Kitesurfing and Cranial Trauma with Frontal Sinus Fracture

Introduction

Kitesurfing is a very popular water sport but is potentially dangerous with injuries due to the powerful tugging force achieved by the large kites and very high jumps. Head injuries are frequent and can be severe with sequelae or fatal with immediate risk of drowning. A helmet is strongly advised as a standard safety precaution.

We report the case of a kitesurfer without a helmet who lost control of his kite during a jump and fell on his board. He presented with a complex fracture of the anterior wall of the right frontal sinus extended to the roof of the orbit with contralateral cortical petechial. A surgical treatment had to be performed.

Case Report

This is a report of a beginner kitesurfer, aged 34 yr without any disease. Kitesurfing is an extreme surface water sport. A kitesurfer uses the power of the wind with a large controllable power kite to be propelled across the water on a kiteboard, with or without foot straps. The kitesurfer can use a leash to hold on to his or her board. A security release system called “Quick Release System” allows the wing to be dropped in the event of loss of control or accident.

Weather conditions were bad with gusty and strong winds (more than 25 knots). From an eyewitness account, the kitesurfer did not wear a helmet or a life vest and had no leash for his board. During a big leap, he lost control of his kite and also lost consciousness up until he was rescued on the beach with a frontal hemorrhagic wound and was then transferred to the hospital. Fortunately, he managed to trigger his quick-release system.

Consequent to the accident, he had no neurological deficit but kept amnesia of the accident. A complete neuro-ophthalmological examination was performed. As a result, he presented with a paresis of the frontal branch of the facial nerve and an open fracture of the right frontal sinus (Fig. 1) without leakage of cerebrospinal fluid. He had no deficit of the superior branch of the trigeminal nerve. A cerebral computed tomography (CT) scan showed a complex fracture of the anterior wall of the right frontal sinus extended to the roof of the orbit (Fig. 2) and a left frontal cortical petechial hemorrhage.

Figure 1: Open fracture of the right frontal sinus.

Figure 2: CT scan with axial, sagittal, and frontal reconstruction—complex fracture of the anterior wall of the right frontal sinus extended to the roof of the orbit.

A surgical treatment was performed with anatomic reduction and osteosynthesis of the comminuted fracture of the anterior wall of the frontal sinus (Fig. 3). We supposed that he fell on the fins of his board because we found traces of green fluorescent paint like that found on the fins on his bone. Antibiotic therapy was prescribed for 8 d with amoxicillin and clavulanic acid.

Figure 3: Osteosynthesis with titanium microplates.

After 4 yr of follow-up, the patient has regained normal facial traction, but kept unilateral supraorbital trigeminal impaired sensation and neuropathic pain and some memory problems. He continues to kitesurf but now wears a helmet.

Discussion

Kitesurfing is a very popular water sport. It combines aspects of several water sports, including surfing, windsurfing, and wakeboarding. With a controllable kite and a small board, kitesurfers travel over the water’s surface with speeds of up to 35 knots. The vertical lift of the kite makes it possible to perform jumps up to 15 m high and 30 m long while doing different maneuvers in the air. Often compared to windsurfing, it has advantages: relatively affordable gear, convenient equipment handling and packaging, ease of learning curve and variability of choices of navigation (free ride, downwind, jumping and freestyle, speed and race, wave riding, foiling, etc.).

However, it seems to be more conducive to injuries (¹) because of the powerful tugging force achieved by the large kites and very high jumps (famous “kite loop”). Reports of these injuries are increasing in kitesurfing media and unfortunate fatal cases have created debates on the safety of materials and local negotiations on the maintenance of permits to access certain beaches. Nevertheless, epidemiological data related to kitesurfing-related trauma is limited and a recent literature review of published cases yielded only 10 reported studies. The true incidence of these injuries is not yet known (²). Noncompetitive kitesurfing resulted in an overall injury rate of 5.9 to 7.0 injuries per 1000 kitesurfing hours. It seems that the risk of injury increases drastically in competitive kitesurfing (³). However, contradictory results have been found. In a prospective study of kitesurfing injuries, Nickel in 2004 (^4,5) showed an overall self-reported injury rate of 7 per 1000 h of practice. Pikora in 2011 (^6,7) found a much higher injury rate of 105 injuries per 1000 h with minor injuries, such as skin bruising.

In a study by Exadaktylos in 2005 (⁸), 83% of injuries were attributed to the inability to detach the kite from the harness in a situation involving loss of control over the kite. In the study by Nickel (^4,5), 56% of the injuries are attributed to this type of situation, more often without a “chicken loop” fitted with a quick-release system in the bar. Fortunately, these systems have recently become an integral and obligatory part of kitesurfing, with international standards. Technological advances in kiteboarding equipment mean today’s kitesurfers are much less likely to find themselves at the mercy of an out-of-control kite. Since 2005, all modern kites dedicated to kitesurfing provide a “total depower” option to reduce the power in the kite. By using depower simply by letting go of the bar, the kite's angle of attack to the wind is reduced, thereby catching less wind in the kite and reducing the power or pulling.

For Nickel (^4,5), the most commonly injured sites were the foot and ankle (28%), skull (14%), chest (13%), and knees (13%). Grimault et al. (⁹) studied 40 kitesurfing accidents in 2004. Head injuries were the most frequent (52.5%) with trauma in 38% and loss of consciousness in 14% of cases. In a recent study by Grunner et al. in 2016 (¹⁰) among the 48 kitesurfing injuries that occurred in Israel from 2000 to 2013, 72.9% were related to the musculoskeletal system, followed by head (18.7%) then chest (14.6%). Among head injuries, there are two concussions, one subdural hemorrhage, one subarachnoid hemorrhage, two skull fractures, and three scalp lacerations. In the group studied, two kitesurfers died due to severe head injuries, including skull fractures with intracranial hemorrhage. Similarly, in the data from the helicopter emergency medical services (HEMS) records in the Netherlands in 2007 (²), one patient died before the arrival of the medical team due to head trauma with a fractured cranium. Head injuries are less frequent than others but more dangerous. Loss of consciousness increases the risk of drowning.

Prevalence of injuries is greater in the upper body. This is easily explained by the forces exerted on the kitesurfer. In case of loss of control of the kite, hydrodynamic force decreases considerably. The resultant force which then applies to the harness is oriented toward the traction of the kite, which causes a tilting of the head toward the front (⁹).

During a series of tests, the French Federation of Free Flight (FFVL includes kitesurfing licensees) measured the force exerted on the lines. In navigation, it is about 2G, which corresponds to twice the weight of the pilot. So, the faster the kitesurfer goes, the more kinetic energy he receives (kinetic energy = 1/2 mass × Speed²). Unfortunately for the kitesurfer, one of the criterias of gravity in human traumatology is high kinetic, because we do not support strong accelerations and decelerations. Furthermore, rises are extremely fast, less than 0.5 s. This explains the inability to trigger the safety, even for the trained kitesurfer.

In the French report of the epidemiology of kitesurfing injuries acknowledged by the FFVL licensees in 2011 (¹¹), 85 accidents were reported in 41% of the casualties, helmets were not worn. Head traumas represented 17% of the injuries. In the study of Petersen (⁵), none of the athletes suffering from head injury wore a helmet, and a board had been thrown against the head by the elastic board leash in all cases. The most common injury situation was the jump.

The rationale for the management of craniofacial injuries is to prevent late infective sequelae and cranio-orbital deformity (¹²). The principles of the surgical management of frontal sinus fractures are based on adequate exposure, minimal brain retraction, rigid fixation of fractures, and in most cases, bone grafting where necessary. Fractures involving the anterior wall of the frontal sinus are treated on the basis of cosmetics. Displaced fractures of the posterior wall of the frontal sinus have a higher risk of dural tear and are treated by cranialization of the sinus and isolation of the sinus contents from the nasal cavity with a vascularized pericranial flap. The risk of mucocele development is minimal in adequately treated fractures of the frontal sinus.

Helmets are highly recommended as a standard safety precaution but are not mandatory. Kitesurfers wear them only if they use a board leash to protect themselves from returns of their board toward the face. Unfortunately, surfers do not take into consideraton practitioners or resellers safety advice. Wearing the board leash or not, the use of the helmet is strongly recommended, and our case report is the perfect example. In addition, today’s helmets are available at very reasonable cost and do not narrow the kitesurfer’s visual field.

Conclusion

Kitesurfing is a natural and trendy evolution of extreme wind-powered sports. However, dangerous situations can occur because of unpredictable wind conditions and inadequate equipment. The severe head traumas described in this article highlight the need for wearing a helmet as a standard safety precaution, with or without the use of a board leash. Without a helmet, the quick-release system remains essential, but not enough to avoid head trauma, loss of consciousness, and/or drowning.