Unfortunately, LPT fractures possess a high morbidity rate, primarily because of frequent delays in diagnosis. Complications of delayed treatment include nonunion, avascular necrosis, and early osteoarthritis of the subtalar joint. Plain radiographs unfortunately provide suboptimal visualization of the lateral process, and computed tomography (CT) is often necessary for diagnosis and providing information regarding displacement and intra-articular involvement. Treatment of LPT fractures is determined in part by the current classification of fracture pattern: type 1 fractures involve a small avulsion without extension to the talofibular joint, type 2 fractures involve a single large fragment (extending from the talofibular articulation to the subtalar joint) (Fig. 3), and type 3 fractures are comminuted (26).
Treatment guidelines generally are based on the amount of fragment displacement, with the foremost concern being maintenance of joint surface congruity. Type 1 fractures generally are treated nonsurgically with 4 to 6 wk of non-weight bearing and cast immobilization. Type 2 fractures typically are treated on the basis of fragment size and amount of displacement. Nondisplaced type 2 fractures (or those <2 mm in size) usually are treated similarly to type 1 LPT fractures. However, type 2 fractures that are displaced or >2 mm in size are treated best with open reduction and internal fixation (Fig. 4). Type 3 fractures are treated best with excision of the small displaced fragments (39).
A recent 3.5-year follow-up study of patients treated for LPT fractures found that 88% of the patients treated surgically had significant concomitant hindfoot injuries. In addition, 45% of their patients had subtalar chondral degenerative changes at follow-up (40). An interesting study by Langer et al. (21) looked at changes of ligamentous attachments after a "simulated fracture" using cadaveric specimens was excised. Significant ligamentous disruption resulted, thus potentially comprising the lateral stability of the ankle and subtalar joint.
Worldwide, head injuries are estimated to account for approximately 15% of all snowboarding injuries. Head injury also has been found to be the leading cause of death among snowboarders (38). Approximately half of these head injuries occur because of collisions with stationary objects such as trees or lift towers (22). A study by Nakaguchi et al. (27) found that snowboarders frequently sustained occipital trauma because of their propensity to fall backward. Beginner riders were particularly at risk for head injuries, and most of the major injuries occurred on lower angled slopes.
Concussions that are common in traditional contact sports similarly are seen frequently in snowboarders. Return-to-sport decisions should be based on current guidelines used for other athletes involved in contact sports. Other head trauma sustained by snowboarders include skull fractures, cerebral contusions, diffuse axonal injury, and intracranial hematomas. Among organic head injuries seen in snowboarders, subdural hematomas occur commonly and are caused usually by direct falls on the snow (11). In addition, snowboarders are at risk for significant maxillofacial trauma, including facial fractures and injuries to dentoalveolar and soft tissues. A steady increase in maxillofacial injuries was seen in a 13-year study done in Austria, where snowboarders were found to have a higher risk of soft tissue maxillofacial injuries (primarily contusions and lacerations) compared to skiers (37).
Spinal injuries and subsequent neurologic sequelae are often catastrophic and are a major cause of permanent disability. An international review by Ackery et al. (1) found that the incidence of both traumatic brain injury and spinal cord injury is increasing in skiers and snowboarders. Spinal trauma occurs four times more frequently in snowboarders compared to skiers (35). Compression, burst, and transverse process fractures are all common, and the lumbar region is the level commonly injured (10). Snowboarders are at risk for serious spinal injuries, due in part to young aggressive riders performing aerial maneuvers in half-pipes or jumping from large elevated platforms. This type of risky behavior can lead to severe falls and improper landings at high speeds, which can transfer tremendous forces to the axial skeleton. Wakahara et al. (41) noted that nearly all snowboarders with traumatic spinal injuries were young men with intermediate or expert levels of skill.
Falls with high-energy forces, such as missed landings when jumping, can lead to serious injuries to the chest and abdomen. Injuries to the chest include rib fractures and pneumothorax. Blunt abdominal trauma is common in snowboarders, especially splenic injuries. A 10-year retrospective review found that the risk of splenic injury in snowboarders was six times higher than that in skiers (14). This type of injury often occurs when the rider's own elbow is driven into his or her abdomen upon falling (36). This relatively common injury in snowboarders has been called "snowboard spleen" or "boarder belly" (18). Splenic ruptures, as well as other abdominal injuries such as liver lacerations, can be life threatening and need to be evaluated promptly. Currently, CT scans (best images provided with intravenous contrast) are the best modality for proper evaluation of such injuries, but ultrasound is capable when rapid assessment is necessary (42).
Helmet use has been shown to be very beneficial in preventing many common head injuries seen in snowboarders, including head contusions and skull fractures (34). Helmets should be strongly encouraged for all snowboarders because the severity of head injuries can be significantly reduced. Children are especially susceptible to head injuries, thus making helmet wear imperative for young riders.
Although helmet use has gained popularity, several issues have affected its overall acceptance. There has been concern that the use of helmets may predispose wearers to neck injuries, but a recent meta-analysis of helmet use among skiers and snowboarders showed no increased risk (30). Some also have expressed concern about the use of helmets interfering with peripheral vision, thus influencing collisions on the slopes. Ruedl et al. (29) showed, however, that reaction times to peripheral stimuli were not altered by wearing a ski helmet. It also has been suggested that the use of helmets with integrated face guards and mouth guards could reduce the incidence of maxillofacial trauma, including mandible fractures (6).
Wrist guards have been shown to be beneficial in preventing serious wrist injuries (31). Beginners and children are particularly vulnerable to wrist injuries and should be encouraged to wear commercial wrist protectors. The American Academy of Pediatrics recommends that snowboarders wear gloves with incorporated wrist guards (2). A review done recently of multiple studies evaluating the effectiveness of wrist guard use in snowboarders found that wrist sprains and fractures were reduced significantly. In addition, other injuries to the upper extremity were not increased significantly by the use of wrist guards (31).
Use and access to backcountry terrain continue to increase. Riders are exposed to additional environmental factors, including uncontrolled areas that are susceptible to avalanches. Many resorts open "sidecountry" gates adjacent to their patrolled areas, which allows easy access to varied terrain for skiers and snowboarders. Deaths due to deep snow immersion, usually due to falls into tree wells, claim many lives each year. Proper safety gear, including an avalanche transceiver, shovel, and probe, is essential for venturing into unpredictable terrain. Advanced skill level, knowledge, and good judgment are imperative for ensuring safety in the backcountry.
The spectrum of snowboarding injuries has evolved significantly during the past 30 years. Multiple risk factors have been identified, and younger riders and beginners are especially vulnerable to traumatic injuries. Head injuries are particularly common and are the leading cause of death in snowboarders. Fractures involving the LPT (snowboarder's fracture) occur frequently, and medical providers should exercise a high level of suspicion for this injury when evaluating ankle pain in snowboarders. This fracture carries with it a high rate of morbidity, and specific management guidelines discussed here should be considered when treating this specific fracture. Helmets have been shown to be beneficial in preventing head injuries in snowboarders, without a concomitant increase in neck injuries. In addition, wrist guards have been shown to prevent serious wrist injuries and should be encouraged especially in young and beginner riders. Young male riders, who are most susceptible to significant injuries, should be encouraged to not overestimate their riding ability.
The author declares no conflict of interest and does not have any financial disclosures.
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