Ski and Snowboard Injuries

 

August 2021

David Tullis, MD

Intermountain Park City Ski Clinics

 

SKI and SNOWBOARD INJURIES

 

Introduction:

This is not meant to be an exhaustive or all-inclusive list of every type of injury presents to the ski clinic. A lot can happen at the intersection of snow, speed, trees, and thousands of snow riders with long objects strapped to their feet, all within a shared space. But this is meant to address some of the more common presenting injuries, as well as some that are unique to this setting.

 

UPPER EXTREMITY INJURIES:

 

SHOULDER:

 

Clavicle Fractures:

1.       Mechanism:

a.       Fall onto the shoulder 87%

b.       Direct impact over clavicle 7%

c.       FOOSH 6%

d.       9% of clavicle fractures have additional fractures, most commonly rib

2.       Allman Classification:

a.       Middle third 80% (group I)

                                                                           i.      SCM often pulls up on the proximal aspect, while the weight of the arm pulls the distal aspect down (inferior displacement of the distal fragment)

b.       Distal third 15% (group II)

                                                                           i.      Often present like AC separation

c.       Proximal third 5% (group III)

3.       Treatment for clavicle fractures of the middle third

a.       Conservative

                                                                           i.      Sling shown to be equal to figure of 8, and with more comfort and fewer skin problems

                                                                         ii.      Immobilization generally 4-6 weeks

                                                                       iii.      Encourage active ROM of elbow, wrist, hand/fingers

b.       Operative

                                                                           i.      Meta-Analysis does not show clinically significant differences in function or pain at one year

                                                                         ii.      When indicated, surgery can be done within 2 weeks from date of injury

                                                                       iii.      Indications for operative treatment

1.       Definitive indications:

a.       Neuromuscular compromise

b.       Respiratory compromise

c.       Tenting of the skin (potential of progression to open fracture)

d.       Open fracture (suspect open fracture if puncture to the skin)

2.       Controversial indications:

a.       “Complete displacement” (Displaced by more than one bone width)

b.       Comminution (Z deformity)

c.       Shortening (more that 1-2 cm)

                                                                       iv.      Key point: get familiar with your orthopedic surgeons and their preferences. In Park City, many are choosing to be a little more aggressive with surgery to get back to activity quicker and to have earlier improvement in pain.

 

 

 

 

 

 

Acromioclavicular Injuries:

1.       Mechanism

a.       Most commonly direct fall onto shoulder with arm adducted

2.       Anatomy    

a.       Acromioclavicular ligament (AC)

                                                                           i.      Normal distance in adult 1-3 mm

                                                                         ii.      Can be wider in youth

b.       Coracoclavicluar ligaments (CC)

                                                                           i.      Normal distance 11-13 mm

 

 

3.       Grading (Rockwood Classification)

a.       Type I: sprain to AC ligament, AC joint intact

b.       Type II: torn AC ligament, CC ligament intact, AC joint subluxed

c.       Type III: torn AC and CC ligament, AC complete joint dislocation

                                                                           i.      On radiograph, measure distance between clavicle and coracoid process (up to 13 mm normal) or compare with contralateral CC distance (25% to 100% increase greater than normal side).

d.       Type IV: distal clavicle displaced posteriorly (into trapezius)

                                                                           i.      Sometimes these can appear almost normal on AP view

                                                                         ii.      Can confirm with axillary view or CT scan

e.       Type V: extreme superior displacement of the distal clavicle

                                                                           i.      CC space 100-300% displaced compared to contralateral

                                                                         ii.      CC distance usually more than 22 mm

                                                                       iii.      Similar to type III but more displacement

f.        Type VI: inferior displacement of the distal clavicle

                                                                           i.      subacromial or subcoracoid

4.       Treatment

a.       Type I:

                                                                           i.       Sling if needed, mobilize as early as tolerated

b.       Type II:

                                                                           i.      Sling for 1-2 weeks, gentle ROM as tolerated

c.       Type III:

                                                                           i.      Sling for 2-3 weeks

                                                                         ii.      Majority will do well without surgery

                                                                       iii.      Generally wait 6 weeks before deciding to do surgery

                                                                       iv.      Outcomes at one year found no difference in operative vs. nonoperative, and increased complications in operative group  

d.       Types IV-VI

                                                                           i.      More severe

                                                                         ii.      Type IV and VI need most urgent referral to ortho and generally treated with open reduction

                                                                       iii.      Type V sometimes treated like type III

                                                                       iv.      Type V may need urgent referral if significant tenting of skin or other neurovascular compromise

               

 

 

 

 

Shoulder Dislocations:

1.       Types:

a.       Anterior 95-97%

b.       Posterior 2-4%

c.       Inferior (luxatio erecta) 0.5%

2.       Anatomical considerations

a.       The glenohumeral joint is very mobile and inherently unstable

b.       Very shallow, with little articulation between humerus and glenoid

c.       Labrum, ring-like cartilage makes it a little deeper

d.       Joint capsule, and inferior-anterior thickening called the inferior

                                                               i.      glenohumeral ligament

e.       Rotator cuff muscles pull the humeral head into the glenoid

3.       Mechanisms

a.       ANTERIOR: Vulnerable position is the abduction and external rotation (quarterback   position)

                                                               i.      Snowboarders often fall, reach out with arm or elbow, forced abduction and external rotation of humerus

b.       POSTERIOR: Often a direct blow to the anterior shoulder, forcing humeral head posteriorly. Also can happen with electrocution.

4.       Evaluation:

a.       Arm often slightly abducted and externally rotated

b.       Neuromuscular exam, particularly of axillary nerve (numbness in “shoulder badge” distribution, sometimes deltoid weakness—but hard to assess due to pain and immobility)

5.       Differentiating shoulder dislocation from AC separation on exam

a.       Look closely at the deformity at the shoulder

                                                               i.      Squaring and loss of the normal rounding of the shoulder at the distal aspect of the acromion=dislocation

                                                             ii.      In AC separations, the deformity more proximally (medially), at the distal aspect of clavicle

                                                           iii.      Dislocation generally unable to move at the shoulder, or have severe pain with movement, including internal/external rotation

                                                           iv.      With AC separation, pain with abduction and crossover, but generally able to    internally and externally rotate some without much pain

6.       Imaging 

a.       Generally we get an AP scout view first

                                                               i.      Imaging helps confirm the diagnosis

                                                             ii.       Dislocation with accompanying proximal humeral fx are often more difficult to reduce, and more painful (may increase need for sedation/ER)

                                                           iii.      If dx not clear, scapular Y view can be helpful, or axillary view, or even CT

                                                           iv.      Posterior dislocations may not be clear on AP X-ray. 4 out of the 5 that I have seen were read as negative or equivocal by the radiologist. Axillary view x-ray helpful.

                                                             v.      Post-reduction films

1.       Confirm reduction

2.       Look for bony fractures:

1. Hill-Sachs: humeral head impression

2. Bankart: inferior aspect of glenoid

 

SHOULDER REDUCTION TECHNIQUES:

·         Desired approach would be relatively comfortable and relatively quick, obviating the need for sedation, or pain meds that increase the risks as well as the time that the patient will be in the clinic

·         Important to help the patient to feel comfortable and relaxed by adequately explaining what will be done and avoiding abrupt movements

·         Vector forces of the rotator cuff muscles will naturally pull the humeral head back into the glenoid as the humeral head is disengaged from where it is stuck under the glenoid

·         Way too many names (Snowbird, Spaso, Cunningham, Scapular Manipulation, Milch, Stimson, Traction-Countertraction, External Rotatoin Technique, etc.)

·         Most of the techniques share many of the same components

·         More important to understand the movements and mechanics of how to reapproximate the humeral head to the glenoid:

 

1.       Traction (or could also be described as distraction, which is not just pulling on the humerus, but separating the humerus from the glenoid)

2.       External rotation

3.       Abduction

4.       Scapular manipulation (pushing the inferior aspect of the scapula towards the spine)

5.       Patient engagement and posture (let the pt help you, have pt sit up straight, push chest out and bring shoulders back)

 

 

MY APPROACH: Modified Snowbird technique

1.       Pt sitting on chair

2.       With the elbow flexed at 90 degrees, a loop used over proximal forearm to step into for downward traction (gradual)

a.       Or alternatively can provide the downward traction manually by pressing down on the proximal forearm with hand

3.       Ask pt to sit up and maintain posture, take a breath in and pull shoulders back

4.       Second person is behind patient, helping to maintain the posture of the patient, and applying pressure to the scapula in a medial direction (which rotates the glenoid to point in an inferior direction and towards the humeral head, which is generally anterior and inferior)

5.       After downward traction (if not yet reduced), begin external rotation (sometimes will do gentle alternating internal and external rotation)

6.       If still not in place, proceed to abduction (Miltch Technique). Bring arm into full abduction, sometimes applying pressure with thumbs over anterior humeral head, then bring arm across the body and down, leaving the arm in a sling position.

7.       Stop and look and the shape of the shoulder. Sometimes the reduction has occurred without a noticeable “clunk”

8.       Ability of the pt to internally or externally rotate, or touch the opposite shoulder with the hand of the affected side suggests adequate reduction

 

Other approaches I commonly use (good to have a few options):

·         Spaso

·         Cunningham

·         Scapular manipulation

 

Analgesia, anesthesia, sedation:

1.       Most of the time the reduction can be done so quickly, and the pt feels so much better afterwards, that I generally do not start with opioids or local anesthesia

2.       Reduction can usually be completed within 1-2 minutes, and prior to medicine taking any effect

3.       When reductions are more complicated or taking longer, or if pt is having a difficult time relaxing, an intraarticular injection can be helpful

a.       Clean skin with chlorhexidine or betadine

b.       Lateral approach, approximately 1 cm below the acromion

c.       Anesthetize skin first with 27 g needle

d.       Inject 20 mL of 1% lidocaine, 18 or 20 g needle

                                                                           i.      Direct needle medially and inferiorly

                                                                         ii.      Depth of approx. 2.5-3 cm

                                                                       iii.      Ultrasound guidance helpful to confirm intraarticular placement

4.       We do not have adequate monitoring equipment to do procedural sedation, which is often done with propofol or ketamine in the ED setting

 

Follow-up care:

1.       Probability of future or recurrent dislocations:

a.       50-90% of those under 20

b.       5-10% in those over 40

2.       Sling for 3 weeks for those under 30

3.       Sling for 1 week and earlier mobilization for those over 30

a.       Gentle pendulum movement okay during immobilization phase to prevent frozen shoulder

4.       Early operative management for:

a.       Irreducible dislocations

b.       Displaced greater tuberosity fractures

c.       Bony Bankart of 20% or more

d.       Soft tissue Bankart in young, active patients

5.       Later surgery for chronic instability, or recurrent dislocations

6.       High risk of rotator cuff tear in >40 patient population. Follow-up with ortho in 2 weeks to determine status of rotator cuff

7.       Evidence to sling in 10 degrees of external rotation has been lacking

8.       We generally refer all patients for follow-up with ortho for follow-up

 

Proximal Humeral Fractures:

1.       Neer classification

a.       Based on 4 anatomical segments

                                                               i.      Greater tuberosity

                                                             ii.      Lesser tuberosity

                                                           iii.      Articular surface

                                                           iv.      Shaft

b.       One-part fractures: no fragments are displaced 

c.       Two-part fractures: one displaced fragment 

d.       Three-part fractures: two displaced fragments, but humeral head in contact with glenoid

e.       Four-part fractures: three or more displaced fragments, and dislocation of articular surface from glenoid f.

f.        considered displaced >1 cm, or >45 degrees of angulation)

2.       Important to know which to determine which are operative vs. non-operative fractures:

a.       OPERATIVE:

                                                               i.      Two-part or more fractures should get ortho referral

                                                             ii.      Surgical neck fx with greater than 45 degrees angulation

                                                           iii.      Greater tuberosity fx with more than 5 mm of displacement

1.       Rotator cuff muscles pull fragment superiorly and posteriorly

b.       NON-OPERATIVE:

                                                               i.      One-part fractures

                                                             ii.      Approximately 80% of proximal humeral fractures

 

 

 

WRIST:

 

FOOSH! (fall on outstretched hand)

 

Distal radius fractures:

1.       Buckle fracture very common in younger patients

a.       Recent study showed excellent sensitivity and specificity using ultrasound to diagnose buckle fractures

b.       Can treat with volar splint or even prefabricated Velcro splint

c.       Require shorter duration of immobilization that other radius fractures, often approximately 4 weeks

2.       Colle’s (dorsal angulation)

3.       Smith’s (volar angulation)—generally unstable (even after adequate reduction) and often need ORIF

4.       Frequently also have ulnar styloid fracture

5.       Complicating factors in distal radius fractures, increase chance of needing ORIF:

a.       Comminution

b.       Intraarticular

c.       Displacement and angulation     

6.       Hematoma block

a.       Used to perform in closed reduction

b.       Not as effective when both radius and ulna fractured, or must do a second block on the ulnar fx

c.       Can use ultrasound guidance

d.       Sterile technique—chlorhexidine or betadine

e.       c. Approx 7-10 mL of lidocaine

                                                               i.      I generally use 27 gauge needle first, then use 18 gauge needle

                                                             ii.      Can alternatively use a 22 gauge needle for both, but more difficult to aspirate blood from hematoma

f.        Attempt to aspirate some blood from the hematoma

g.       Be patient, wait for at least 10 or more minutes, can hang in finger traps

h.       After reduction, generally placed in a sugar tong splint and post-reduction films obtained

                                                               i.      Planning to implement ultrasound to look at alignment to confirm adequate reduction prior to splinting

 

 

Scaphoid fractures:

1.       Anatomic snuff box, but also palpate volar aspect

2.       If tender, even with negative radiograph, splint and follow up in 10-14 days

3.       False negative rate of initial plain X-ray 20%

4.       Thumb spica splint

5.       Can get MRI if immediate diagnosis needed

6.       Risk of avascular necrosis and non-union due to tenuous blood supply

 

 

 

HAND:

 

SKIER’S THUMB:

1.       Ulnar collateral ligament injury

a.       Mechanism: landing on ski pole, forced abduction of MCP joint of thumb

b.       Tender over ulnar aspect of thumb MCP joint

c.       Valgus stress with laxity of MCP joint (best done with MCP flexed at about 45 degrees to isolate the UCL ligament)

                                                               i.      Compare with contralateral thumb

                                                             ii.      Safe to perform valgus stress prior to xray, but may choose to get xray first

                                                           iii.      Was previously thought to potentially cause a Stener lesion, but unproven

d.       Sometimes with bony avulsion, usually of the proximal phalynx

e.       MRI very sensitive if unclear

f.        Conservative management:

                                                               i.      If partial tear suspected, immobilize for at least 3 weeks, after which gentle passive exercise can be initiated. Generally splint when not doing exercises for another 3 weeks

g.       We generally place in a prefabricated thumb spica splint, or make an custom orthoglass splint in the ski clinic

h.       Occupational therapy/Hand therapy can make a plastic, heat-molded splint that immobilized the MCP of the thumb, but not the wrist, which is much more tolerable to the pt over approximately 6 or more weeks of immobilization

i.         Possible surgical indications:

                                                               i.      Stener Lesion: the aponeurosis of the adductor pollicis becomes trapped between the ends of the torn UCL (can look for free movement of aponeurosis on ultrasound)

                                                             ii.      Avulsion fracture with more than 2 mm or more than 10-20% of articulation surface

                                                           iii.      Complete tear of UCL

j.         We generally refer to hand specialist to follow patients through this process

 

 

 

 

 

 

 

LOWER EXTERMITY INJURIES:

 

KNEE:

 

ACL

1.       The ACL is the primary knee stabilizer, and prevents anterior translation of the tibia in relation to the femur

2.       Much more common in skiers, as opposed to snowboarders

3.        “The Story.”    Key phrases that are often reported by the patient:

·         Making a turn

·         Twisting to the knee

·         Binding did not release, or released late

·         Felt or heard a “pop”

·         Felt pain immediately, but after sitting for a few minutes, pain decreased and felt like knee might be okay

o   With isolated ACL tear, there is often not a lot of pain

o   With other associated injuries, such as meniscus or MCL, more painful typically

·         Then tried to ambulate, or tried to put ski into binding, or tried to ski again, and felt instability

·         Often say that it felt like their knee “dislocated,” or that they can’t trust the knee

·         “Double fist sign”

4.       Long lever arm of the ski produces a lot of torque

a.       Try to tear a licorice rope with direct traction, and then try again using some concurrent rotation—much easier to tear with a twisting motion

5.       Rigid boot connected to ski when binding does not release keeps tibia upright, while pt is falling backwards, which forces the tibia to translate anteriorly in relation to the femur, which is moving posteriorly

6.       Effusion takes some time to develop, so often not immediately noted upon arrival in ski clinic, but more noticeable over next few hours and by the next day

a.       Tibial plateau fractures by contrast generally have a very brisk and large knee effusion

b.       Tibial plateau fractures are also much more painful, especially with movement, in comparison to ACL tears

7.       Exam

a.       Look for effusion/hemarthrosis

b.       Lachman (more sensitive than anterior drawer)

                                                   i.      Important to compare with contralateral knee

                                                 ii.      Looking for distinct endpoint

                                               iii.      Easier to perform when hip is slightly abducted and leg slightly externally rotated, which disengages the quadriceps muscles

                                               iv.      Sometimes easier to see translation better from an oblique view, rather than looking straight down at the knee

c.       Lelli’s test (lever test)

                                                   i.      Place fist under proximal tibia, and press down on distal femur

                                                 ii.      Positive test if heel of foot does not raise off of the table

                                               iii.      In my experience, less sensitive, but very specific

d.       Pivot shift—not generally helpful in the acute setting, as it can be very painful and anxiety provoking to the patient

8.       Associated injuries can include meniscus, MCL, LCL, joint capsule, subchondral bone, articular cartilage

9.       Imaging

a.       X-ray

                                                   i.      Segond fracture

1.       Essentially pathognomonic for ACL tear

2.       Avulsion fracture from the “anterior lateral ligament” (ALL), also known as the “lateral capsular ligament”

3.       After the ACL is torn, the anterior lateral aspect of the joint capsule is stressed as it is all that is keeping the tibia from translating further antiorly, and can avulse a bony fragment from the proximal tibia on the lateral aspect, along the joint line

                                                 ii.      Avulsion of the anterior tibial spine (more common in kids)

                                               iii.      Lateral femoral condyle notch sign—indent into lateral femoral condyle suggestive of ACL tear

1.       Often on MRI there is more evidence of a “kissing lesion,” or bone bruising or mild fracture where femoral condyle and tibial plateau impact

b.       MRI—definitive imaging to confirm ACL and associated injuries

10.   Immediate treatment

a.       Generally placed in hinged knee brace, and can often ambulate without crutches in isolated ACL tears (less atrophy of muscles compared to straight leg immobizer)

b.       Often apply ace wrap under knee brace for comfort

c.       If patient feels too unstable, crutches for first few days as needed

d.       Straight leg immobilizer if extremely unstable or anxious

e.       Follow-up with ortho

                                                   i.      Most younger, active patients have surgical repair

                                                 ii.      Rehab with a knowledgeable physical therapist also an option, especially for older patients and those with less demanding activities

 

MCL

1.       Valgus stress test, causing pain and/or laxity

a.       Pain but no laxity likely grade I or II

b.       Grade III (complete tear) often not painful, but significant laxity

2.       Hinged knee brace and ace wrap

3.       Usually nonsurgical management, unless other concurrent injuries

 

Tibial Plateau Fracture

1.       Mechanism: varus or valgus load, with or without axial load

2.       Soft tissue injuries often also involved (meniscus, ligaments)

3.       Present with significant pain with movement of the knee, and often have a very large hemarthrosis/effusion

4.       Risk for compartment syndrome

5.       Imaging

a.       X-ray with 4 views (adding the two oblique views to the standard AP and lateral) helpful to identify the fracture and measure the degree of depression

b.       CT scan is generally indicated to better assess for comminution, articular surface depression, and to determine need for surgery and best surgical approach

6.       Management:

a.       Acute management in the ski clinic: placed in straight leg immobilizer or ortho-glass splint with knee in near-full extension and pain control, arrange for follow-up with orthopedic surgeon, often immediate

b.       A small subset of minor fractures can be treated conservatively with hinged knee brace and partial-weight bearing for 8-12 weeks

c.       Operative management indicated for:

                                                               i.      articular stepoff > 3mm

                                                             ii.      condylar widening > 5mm

                                                           iii.      varus/valgus instability

                                                           iv.      all medial plateau fxs 

                                                             v.      all bicondylar fxs

4. Most tibial plateau fractures require ORIF
5. With severe of comminuted fractures, sometimes must first do external fixation, with subsequent ORIF

 

LOWER LEG:

 

Tibial Shaft Fractures

1.       Often referred to “boot-top fracture”

2.       Often also with associated fibular shaft fracture

3.       Risk for compartment syndrome

4.       Management:

a.       Initially placed in long leg splint (generally stirrup and posterior slab with a lot of padding

b.       Minimally displaced fractures can sometimes be treated with casting

c.       More commonly treated with intramedullary nailing in adults

d.       External fixation sometimes needed in proximal and distal metaphysis fractures

e.       More likely to treat nonoperatively in children (open growth plates)

 

 

 

Future topics to be added:

 

Ankle Fractures

                Tibial plafond fractures (pilon fractures)

                Isolated lateral malleolar fx

                Isolated medial malleolar fx

                Bimalleolar fracture

                Functional bimalleolar fracture

                Syndesmotic injury

 

Fibula Fractures

                Maisonneuve fx

                Fibular shaft

                Distal fibula

 

Hip and Pelvis

If unable to bear weight, need CT to rule out acetabular fracture, and other pelvic fractures (even if xray is negative)

 

 

 

GENERAL OBSERVATIONS:

● Snowboarders more often injure the upper extremity (AC, clavicle, wrist)

● Skiers more often injure lower extremity (knee)

● Snow conditions affect the conditions that present to the clinic

● Age of patients

○ There are a lot of skiers in their 70s, 80s, and even 90s

○ Higher risk of fractures (proximal humerus, hip, pelvis)

○ Higher risk of intracranial bleeds

 

Statistics of ski injuries:

1. 3 injuries per 1000 skier days

2. 4-16 injuries per 1000 boarder days

 

Winnie stuff:

·         These patients are often away from home and completely new to the area and the medical resources available

·         Go the extra mile to make it a comforting experience, and to get them the help they need

·         Enjoy the patient interaction and cultural elements of the encounter

·         Patients are generally very grateful

·         Highest patient satisfaction for 2 years in a row (ever since comparing) among InstaCares

·         Hot chocolate with whipped cream

 

Helmet use:

1. Clear evidence of decreased risk and decreased severity of head injury in both skiers and boarders

2. Beneficial effects not negated by increased cervical spine injuries

3. Also not negated by risk of compensation behavior (“An Evidence Based Review: Efficacy of Sefety Helmets in Reduction of Head Injuries in Recreational Skiers and Snowboarders,” Haider, Salem, et al 2012)

 

Wrist guards in snowboarders:

1. Clear benefit, especially in new snowboarders

 

Concussions

 

Spine injuries and criteria for imaging

(c-spine, t-spine, l-spine)

 

Anticoagulation for tibia fractures

 

Altitude sickness

 

Make some instructional videos

 

Good resources:

Orthobullets.com

Fracture Management for Primary Care (Eiff, Hatch, Calmbach)

Handbook of Fractures