Sachtleben, Thomas R. MD, MS
Snowboarding has seen tremendous growth and popularity since being developed in the 1970s. It is one of the fastest growing sports worldwide and has been an Olympic sport since 1988. There are more than 6 million snowboarders in the United States, with typical riders being men in their 20s. Snowboarders not only share the slopes at winter resorts with skiers but also enjoy half-pipes, terrain parks, and backcountry riding. Snowboarders have a three times higher injury rate compared to skiers (23). Children and beginner riders are particularly at risk for injury, with more than half of snowboarding injuries occurring in beginners (13).
Fast learning curves on snowboards allow rapid progression to higher speeds and more dangerous maneuvers. Many have had limited formal instruction. Snowboarders commonly advance their skills to allow riding in steeper terrain and into terrain parks with multiple jumps and obstacles. Young aggressive riders often engage in high-risk maneuvers and, as a result, create high-energy forces that frequently inflict severe traumatic injuries.
Snowboarding requires specific equipment for its participants. The rider is attached to the snowboard with boots and bindings that allow the transfer of energy from the rider to the board. Safety equipment is used by many riders, including helmets, goggles, and wrist guards. Beginner riders often use additional protective pads for the hips, knees, and back as well.
Unique injury patterns occur in snowboarding because of the fixed sideways stance on the snowboard and because of riders not having poles to help brace their falls. Thus, upper extremities usually absorb maximal forces during falls and are injured frequently. Snowboarders frequently fall backward because of the "opposite-edge" phenomenon (25). As the riders make turns, the opposite edge of the snowboard may come in contact with the snow surface, causing powerful angular acceleration and a forceful fall backward. Wasden et al. (43) found that the head was the most common injury site in a review of injuries treated in an emergency department in Utah.
Injury rates have decreased in recent years, primarily because of technological advances in equipment design and the use of protective devices. Falls are the most common mechanism of injury, but collisions with other riders or stationary objects also occur. Awkward landings from extreme heights when jumping often cause significant injuries as well. Brooks et al. (5) noted that injuries sustained in terrain parks tend to be more severe in nature than injuries sustained elsewhere on the slopes. These injuries included head injuries, as well as spinal injuries, fractures, and chest/abdominal trauma that required hospital transport.
Improper binding adjustment and the lack of proper protective equipment (helmets, wrist guards) have been linked to increased injury. Additional risk factors that have been associated with injuries in snowboarders include younger age, beginner status, and the female gender (16). Self-reported expert snowboarders, however, have been found to have a higher rate of severe injuries compared to less experienced riders (15). Also, Hasler et al. (17) observed that being unprepared for higher speeds and poor snow surface conditions were associated with increased injuries in snowboarders.
Upper Extremity Injuries
Snowboarders are particularly at risk for injuries to the upper extremity because they often have their arms outstretched for balance. The wrist is the most common upper extremity site injured in snowboarders. It is especially vulnerable because riders use their wrists to brace themselves when jumping or falling. In addition, snowboarders often use their wrists for speed control and to aid with terrain park maneuvers. A 10-year study noted that wrist injuries account for approximately 22% of all snowboarding injuries (19). In addition, 78% of the wrist injuries in this study involved a fracture. Distal radius fractures are especially common, with approximately half being comminuted or involving intra-articular components that require surgical repair (32).
Because of riding at higher speeds, advanced riders are also susceptible to clavicle fractures, acromioclavicular joint separations, and shoulder dislocations. Because they do not use poles, snowboarders frequently fall with their arm abducted and in external rotation. Bissell et al. (3) found that humeral fractures occurred significantly more frequently compared to skiers. Most humeral fractures occurred on the left side, likely because of the assertion that most snowboarders ride with their left foot forward. Beginners were found to be at increased risk for this serious injury (3). Elbow fractures and dislocations also occur frequently, especially in advanced riders (19).
Lower Extremity Injuries
As boot and binding technology continues to evolve, lower extremity injuries are becoming less common. Snowboarders suffer fewer serious ligamentous knee injuries compared to skiers because of lower torsional forces. Because most binding systems are nonreleasable, rotary forces are reduced significantly, thus preventing many anterior cruciate ligament (ACL) injuries. Advanced riders landing big jumps have been found to be at risk for ACL tears, however (7). Eccentric quadriceps contraction while landing on flat terrain from jumps with a flexed knee has been suggested as a typical mechanism. The lead knee usually was involved, with internal tibial rotation predisposing the ACL to injury when landing. All snowboarders keep one leg out of the binding to propel themselves on flat terrain and to get on and off the lifts. This can be an awkward stance for beginners and can result in an increased risk for ACL injuries to the leg that remains bound to the snowboard. Snowboarders are also at risk for hip injuries and have a five times higher risk of hip dislocation compared to skiers (24).
The most common lower extremity injury involves the ankle, and ankle injuries make up approximately 15% of all snowboarding injuries (20). Approximately half of ankle injuries involve fractures. Most are left sided, affecting the lead foot (28). Soft tissue injuries often are seen in snowboarders, including adventitious bursae that can develop around the malleoli from repetitive friction. Subcutaneous soft tissue compressed by the snowboard boot can lead to a chronic inflammatory pseudotumor.
This relatively unique injury involves a fracture of the lateral process of the talus (LPT). The LPT is a large wedge-shaped prominence that articulates with both the calcaneus and distal fibula (Fig. 1). There are three lateral stabilizing ligaments that attach to the LPT: the lateral talocalcaneal, anterior talofibular, and posterior talofibular ligaments (8). LPT fractures account for 15% of all ankle injuries and 34% of all ankle fractures (20). Snowboarder's fracture usually occurs because of sudden ankle dorsiflexion with concomitant hindfoot inversion and axial loading. Recent studies suggest that eversion/external rotation is also a key component (4,12). This mechanism often is seen upon landing after jumps. Fractures of the LPT often present clinically similar to lateral ankle sprains, and a high level of suspicion should be considered in patients who have persistent pain with attempted weight bearing. Proper clinical examination should include the LPT "stress test" (Fig. 2), which is performed by passive dorsiflexion and eversion of the foot while the lower leg is held in external rotation (39).
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).
A recent study by Schmitt et al. (33) looked at the effectiveness of commercially available back protectors, often worn by snowboarders hoping to prevent serious spinal injuries. The ability of these back protectors to significantly lessen the impact and penetrative forces to the spinal column was studied in laboratory conditions. Current safety standards used for motorcycle protectors and helmets were used, and both hard-shell and soft-shell protectors were evaluated. Hard-shell protectors generally provided more protection to penetrative forces, while soft-shell protectors were better in damping energy generated by impact forces. Many of these back protectors did pass safety standards, but whether these standards are appropriate in snowboarders remains unanswered. In addition, spinal injuries in snowboarders frequently are caused by jumping maneuvers with the spine in flexion (9), thus inducing axial forces on the spine, which unlikely would be reduced by the use of back protectors.
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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