Ski and Snowboard

Preventing Ski

Snowboarder Injuries

Both skiing and snowboarding continue to gain popularity. Both sports have participants reaching high speeds. Injuries usually are the result of falls, collisions, or overuse. Loose heavy snow can entangle skis leading to knee and ankle injuries. Icy conditions lead to more falls and upper extremity injuries. Unstable snow masses or cornices can precipitate avalanches. Many injuries follow specific patterns and can be anticipated and prevented. The purpose of this pamphlet is to show skiers how to avoid preventable injuries.

Snow and Injury

Since the 1970's, ski injuries have decreased by 50% and now are estimated at 2-4 injuries per 1000 ski days. This improvement is due to advances in ski equipment.

Releasing binding systems and plastic shelled boots have decreased lower limb fractures.

Head injuries, along with shoulder and thumb injuries have remained the same. ACL knee tears have increased 240%, which may be due to the improvement in boots and binding systems.

Traumatic deaths either from avalanche or high-speed collision are 0.75 per million ski days.

Knee Injuries

Knee injuries account for 30-40% of all injuries in alpine skiing. Usually the Anterior Cruciate Ligament (ACL), Medial Collateral Ligament (MCL), or Medial Menicus are involved. Mechanism of injury usually involves a twisting force to a weight-bearing knee.

With most injuries some degree of swelling will develop in the first 24 hrs. after injury is highly suggestive of a ligamentous injury. An accurate history of the mechanism of injury will help characterize the injury.

MCL Injuries

Torn MCLs are the most common injury in skiing (20-25% of all injuries). Typically the skier is a beginner or low intermediate and the injury occurs in the “snowplow” position correctly and help stay in control. A valgus load is applied to the knee joint as a result of a fall, skis crossing or the snowplow stance widening.

In more advanced skiers, this injury occurs when they catch an edge.

Symptoms include tenderness over medial joint line and pain on weight bearing. Examination of the joint should include valgus stress with the knee in 30 o of flexion.

ACL Injuries

ACL tears make up 10-15% of all ski injuries.

Several ski mechanisms have been identified:

The mechanism of injury most commonly determined is the “ phantom foot ” fall. This occurs when the tail of the downhill ski and the stiff back of the ski boot act as a lever to apply a bending and twisting force across the knee of the down hill knee.

Technique and Injury

Certain body position also correlate with the Phantom Foot Fall:

• Uphill arm is back.

• Skier is off balance to the rear.

• Hips below the knees.

• Bodyweight is on inside edge of downhill ski tail.

• Uphill ski is unweighted.

• Upper body is facing the downhill ski.

Phantom Foot Fall Boot Induced Mechanism

When all 6 components are present an ACL injury is felt to be extremely likely. The patient may give a history of this position when their injury occurred along with a pop or snap heard and felt.

Phantom foot fall is likely to happen in the following specific scenarios:

Attempting to get up whilst still moving after a fall.

Attempting a recovery from an off-balance position.

Attempting to sit down after losing control.

The boot-induced mechanism occurs when a skier becomes off balance to the rear whilst attempting a jump. Instinctively, the skier's leg fully extends. As a result the skier lands on the tails of the ski, which force the back of the ski boot against the calf, which drives the tibia out from under the femur and the ACL tears.

A third mechanism is now recognized whereby a stationary skier is hit from behind on the lower leg (often by a snowboarder)-this again applies sudden extreme pressure on the back of the calf, forcing the tibia forwards with resultant ACL damage.

Meniscus Injuries

Occur in approximately 5-10% of all ski injuries. May be difficult to diagnose acutely but should be suspected. The Triad of Donohue occurs when the skier report 3 subsequent pops as the MCL, ACL and Medial Meniscus are torn in sequence.

An inability to straighten the leg, sensation that something is inside the joint, or bucking or instability of the knee are all very suspicious for medial meniscus tears.

On the field treatment for knee injuries:

PRICES routine: Protection Rest Ice (or in this case snow) Elevation Stabilization. A splint for the knee can be made using adding and support (Robert Jones Dressing) out of available materials.

Tibial Plateau Fractures

1% of all ski injuries. Usually affect older, more experienced skiers. Mechanism of injury: Severe valgus stress often with compressive forces (the result of a bad landing after a jump).

Symptoms: There may be bruising and/or abrasions over the lateral joint with associated valgus deformity of the knee. Usually evident on plain radiographs and sometimes tomography is used. CT scanning may be required to determine the exact degree of displacement and area of articular surface involved. If the fracture is displaced or depressed by more than 4mm, then surgery is advised. There is often damage to other soft tissue structures-particularly the ACL and MCL-which requires surgical intervention.

Upper Extremity Injuries

In skiing, four major types of injuries occur: dislocated shoulder, fractured humerus, injured thumb, and injured wrists.

Shoulder Dislocation

Dislocated shoulders usually occur after a fall onto an outstretched hand. Majority of these are anterior dislocations from this type of mechanism although in high-speed injuries, posterior dislocation could occur.

Symptoms are usually noticeable with deformity and loss of the normal contour.

Management in field: This depends on the comfort level of the clinician at the scene. In general it is best to involve minimal intervention.

Having a patient prone with a lightweight attached to their hand may facilitate reduction, as all that is necessary is to overcome muscle spasticity. It may be easier to reduce in the field but this may be delayed if there is a suspicion of fracture.

Other methods of reduction: Axial traction with counter traction with a sling around the axilla by an assistant, the Hippocratic technique and the Scapular reduction techniques may be tried. After reduction place the arm in a sling to maintain reduction and comfort.

Fractured Humerus

This usually develops after a direct blow or fall onto an outstretched hand. Palpation directly along the suspected fracture will suggest a fracture. Sling and swathe the arm until X-rays are available. Suspect an open fracture and when feasible expose the arm to determine that an open fracture has not occurred.

Thumb Injuries

Skiers Thumb is very common. It happens as a ski pole is caught between the thumb and index finger levering the thumb joints. Also when a skier falls with a pole grasped in their hand they will open their hand and catch their full weight on their outstretched thumb tearing the ulnar collateral ligament at the MCP joint. Fractures may also occur with avulsed fragments that complicate therapy. X-rays are helpful in ruling out a fracture first.

The thumb can carefully be examined after X-ray with stabilization on the first metacarpal and applying valgus load to the metacarpal phalangeal joints.

Symptoms: Tenderness is localized to the ulnar collateral ligament. Splint in a safe position around an ace bandage until definitive examination. Once the diagnosis is known athletic taping of low-grade strains or thumb spica casting of 2-3 o tears.

Head Injuries

Most skiing deaths involve head injuries after a high-speed collision. Usually head injuries are just concussions but with significant speed and force. Neck fractures also occur and should be suspected. Neck and spinal immobilizations should be done for all unconscious ski trauma victims.

Snowboarders

Wrist injuries are very common for snowboarders.

Falling onto an outstretched hand is the usual mechanism and with the promotion of wrist guards, this has become less common.

Protective Devices

Helmets to prevent head injury are promoted in the ski industry. Wrist guards for snowboarders and wrist/elbow attachments for ski poles are make wrist and thumb injuries less common.

Prevention of Ski Injuries

In general, always aim to keep arms forward, feet together and hands over skis. An ACL Awareness program devised by Dr. Ettinger has reduced the incidence of ACL injuries by 62%.