier forcefully edges the downhill ski during a turn. At this point, because the peroneal tendon is supporting the full weight of the ski and foot, the peroneal retinaculum is subject to tears.60 If the tendon sheath alone is torn, the tendon may dislocate anteriorly.61
About 1% of all reported skiing injuries involve the peroneal tendon.60 This injury also can occur when the skier hits a mogul or some other object and continues in forward motion while the skis stop. If the skier falls forward with the foot in dorsiflexion and external rotation, the peroneal retinaculum or the peroneal tendon may be torn. Typically, the patient will describe the fall, followed by pain, swelling, ecchymosis, and tenderness that occur posterior to the lateral malleolus.
On physical examination, the physician should palpate for tenderness on the lateral and posterior aspect of the malleolus. If the peroneal tendon subluxes during dorsiflexion and external rotation, the diagnosis is confirmed. Radiographs may demonstrate little more than a small avulsion fracture of the posterior lateral malleolus, right at the attachment of the peroneal retinaculum (a fracture fragment may be demonstrated on an overrotated lateral view of the ankle).62 When detected, this subtle fracture is highly suggestive of a torn peroneal tendon or sheath.
These patients require surgical repair of the tendon and/or tendon sheath. In the emergency setting, the patient requires immobilization, ankle elevation, and referral to an orthopedic surgeon.
Tibia Fractures. Fractures of the tibia are common and dramatic reminders of the magnitude—and potential destructiveness—of forces that act on the falling skier. If a prominent rotatory component is present, a spiral fracture of the tibia and fibula may result.35 However, when the primary force is a bending motion at the top of the boot, a boot-top fracture should be suspected. If some combination of both forces is present, elements of both injuries may be found. These fractures are usually easy to diagnose with AP and lateral x-rays of the lower leg.
The incidence of these fractures has remained constant or slightly increased in frequency.63 Spiral fractures have decreased markedly since the 1960s. Since torque at the toe will release current dual-mode bindings, these are precisely the fractures that modern bindings are designed to prevent.
Children who fall and develop shin pain should be assumed to have a tibial or fibular fracture.64 In childhood, ligaments and muscles are strong and do not easily give. Special attention should be paid to the joints and epiphysis in children. Fractures at this age are more common than sprains. Isolated tibial fractures are more common in children than adults. If the child has tenderness near the joint, look for an epiphyseal fracture.
Standard care for fractures includes immobilization and referral to an orthopedic surgeon. Appropriate elevation and pain medication are essential. Open fractures should be cultured and the patient should be started on IV antibiotics.
Fibula Fractures. Most fibular fractures are found in association with fractures of the tibia. If an isolated fibular fracture is found, the emergency physician should assume there is an associated severe ankle injury until proven otherwise. If a spiral fracture is found, a major ankle injury is extremely common. A backward or lateral fall may cause a boot-top fracture of the fibula alone, but this is unusual. Radiographs of the lower leg will usually confirm presence of the injury. Boot-top fractures of the fibula are often subtle, hair-line fractures; therefore, detection of these injuries may require a magnifying glass.65
Treatment is immobilization of the ankle and lower leg. If an isolated boot-top fracture is confirmed, a compression dressing, ice, NSAIDs, elevation, and limitation of weight-bearing are adequate therapy. Weight bearing can be resumed when the patient is pain-free.
Knee Injuries. About 20% of all downhill ski injuries involve the knee.66 Although overall ski injury rates have been reduced, knee injuries have increased in the last 20 years.67 Fortunately for skiers, 90% of these knee injuries are minor.66 Most are ligament sprains, but bony fragments may be torn free. Fractures and avulsion fractures are more common in younger patients, so the emergency physician should carefully examine films of the knee looking for subtle signs of bony avulsion fractures in children with knee injuries.
Skiers may also sustain lacerations, contusions, or patellar injuries if the knee strikes other objects or the ground. Dislocations of the knee are rare.
Medial Collateral Sprains. Catching the inside edge of the ski will rotate the ski and attached foot externally, a motion that will stress the medial collateral ligament of the knee on the same side. This is a common injury in skiers and, with or without rupture of other ligaments, may account for as many as 60% of all ski-related knee injuries and 83% of all knee ligament injuries.68 If the external rotation and lateral forces are pronounced, then the anterior cruciate ligament also may be involved. Both medial and lateral collateral ligament strains may demonstrate tenderness around the involved ligament. It should be emphasized that if the ligament is completely torn, laxity of the knee with medial (varus) and lateral (valgus) knee stress will be noted on exam. Evaluation is enhanced if the knee is examined both in full extension and with 20-30° of flexion.
The acute injury should be treated with immobilization, ice, and decreased weight-bearing. Referral to an orthopedic surgeon for management of rehabilitation is appropriate.
Lateral collateral ligament sprains are far less common, probably because it is more difficult for skiers to catch an outside edge at high speed. Consequently, this injury accounts for about 4% of all knee sprains.
Anterior Cruciate Injuries. During early surveys of skiing injuries, only 7% of knee sprains involved the ACL.66 However, as a result of improved bindings and boots designed to protect the tibia, ACL injuries have rapidly increased in incidence and now account for more than 33% of all skiing injuries.35 In fact, the ACL is now the most frequently injured part of the lower extremity.69
As might be expected, this injury is produced when the skier hyperextends the knee and stresses the ACL. Typically, this mechanism of injury is encountered in the following ski-related movements:
1) When the skier catches the inside edge of the ski with the tip pointed outward and continues traveling forward.70,71 This rotates the skier’s knee internally and places valgus (lateral) stress on the knee. In this case, the medial collateral ligament and the medial meniscus may also be involved.
2) When the skier sits down to stop or regain control of forward motion. This is a common technique used by less-experienced skiers. In this case, a single ski may slide forward and the other knee flexes. The boot top forces the tibia forward, and the ACL is torn by anterior "drawer" loading.
3) When the skier lands on the tails of the skis from a jump or fall and one of the skis shoots forward. This is analogous to the novice’s stopping technique and also forces the tibia forward and stretches the ACL. Finally, "isolated" ACL injuries may also occur with these mechanisms, which tend to occur when the skier is wearing high and stiff boots.
4) In the experienced and fit skier, rearward movement of the body is counteracted by a very powerful quadriceps contracture. This may generate an anterior vector strong enough to rupture the ACL at knee flexion angles of less than 50°.6
It should be stressed the ACL tear may be a very subtle injury; consequently, the emergency physician must carefully consider an ACL whenever the patient presents with knee pain after skiing. The skier will often describe both feeling and hearing a "pop" in the knee during the injury. Immediately following the accident, a joint effusion is often found on physical examination and, if aspirated, it will usually be bloody. In fact, the presence of a rapidly evolving effusion after a fall while skiing is associated with a 75% or greater chance of an ACL sprain.72,73 An anterior "drawer" sign also may be positive. This test is performed on a supine patient. The hip is bent at a 45° angle and the knee is bent to 90°. The foot should be immobilized by sitting on it. The calf is pulled forward while the examiner palpates the anterior knee. Anterior motion of the tibia is found with an ACL injury.
There is substantial controversy regarding treatment of ACL injuries. Generally, ACL injuries are most often treated with surgical repair and may involve a protracted recovery period. Rarely, ACL injuries result in permanent disability of the skier. Emergency treatment of the injury is immobilization, ice, and relief of pain, followed by prompt orthopedic referral.
Posterior Cruciate Injuries. Only 1% of knee sprains are posterior cruciate ligament injuries.74 These injuries most frequently occur when the skier hits a fixed object with knee flexed. The same mechanism of injury may cause a patellar fracture so addition of a sunrise view is appropriate.
Meniscus Injuries. About 7% of knee injuries involve the meniscus.74 Patients with these injuries often present with complaints of intermittent locking or giving way of the joint. Pain, clicks, and effusions are also associated with these injuries. Meniscal tears may occur without any other significant knee injury. These isolated meniscal tears may occur when an aggressive skier lands during mogul skiing or jumping over small hills. In many cases, the skier doesn’t even fall. Orthopedic consultation and arthroscopy will improve diagnostic accuracy.
Patellar Injuries. Patellar injuries may be either fractures or lateral dislocation of the patella.
Patellar fractures occur when the patient leads with the knee during a collision. When a patellar fracture is suspected, a sunrise view of the knee is indicated. Treatment of these patellar fractures routinely requires immobilization of the knee. The clinician should always exclude complete disruption of the patellar ligament by having the patient lift the straightened leg off the bed. Inability to perform this motion or palpation of distracted patellar fragments usually means that the patient will require urgent surgical repair of the distracted fragments.
Lateral dislocations of the patella occur when the skier catches the inside edge of the ski and externally rotates the leg. Contraction of the quadriceps muscle forces the patella laterally and out of the femoral groove. Diagnosis and treatment of this injury are straightforward. The patella may be relocated with medial pressure and passive extension of the knee. Immobilizing the knee in a cylindrical plaster cast for four weeks has been advocated. In most cases, a knee immobilizer is sufficient.
Upper Extremity Injuries
"Skier’s Thumb." The term "skier’s thumb" has been used since 1981 to denote a tear of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb.75 This injury is often also called a gamekeeper’s thumb, particularly in older texts. The mechanism of injury of the two is somewhat different, however. The gamekeeper’s thumb is described as a chronic laxity rather than an acute injury.76 In any event, a tear of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb may be the most common injury sustained in skiing, with a reported incidence of up to 9% of all skiing injuries.76,77 On indoor (dry) training slopes, as many as 70% of all injuries sustained are to the hand and thumb.78
Various mechanisms of injury have been proposed to explain ulnar collateral ligament injuries in skiers.79 In general, however, it is agreed that these injuries occur when the skier sustains forced abduction of the thumb, which, in the context of skiing, is most likely to occur when the skier attempts to break a fall with an outstretched hand while the hand is still interlocked with the ski pole and strap. Alternatively, this injury may also occur when the skier strikes the ground or has the thumb entangled in the strap, in which case the pole, ground, or strap will push the thumb backward and outward.80 In the process, the ligament will be stretched, torn, or avulsed from the base of the first phalanx.
The patient will complain of tenderness over the ulnar collateral ligament. If the ligament has been displaced, there may be a bulge over the site of the ulnar collateral ligament. The physician should be gentle when examining sprains of the ulnar collateral ligament since this will be painful and the ligament may be further displaced by a vigorous examination.
Prudent care dictates that an x-ray of the thumb be obtained in all thumb sprains, even if they appear minor. A fracture may be associated with the sprain in up to 30% of cases.81 Surgery is required if the fracture is significantly displaced or if it involves a significant portion of the articular surface.
A significant complication results when the ulnar collateral ligament is completely torn and displaced. In some cases, the torn end may be displaced outside of the adductor aponeurosis. When the thumb heals in this position, the patient develops an instability of pinch grip. This complication is called a Stener’s lesion and must be surgically reduced.82 Unfortunately, there is no generally accepted nonsurgical method that will distinguish an undisplaced, torn ulnar collateral ligament from one that has significant displacement.83
Probably the best diagnostic technique is stress examination of the ligament. The normal amount of lateral motion of the metacarpophalangeal joint ranges from 0-30° in extension. With the joint in full flexion, there is an average of about 1° of radial deviation.83 It is important to examine the uninvolved thumb and note whether the skier has had an injury to the uninvolved thumb. To test the integrity of the ulnar collateral ligament, first stabilize the metacarpal with the thumb and index finger. Then apply radial stress to the distal phalanx. This should be checked with the thumb both flexed and fully extended. When the thumb is fully flexed, the ulnar collateral ligament is assessed. When the thumb is fully extended, the accessory collateral ligament and the volar plate are tested. The injury may be graded from 1 to 3. (See Table 2.)
| Table 2. Classification of Skier's Thumb | ||
| Injury | Classification | Findings Treatment |
| Grade 1 | Pain without instability of UCL on stress testing | Symptomatic treatment, protect the thumb from re-injury |
| Grade 2 | Instability on stress testing with a firm end point | Cast for 2-4 weeks and follow-up with orthopedic surgeon |
| Undisplaced or chip fracture | ||
| Grade 3 | Instability on stress testing with a firm end point | Immediate referral to orthopedic surgeon |
| Displaced fracture fragments | ||
| Adapted from: Rettig AC, Wright HH. Skier's thumb. Phys Sports Med 1989;17:65-75. | ||
If the patient wishes to continue skiing with a minor injury, a thumb spica splint should be molded to fit around the ski pole to prevent any further damage. The patient may remove the splint daily and use ice and range-of-motion exercises. An unstable injury should not be treated in this manner. If the patient has significant pain or swelling, then more conservative therapy is indicated.
A thumb spica cast is used for patients with either an incomplete tear or an avulsion fracture. After adequate immobilization in a thumb spica splint, these patients should be referred to an orthopedic surgeon familiar with this injury. A delay of more than three weeks before surgery increases the risk of diminished thumb function.4 Treatment of a serious (grade 2 or 3) injury is either surgical repair or immobilization in a thumb spica cast. Surgical repair is usually reserved for those with displaced fractures and completely torn ligaments (grade 3). These patients should be referred on an immediate basis to an orthopedic surgeon for further management.
Shoulder Injuries
Dislocations. The most common type of shoulder injury sustained in downhill skiing is the anterior dislocation (52%), followed by rotator cuff tears (20%).84 (See Emerg Med Rep 1995;16:95-104 on shoulder injuries.) Acromioclavicular separations account for an additional 18% of shoulder injuries.84 (See Table 3.)
| Table 3. Incidence of Shoulder Injuries in Downhill Skiing | |
| INJURY | INCIDENCE |
| Anterior dislocation | 52% |
| External rotation and abduction from the ski pole | 60% |
| Direct fall on the shoulder | 40% |
| Rotator cuff tear | 20% |
| Direct impact (AC separation) | 18% |
| Fractures | 4% |
| Adapted from: Weaver JK. Skiing-related injuries to the shoulder. Clin Orthop Rel Res 1987;216:24-29. | |
Two different mechanisms of injury account for these dislocations. Most (60%) have the arm externally rotated and forcibly abducted; the ski pole is implicated in 50% of these hyperabduction shoulder injuries.33,34 About 40% of patients fall directly onto the shoulder and sustain a dislocation from this mechanism. Ten percent of shoulder dislocations have a minimally displaced fracture of the greater tuberosity.34,35 Dislocations are best managed with immediate reduction. The patient should be carefully examined for associated fractures and upper extremity neurological problems.
Rotator Cuff Tears. Rotator cuff tears occur when the skier falls on his or her side with the arm in abduction to ward off the impact from a fall. Since partial rotator cuff tears are not always easy to diagnose, these injuries are probably underreported. The most important physical finding elicited in a rotator cuff tear is the inability to actively abduct the arm.
Clavicle Fractures. Clavicle fractures occur from direct trauma to the clavicle or from falls on the outstretched arm. Neither the diagnosis nor the treatment differ from usual management of clavicle fractures from other causes.
Acromioclavicular (AC) Separation. Patients who sustain an AC separation universally describe a fall directly on the point of the shoulder. Physical findings and treatment of AC separations are unchanged from any other mechanism that produces these injuries. Fractures of the area around the shoulders are relatively rare. The most common ski fracture of the shoulder is a fracture of the greater tuberosity, usually minimally displaced. This may occur when the patient falls on the elbow and the force is directly transmitted to the shoulder. Fractures of the clavicle may occur from direct trauma to the area.
Cross-Country Skiing
There is little literature specific to the pediatric or adolescent cross-country skier. In general, Nordic, or cross-country skiing can be performed wherever there is snow, and may be done in quite isolated areas.
In spite of the growing interest in Nordic skiing, there is much less documentation in the literature about the injuries that can be sustained by the cross-country skier. There are several reasons for this paucity of literature.
It is suspected that cross-country skiers are injured less frequently than their alpine counterparts, and that these injuries are often less severe. Unfortunately if underreporting is a problem when the alpine skier is injured at the resort, it is far worse for injuries resulting from cross-country skiing. Injured skiers, far from centralized help, will be taken either to the nearest medical facility or evacuated to home.
Cross-country skiers are often superior athletes. Nordic skiing is "real work." Caloric expenditures for cross-country skiers range from 0.098 Kcal/min/kg for leisurely skiing on level ground to 0.274 Kcal/min/kg for maximal uphill skiing on hard snow.85 This corresponds to an energy expenditure of 446-1244 Kcal per hour for the standard 70 kg body weight.86 Athletes at this level of experience and conditioning often will not seek medical care for minor injuries.
Risk Factors
In the few reports that are available, it seems that cross-country skiers are injured at a rate about one-tenth that of the downhill skier. Generally, more gentle slopes are used by Nordic skiers than are used by alpine skiers. Cross-country skiers have an increased risk for fractures but also have decreased risk for lacerations and collisions. Injuries from Nordic skiing are becoming more severe than in the past; partly due to the popularity of faster, more rigid skis, and heel fixation devices that give more edge control.87 In many ways, the modern Nordic skier has merely reverted to alpine skiing as it was before the extensive development of safer equipment. Heel fixation devices, lower boots, and more rigid skis are equipment similar to that used by downhill skiers 20-30 years ago, yet permit faster speeds than these older skiers were able to achieve.
Unsurprisingly, 88% of all acute injuries to cross-country skiers occur on downhill terrain.88 Telemark skiing, a downhill variant of cross-country skiing, brings the skier full circle to downhill skiing with older-style bindings and lower boots. Knee injuries sustained by telemark skiers are less severe than those found in alpine skiers, with less duration of disability and lower surgical rates.89
Cold injuries comprise about 20% of reported injuries.90 This is far higher than that found in alpine skiers, and is probably due to the remote terrain sought by cross-country skiers. Remote terrain, coupled with changes in weather, may spell disaster for an unprepared cross-country skier.
To all of these troubles must be added the problem of evacuation after an injury. Since many cross-country skiers seek remote areas for their avocation, this is often a major problem. These skiers, unlike those found in alpine resorts, do not have the services of a paid or highly trained volunteer ski patrol for evacuation and care.
Common Types of Overuse Injuries
Most cross-country skiing injuries are due to overuse.91 In elite cross-country skier-athletes, about 75% of injuries are overuse injuries. These occur in two distinct patterns; those due to a skating stride and those due to the classic cross-country stride.
Diagonal Stride Overuse Injuries. With the classic stride (also called the diagonal stride), the most common overuse syndromes are shin splints, Achilles tendinitis, and low back pain.35 Since this is the most common stride used by recreational skiers, these injuries are more often found in the less conditioned skier.
Skating Overuse Injuries. A "freestyle" or skating stride is often used by racing skiers. Freestyle skiers or those using a skating technique will have more trouble with the adductors and internal rotators of the hip.92,93 The anterior and medial compartment muscles of the lower leg also will be stressed.93 Longer ski poles put additional stress on the wrist and carpal tunnel, increasing the incidence of extensor tendinitis and carpal tunnel syndrome.
Skier’s Toe. Increased stress to the flexor hallucis longus muscle during the push-off part of the skating technique (dorsiflexion of foot) can cause a stress injury. This injury of the flexor hallucis longus muscle is termed "skier’s toe."
Treatment of Overuse Injuries. Since most of these injuries will neither be reported nor be presented for formal medical attention, it is obvious that treatment is simple. Reduce the stress by decreasing the intensity or duration of the exercise. Apply ice to the area for 10-20 minutes after the exercise. Stretching and strengthening exercises are often helpful. NSAIDs will both reduce the inflammation and relieve the pain in acute injuries.
Lower Extremity Injuries
In cross-country skiing, the knee remains the most often injured joint (about 31% of injuries in one large study).88 Since the ankle remains free, the number of anterior cruciate ligament injuries is lower but the medial collateral ligament is more frequently injured.94
Heel fixation with cross-country bindings increases the number of twisting, lower extremity injuries. With these devices, sprains of the ankle are common. Fortunately, cross-country skiing is not associated with the high incidence of ankle fractures described with older skiing equipment. This may change as Telemark skiing gains popularity. The ankle and lower leg are more frequently injured by the stresses of Nordic skiing than in alpine skiing. This may be due to the lower boots of the cross-country skier and subsequent lesser protection from ankle and lower leg injuries.
Upper Extremity Injuries
Upper extremity injuries associated with cross-country skiing can be divided into overuse injuries and injuries due to falls.
Upper Extremity Overuse Injuries. As noted earlier, cross-country skiers have an increased incidence of both extensor tendinitis of the wrist and carpal tunnel syndrome. This is thought to be due to the high position of the wrists when using properly adjusted Nordic ski poles. Ulnar collateral ligament sprains of the thumb occur in the same manner as for alpine skiers.42 In cross-country skiers as in downhill skiers, it is the single most common hand injury. Diagnosis and treatment of this problem has been already discussed.
Falls. The most common shoulder injury due to cross-country skiing accidents is an anterior shoulder dislocation. Shoulder dislocations are usually caused by catching the arm or pole in underbrush as the skier goes rapidly downhill. The arm is then forced into abduction and external rotation with resultant dislocation.
Treatment of this injury in the field is a dilemma. Most providers are simply not trained in how to reduce a dislocated shoulder. On the other hand, the injured skier, in the remote wilderness is a distinct liability. That liability can be reduced markedly by manipulation of the shoulder. Probably a single attempt in the field by an appropriately trained provider is reasonable therapy. If this is not successful, repeated attempts without x-ray are unlikely to be beneficial. The patient should be transported to a medical facility.
AC separations are usually caused by direct trauma and are the second major shoulder injury found in the Nordic skier. Only rarely is an AC separation of such magnitude as to require any therapy beyond a sling for comfort.
Ski Jumping
Although ski jumping is quite spectacular and gives the appearance of being very dangerous, it has a surprisingly low injury rate.95 Injury rates for non-World Cup competitions and World Cup competitions were 4.3 and 1.2 injuries per 1000 skier days, respectively.43 Ski jumpers tend to be young, aggressively trained athletes in outstanding physical condition. The sport is rigidly controlled, and those who have not been properly trained essentially are not allowed on the jump. These well-supervised conditions result in exceptionally low injury rates. Moreover, the jump is controlled so that the skier lands on the steep downhill portion of the hill. As long as the jumper lands in this part of the hill, the kinetic energy can be dissipated by sliding. On the other hand, if the fall is very long or very short, the jumper can be badly injured by a failed jump.
Like all falls, damage may be internal, usually to abdominal organs, or to the extremities. The most common injuries are contusions, abrasions, and dislocations, primarily of the shoulder. Fractures account for about 15% of the total injuries, most of which involve the upper extremity injuries.95 Only 10% of ski jump injuries involve abdominal organ damage due to the impact.95
Summary
Winter sports are associated with a distinct spectrum of injuries and are a significant cause of morbidity and potential mortality in youngsters. Recognizing specific mechanisms of injury and performing appropriate radiographic studies will speed diagnosis of these injuries. In general, treatment is similar to that required for fractures, strains, and ligamentous tears seen in non-skiing injuries.
Finally, prevention of these injuries is possible if already developed equipment is used appropriately. Requesting that youngsters stick to marked and groomed trails will prevent a large number of collisions and falls. Making sure that intoxicants are kept away from children and that children are not encouraged to take "one last run" in the afternoon will also eliminate easily preventable accidents.
Ensuring that sleds and toboggans have a stump, tree, and rock-free course and appropriate "run-off" areas at the end of the hill will reduce the most common injuries for these sports. The proven benefit of helmets in reduction of mortality and morbidity of bicycle accidents in children should prompt use of this protection in snow sports.
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Physician CME Questions
9. Which of the following is associated with higher injury rates in skiers?
A. Skiing in the morning
B. Powder snow
C. Alcohol
D. Experience and athletic proficiency
E. Use of safety equipment
10. Which of the following injuries are more common in snowboarders than skiers?
A. Foot fractures
B. Tibia fractures
C. Distal radius fractures
D. Knee fractures
E. Hip fractures
11. The injury commonly seen in skiers is:
A. spiral fracture of the tibia.
B. anterior dislocation of the shoulder.
C. knee ligament strains.
D. patellar dislocation.
E. peroneal tendon dislocation.
12. When do most ski injuries occur?
A. Early in the morning (i.e., dawn patrol)
B. Night skiing
C. About dinner time
D. Just after breakfast
E. Last run of the day
13. Snowboarders are more likely to get a skier’s thumb fracture.
A. True
B. False
14. The most common type of shoulder injuiry sustained in downhill skiing is:
A. Rotator cuff tear
B. Clavicle fracture
C. AC separation
D. Anterior shoulder dislocation
E. Posterior shoulder dislocation
15. Overuse injuries make up about what percentage of reported cross-country injuries?
A. 10%
B. 20%
C. 30%
D. 40%
E. 75%
16. The most common injury to a snowboarder is:
A. hyperdorsiflexion of the ankle as the rider falls forward.
B. torsion injuries to knee and ankle.
C. direct impact injuries to the shoulder, elbow, wrist, or hand.
D. inversion and eversion ankle injuries.
E. none of the above.
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