SKI AND SNOWBOARD INJURIES

Outdoor Emergency Care, 4th Edition AAOS/NSP 1

Statistics: (Scottish Snow Sports Safety Study)

** Skiers mainly injure Knee, then head/face, then limbs

Outdoor Emergency Care, 4th Edition AAOS/NSP 2

Statistics: (Scottish Snow Sports Safety Study)

** Skiers injure knees and snowboarders injure wrists

Outdoor Emergency Care, 4th Edition AAOS/NSP 3

Statistics: (Scottish Snow Sports Safety Study)

** Skiers sprain more and snowboarders fracture more

Outdoor Emergency Care, 4th Edition AAOS/NSP 4

Conclusion (Scottish Snow Sports Safety Study)

•Injury rate in Scotland is 2.24 injuries per 1000 skier days •Over the four years of the study there was a trend toward less injury •Attributed this to increased use of helmets, wrist guards, awareness •No mention of skiers using knee braces for primary prevention of joint injury Outdoor Emergency Care, 4th Edition AAOS/NSP 5

Outdoor Emergency Care, 4th Edition AAOS/NSP 6

Statistics:

(

Geddes, R et al. Boarder Belly: splenic injuries reslting from ski and snowboarding accidents. Emergency Medicine Australia. April, 2005.17 (2): 157-162

•Ten year retrospective review on splenic injury in skiers and snowboarders (boarder belly).

•Snowboarders are six times more likely to sustain splenic injury than skiers •Males 21 times more likely than females to sustain such injury •Most injury in snowboarders resulted from falls or jumps. Outdoor Emergency Care, 4th Edition AAOS/NSP 7

Statistics:

(

1995 - U.S. Consumer Product Safety Commission)

•Through the National Injury Information Clearinghouse the looked at

head injury

from skiing.

•42% of head injuries were concussions •24% of head injuries were lacerations •CPSC estimates that each year more than 7,000 head injuries could be prevented or reduced in severity with helmet use. Outdoor Emergency Care, 4th Edition AAOS/NSP 8

Statistics:

Snowsport Deaths •Occurrence of death in USA from 1991-2004 is 469 •58 snowboarders. 401 Skiers.

•1 death/ 1.4million skier days •Average 35 deaths per season •No decrease in mortality despite increased helmet use!

Outdoor Emergency Care, 4th Edition AAOS/NSP 9

Statistics: Final Conclusions

•Skiers: lacerations, boot-top contusions, thumb injuries, and complex knee injuries. •Snowboarders: distal radius fractures, foot or ankle injuries •Serious injuries: equal rates of closed head injuries but snowboarders suffer more intra-abdominal injuries (boarder belly) •Snowboarders suffer from falls or jumps while skiers from collision.

•Unique pattern of injuries. Accident prevention must focus on sport specific education and equipment design Outdoor Emergency Care, 4th Edition AAOS/NSP 10

Common Recommendations

•Make sure items such as bindings and boots are adjusted to fit properly. •Don't ski or snowboard beyond your ability. •Ski and snowboard in control, and follow the rules of the slopes. •Never ski or snowboard alone. •Get in shape before you hit the slopes •*Wear warm, close-fitting clothing. Loose clothing can become entangled in lifts, tow ropes and ski poles. Outdoor Emergency Care, 4th Edition AAOS/NSP 11

Recommendations are helpful but is there any evidence on protective equipment- Helmets, wrist guards, knee braces?

Outdoor Emergency Care, 4th Edition AAOS/NSP 12

Helmets: Hagel, I et al.

•Assumption that they are helpful is based on bicycle helmet data that does prove usefulness •Children have large head:body ratio •Could helmets exert excessive bending or twisting on the neck in simple falls Outdoor Emergency Care, 4th Edition AAOS/NSP 13

Outdoor Emergency Care, 4th Edition AAOS/NSP 14

Helmets: Hagel, I et al.

Conclusions:

• Wearing helmet may reduce risk of head injury by 29-56% •Although not statistically significant, there was a trend toward helmet use causing an increase in neck injuries.

Limitations:

•Snowsport participants that fell but were not injured as a result of wearing a helmet could not have been reported •Benefits of wearing a helmet may have been underestimated Outdoor Emergency Care, 4th Edition AAOS/NSP 15

Helmets: Sulheim, et al.

•Norwegian study in skiers and snowboarders

Methods

• Case control study at 8 major alpine resorts during 2002 season •3277 injured and 2992 non-injured controls interviewed •Multivariate logistic regression analysis Outdoor Emergency Care, 4th Edition AAOS/NSP 16

Helmets: Sulheim, et al.

Results

• 578 (17.6%) head injuries. •Helmet use reduced head injury by 60% even after adjusting for other factors like skill level, equipment, et cetera •The risk for head injury was higher in snowboarders Outdoor Emergency Care, 4th Edition AAOS/NSP 17

Helmets: Macnab, et al.

Results

1. No difference in serious neck injury between groups (helmet vs non-helmet) 2. Failure to use helmet increase head injury (RR 2.24; 95% CI 1.23-4.12) Outdoor Emergency Care, 4th Edition AAOS/NSP 18

Snowboarding Injury: Epidemiology

Results

1. Ratio of upper extremity injury to all types of injury was significantly higher in snowboarders than skiers by three times 2. Snowboarders fracture wrists and skiers fractures clavicles 3. Snowboarders dislocate elbows and skiers dislocate shoulders 4. In snowboarders, the left upper extremity was more frequently affected due to their orientation on the board Outdoor Emergency Care, 4th Edition AAOS/NSP 19

Snowboarding: Wrist Guards

O’Neill et al.

1. Studied rate of injury in first time snowboarders 2. Compared 551 wore wrist guards and control was more than 1800; no wrist guards.

Outdoor Emergency Care, 4th Edition AAOS/NSP 20

Snowboarding: Wrist Guards

Results

1. 40 wrist injuries in Control (unguarded) and 0 injuries in experimental (guarded) in first timers 2. No higher rate of other upper extremity injury in guarded group

Should they have stopped and given everyone wrist guards?

Outdoor Emergency Care, 4th Edition AAOS/NSP 21

Snowboarding: Wrist Guards

Ronning et al. - Results

1. Significant difference between the two groups 2. Wrist guards were protective 3. More injuries if first-timers and those who rented equipment Outdoor Emergency Care, 4th Edition AAOS/NSP 22

Statistics: Boarder Belly

Outdoor Emergency Care, 4th Edition AAOS/NSP 23

Skiing: Bindings

•

Very poor evidence for studies on bindings

Finch et al: 1. Review article based on 15 low level evidence studies 2. Bindings currently have one pivot point to release for rotational forces exerted on the ski from the front, but this does not account for rotational forces from the back 3. Adjustments, especially in children, tends to be inadequate 4. Suggests that a binding testing device should be used to optimize and standardize adjustments Outdoor Emergency Care, 4th Edition AAOS/NSP 24

Skiing: Knee Braces

Oates et al:

1. Three groups of skiers: (1) No previous ACL injury- 4748 (2) ACL deficient- 138 (3) ACL reconstruction- 274 2. Put them all in knee braces 3. Ligament deficient knees had 6.2x higher rate of injury than intact knees 4. Ligament reconstructed knees had 3.1x higher rate than intact 5. Injuries in intact knees were also less severe Outdoor Emergency Care, 4th Edition AAOS/NSP 25

Skiing: Knee Braces

• •

Kocher et al:

Cohort study of 180 ACL deficient skiers who were a mix of braced and non-braced knees Unbraced knees had higher injury rates (P=0.005)

No evidence on knee braces for primary injury prevention

Outdoor Emergency Care, 4th Edition AAOS/NSP 26

Outdoor Emergency Care, 4th Edition AAOS/NSP 27

Classic Injuries: Skier’s Thumb

Background •Skier’s thumb, aka gamekeepers thumb •Ski pole injuries and football injuries are now most common cause Outdoor Emergency Care, 4th Edition AAOS/NSP 28

Classic Injuries: Skier’s Thumb

Presentation •Acute trauma or repeated stress typically results in ulnar collateral ligament tendonopathy or disruption •Leads to swelling, pain, tenderness and/or loss of stability Outdoor Emergency Care, 4th Edition AAOS/NSP 29

Classic Injuries: Skier’s Thumb

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Classic Injuries: Skier’s Thumb Prevention

Outdoor Emergency Care, 4th Edition AAOS/NSP 31

Conclusions: General

Skier, think knee sprain then ACL or ligament disruption Snowboarder think wrist fracture of left hand Outdoor Emergency Care, 4th Edition AAOS/NSP 32

Conclusions: Skiing Injuries

•If points to knee  Think ACL tear or sprain and consider brace in future •If points to hand  Think skier’s thumb and search and qualify avulsion fracture and/or ligament disruption •If points to arm  Think clavicle fracture and/or shoulder dislocation Outdoor Emergency Care, 4th Edition AAOS/NSP 33

Conclusions: Snowboard Injuries

•If points to knee  Think sprain •If points to hand/wrist  Think distal radius fracture and give them a brace to use in future •If points to arm  Think elbow dislocation •If points to foot/ankle  Think snowboarder’s ankle •If points to abdomen  Think boarder belly Outdoor Emergency Care, 4th Edition AAOS/NSP 34

Objectives

(1 of 5) • List the functions of the central nervous system.

• Define the structure of the skeletal system as it relates to the nervous system.

• Relate mechanism of injury to potential injuries of the head and spine.

• State the signs and symptoms of a potential spinal injury.

Outdoor Emergency Care, 4th Edition AAOS/NSP 35

Objectives

(2 of 5) • Describe the method of determining if a responsive patient may have a spinal injury.

• Relate the airway emergency medical care techniques to the patient with a suspected spinal injury.

• Describe how to stabilize the cervical spine.

• List the steps in performing rapid extrication.

Outdoor Emergency Care, 4th Edition AAOS/NSP 36

•

Objectives

(3 of 5) Explain the rationale for immobilization of the entire spine when a cervical spine injury is suspected.

• Explain the rationale for utilizing rapid extrication approaches only when they indeed will make the difference between life and death.

• Demonstrate opening the airway in a patient with a suspected spinal cord injury.

Outdoor Emergency Care, 4th Edition AAOS/NSP 37

•

Objectives

(4 of 5) Demonstrate evaluating a responsive patient with a suspected spinal cord injury.

• Demonstrate stabilization of the cervical spine.

• Demonstrate the four-person log roll for a patient with a suspected spinal cord injury.

• Demonstrate how to log roll a patient with a suspected spinal cord injury using two people.

Outdoor Emergency Care, 4th Edition AAOS/NSP 38

•

Objectives

(5 of 5) Demonstrate securing a patient to a long backboard.

• Demonstrate the procedure for rapid extrication.

• Demonstrate helmet removal techniques.

Outdoor Emergency Care, 4th Edition AAOS/NSP 39

Spinal Column

Outdoor Emergency Care, 4th Edition AAOS/NSP 40

Assessment of Spinal Injuries

• • • • • • • • Vehicle crashes (snowmobile, car, motorcycle) Snow rider collisions with fixed objects Snow rider collisions with other snow riders Falls from heights Blunt or penetrating trauma Blunt trauma Hangings Diving accidents Outdoor Emergency Care, 4th Edition AAOS/NSP 41

• • • •

Questions to Ask Responsive Patients

Does your neck or back hurt?

What happened?

Where (specific location) does it hurt?

Can you feel me touching your fingers? Your toes?

• Can you move your hands and feet?

Outdoor Emergency Care, 4th Edition AAOS/NSP 42

Assessment of Spinal Injuries

• • • Assess DCAP-BTLS.

Avoid any excessive motion.

Assess strength in each extremity and compare. • • Absence of pain does not rule out injury. Ability to move or walk does not rule out injury.

Outdoor Emergency Care, 4th Edition AAOS/NSP 43

• • • • • •

Signs and Symptoms of Spinal Injury

Pain or tenderness of spine Deformity of spine Tingling and/or weakness in the extremities Loss of sensation or paralysis Incontinence Soft-tissue injuries to head, neck, back Outdoor Emergency Care, 4th Edition AAOS/NSP 44

• • •

Emergency Medical Care

Follow BSI precautions.

Manage the airway.

– Perform the jaw-thrust maneuver to open the airway.

– Consider inserting an oropharyngeal airway.

– Administer oxygen.

Stabilize the cervical spine.

Outdoor Emergency Care, 4th Edition AAOS/NSP 45

Stabilization of the Cervical Spine

(1 of 3) • • • • Hold patient’s head firmly with both hands.

Support the lower jaw.

Move to patient’s head to eyes-forward position.

Maintain position until patient is secured to backboard.

Outdoor Emergency Care, 4th Edition AAOS/NSP 46

Stabilization of the Cervical Spine

(2 of 3) • • • • Assess and monitor CMS functions.

Cervical collars do not replace manual stabilization. Improperly fitted collars may be harmful.

Towel rolls and/or blanket rolls can be substituted for cervical collar. Outdoor Emergency Care, 4th Edition AAOS/NSP 47

•

Stabilization of the Cervical Spine

(3 of 3) Do not force the head into a neutral, in-line position if the following develop: – Muscles spasms – Increase in pain – Numbness, tingling, or weakness – Compromised airway or breathing Outdoor Emergency Care, 4th Edition AAOS/NSP 48

Preparation for Transport: Supine Patients

(1 of 2) • • • • • Maintain in-line stabilization.

Assess and monitor distal CMS functions in each extremity.

Apply a cervical collar, sized appropriately.

Have other team members position immobilization device.

Log roll patient; quickly assess the back. Outdoor Emergency Care, 4th Edition AAOS/NSP 49

Preparation for Transport: Supine Patients

(2 of 2) • • • • • • Center patient on device. Secure upper torso to device.

Secure pelvis, legs, and feet. Immobilize and secure the head. Check and adjust all straps. Reassess distal CMS functions. Outdoor Emergency Care, 4th Edition AAOS/NSP 50

Preparation for Transport: Sitting Patients

• • • • • • • Maintain manual in-line stabilization. Assess CMS functions, apply a cervical collar.

Place a short board or short immobilization device behind patient.

Position device around patient and secure.

Turn and lower patient to long backboard.

Secure short and long backboards together.

AAOS/NSP 51

Preparation for Transport: Standing Patients

• • • • • Stabilize the head and neck from behind and apply a cervical collar.

Position board upright behind patient and secure.

A rescuer stands at each side, facing the patient. Reach under each arm, grasp board near patient’s shoulder.

Carefully lower patient to ground.

Outdoor Emergency Care, 4th Edition AAOS/NSP 52

Head Injuries

• • All head injuries are potentially serious. Types include: – Scalp lacerations – Skull fractures – Brain injuries – Medical conditions – Complications of head injuries Outdoor Emergency Care, 4th Edition AAOS/NSP 53

Scalp Lacerations

• • • • • • • Scalp has a rich blood supply.

There may be more serious, deeper injuries.

Follow BSI precautions.

Fold skin flaps back down onto scalp.

Control bleeding by direct pressure.

Watch for skull fractures Add additional dressings as needed. Outdoor Emergency Care, 4th Edition AAOS/NSP 54

Skull Fracture

• • Indicates significant force Signs: – Obvious deformity – Visible crack in skull – Raccoon eyes – Battle’s sign – Cerebrospinal fluid Outdoor Emergency Care, 4th Edition AAOS/NSP 55

Concussion

(1 of 2) • • Minor traumatic brain injury (TBI) • Temporary loss or alteration in brain function • May result in unresponsiveness, confusion, or amnesia

Retrograde amnesia

leading up to injury : forgetting events Outdoor Emergency Care, 4th Edition AAOS/NSP 56

Concussion

(2 of 2) • • • • •

Anterograde (posttraumatic) amnesia

: forgetting events after the injury

Perseveration:

patterns repetitive speech Brain can sustain bruise when skull is struck.

There will be bleeding and swelling.

Bleeding will increase pressure within skull.

Outdoor Emergency Care, 4th Edition AAOS/NSP 57

Intracranial Bleeding

• • Major TBI Laceration or rupture of blood vessel in brain – Subdural – Intracerebral – Epidural Outdoor Emergency Care, 4th Edition AAOS/NSP 58

Other Brain Injuries

• • • Brain injuries are not always caused by trauma.

Medical conditions may cause spontaneous bleeding in the brain.

– Example: high blood pressure Signs and symptoms of nontraumatic injuries are the same as those of traumatic injuries.

– There is no MOI.

Outdoor Emergency Care, 4th Edition AAOS/NSP 59

Complications of Head Injury

• • • • Cerebral edema is one of the most serious complications.

– Ensure airway and provide oxygen.

Seizure (convulsion) may occur.

Vomiting may occur.

– Common in children Leakage of cerebrospinal fluid may occur.

– Do not pack ears or nose.

Outdoor Emergency Care, 4th Edition AAOS/NSP 60

Assessing Head Injuries

(1 of 2) • Common causes: – Skier-object (fixed or moving) collisions – Direct blows (deformed or dented helmet) – Falls from heights – Sports injuries, especially involving speed • Evaluate and monitor level of responsiveness Outdoor Emergency Care, 4th Edition AAOS/NSP 61

Assessing Head Injuries

(2 of 2) • Blunt injuries are associated with trauma.

• • Consider MOI. Assess and monitor level of responsiveness. • Evaluate and compare pupil size, shape, and reaction to light.

• Injury may be closed or open.

Outdoor Emergency Care, 4th Edition AAOS/NSP 62

•

Signs and Symptoms

(1 of 3) Lacerations, contusions, hematomas to scalp • • • • • Soft areas or depression upon palpation Visible skull fractures or deformities Ecchymosis around eyes and behind ear Clear or pink CSF leakage Failure of pupils to respond to light Outdoor Emergency Care, 4th Edition AAOS/NSP 63

Signs and Symptoms

(2 of 3) • Unequal pupils (anisocoria) – Occurs naturally in 5% of the population • • • Loss of sensation and/or motor function Period of unresponsiveness Respiratory distress due to bleeding or swelling of the airway • Amnesia Outdoor Emergency Care, 4th Edition AAOS/NSP 64

Signs and Symptoms

(3 of 3) • • • • • • • Seizures Numbness or tingling in the extremities Irregular respirations Dizziness Visual complaints Combative or abnormal behavior Nausea or vomiting Outdoor Emergency Care, 4th Edition AAOS/NSP 65

• • • •

Level of Responsiveness

Change in level of responsiveness is the single most important observation.

Use the AVPU scale or Glasgow Coma Scale (depending on local protocols).

Reassess level of responsiveness: – Every 15 minutes if patient is stable.

– Every 5 minutes if patient is unstable.

Levels may fluctuate or progressively deteriorate.

Outdoor Emergency Care, 4th Edition AAOS/NSP 66

•

Change in Pupil Size

Unequal pupil size may indicate increased pressure on one side of the brain.

Outdoor Emergency Care, 4th Edition AAOS/NSP 67

Emergency Medical Care

• • Protect the cervical spine.

Follow these three principles: – Establish an adequate airway, provide high flow oxygen.

– Control bleeding, provide adequate circulation.

– Assess baseline vital signs and monitor patient’s level of responsiveness.

Outdoor Emergency Care, 4th Edition AAOS/NSP 68

Managing the Airway

• • • • • • First priority! Use jaw-thrust maneuver. Maintain neutral, in-line stabilization. Use suction and remove foreign bodies. Provide high-flow oxygen. Assist ventilations as needed.

Outdoor Emergency Care, 4th Edition AAOS/NSP 69

Circulation

• • • • Start CPR in patients with cardiac arrest.

Control bleeding. Shock is usually due to bleeding.

Patients with a medical condition or nontraumatic brain injury should be placed on side to avoid aspiration.

Outdoor Emergency Care, 4th Edition AAOS/NSP 70

Cervical Collar

• • Provides preliminary, partial support Applied to every patient with a suspected spinal injury • Used with manual stabilization until patient is secured to spinal immobilization device • Must be correctly sized Outdoor Emergency Care, 4th Edition AAOS/NSP 71

Applying a Cervical Collar

• • • • • • One rescuer provides

continuous

manual in line support of head.

Measure proper size collar.

Place chin support snugly under chin.

Maintain manual support.

Wrap collar around neck.

Ensure that collar fits.

Outdoor Emergency Care, 4th Edition AAOS/NSP 72

•

Backboards

Short backboards, vests – Used on patients found in sitting position – Used in extrication • Long backboards – Provide full-body immobilization – Can be used to splint many injuries Outdoor Emergency Care, 4th Edition AAOS/NSP 73

Helmet Removal

(1 of 5) • Is airway clear and is patient breathing adequately?

• Can airway be maintained and ventilations assisted with helmet in place?

• How well does helmet fit?

• Can patient move within helmet?

• Can spine be immobilized in a neutral position with helmet on?

Outdoor Emergency Care, 4th Edition AAOS/NSP 74

•

Helmet Removal

(2 of 5) A helmet that fits well prevents the head from moving and should be left on, as long as: – There are no impending airway or breathing problems.

– It does not interfere with assessment and treatment of the airway.

– You can properly immobilize the spine.

Outdoor Emergency Care, 4th Edition AAOS/NSP 75

•

Helmet Removal

(3 of 5) Remove a helmet if: – It makes assessing the airway difficult.

– It interferes with spinal immobilization. – It allows excessive head movements. – Patient is in cardiac arrest. Outdoor Emergency Care, 4th Edition AAOS/NSP 76

Helmet Removal

(4 of 5) • • • • Remove glasses or goggles. Stabilize head and loosen strap. Place hands at the jaw and back of head. Begin to gently slide helmet up and off. Outdoor Emergency Care, 4th Edition AAOS/NSP 77

Helmet Removal

(5 of 5) • • • • Slide hand up the back of head to prevent it from moving. Rotate helmet all the way off head. Manually stabilize cervical spine as normal. Apply cervical collar. Outdoor Emergency Care, 4th Edition AAOS/NSP 78

Pediatric Needs

(1 of 2) • • Children will need additional padding to prevent neck flexion. Blanket rolls can be used in place of cervical collars.

Outdoor Emergency Care, 4th Edition AAOS/NSP 79

• •

Pediatric Needs

(2 of 2) Children may need extra padding to maintain immobilization.

Car seats can be used as immobilization devices.

Outdoor Emergency Care, 4th Edition AAOS/NSP 80