Introduction
Skiing and snowboarding are two of the most popular winter sports, with more than 9 million active participants in the 2017 to 2018 season (1). The rise in snowboarding occurred much later as it was first introduced in the 1970s and was not seen as an Olympic sport until 1998 (2). Both sports continue to maintain worldwide popularity as mentioned above.
This review will focus on the most common acute alpine skiing and snowboarding injuries encountered by sports medicine physicians and also discuss considerations about initial assessment and triage to the appropriate level of care for these injuries.
Epidemiology
There are several important differences in the pattern and severity of injuries among skiers and snowboarders. Due to methodological variation in epidemiologic studies, determination of exact injury rates in these sports is difficult. Most injury reports are based on data from self-reports, ski patrols, or tertiary trauma centers. In general, the rates of injuries in these settings have been reported as 1 to 5 per 1000 athlete days (2–6). Snowboarders are more likely to sustain an acute injury than skiers (7). The rates of injury for snowboarding have continued to increase over the past 10 years, while skiing injury rates have stabilized (2,5,7). Males have a higher frequency of injury in both alpine skiing and snowboarding (2,5,7–10). The average age of injured skiers also is shown to be higher than injured snowboarders (2,11).
There is robust evidence that skiers suffer more lower-extremity injuries, while snowboarders suffer more upper-extremity injuries (2–6,12–14). The most common lower-extremity injuries in skiers involve the knee, and in snowboarders involve the lower trunk (lumbar spine, pelvis, and hip) (2,5,7–10). The Table summarizes the most common injuries in alpine skiing and snowboarding.
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Table: Most common skiing and snowboarding injuries categorized by age/competition level (
2–5,7–10,14–16).
When studies have compared specific injury types between the two winter sports, snowboarders suffer more shoulder, neck, humerus, and abdominal injuries than alpine skiers (2,5,7–10,17). Snowboarders are at a higher risk than skiers for sustaining head trauma, specifically concussions (2,4,5,7,9,10,17–21). While lower-extremity injuries, particularly knee injuries, are less common in snowboarders, ankle injuries appear to be more common in snowboarders (2–4,7,8,10,15,17).
Clinical Setting
Typically, injured ski and snowboard athletes are initially managed on the slope by ski patrol (22). After triage, depending on the setting, athletes may be seen in a clinic at the resort, in a clinic nearby or at a nearby emergency department. While most of the larger ski resorts will have their own imaging capabilities, such as plain radiography or ultrasound, smaller mountains or events held at remote destinations will likely not be able to provide these services (22). Ultrasound can be an important tool to help identify certain potentially life-threatening conditions by performing evaluations, such as focused assessment with sonography for trauma (FAST) and extended FAST (eFAST). Computed tomography (CT) scan is an excellent modality to evaluate for internal soft tissue injuries (e.g., intracranial hemorrhage, blunt intra-abdominal solid organ lacerations) and characterize fractures, but smaller clinical settings may not have advanced imaging modalities, such as CT scan and magnetic resonance imaging (MRI). MRI has advantage over CT scan in evaluating soft tissue injuries, particularly in extremities. Therefore, transportation of injured athletes to a facility with a higher level of care is critical for cases with major trauma (23,24).
Due to the high acuity and sometimes life-threatening nature of injuries in these sports, it is critical that medical personnel treating skiers and snowboarders are adequately trained to treat a variety of medical conditions and feel confident providing care during emergency situations. It would be advised that medical personnel who are working in ski mountain clinics or an urgent care setting should have training that includes, but is not limited to, Basic Life Support, Advanced Cardiac Life Support, and Advanced Trauma Life Support. In addition, providers should be competent in using ultrasound and some forms of anesthesia (e.g., conscious sedation) as it may be necessary for fracture and joint reduction procedures. Medical personnel in smaller clinical settings without the same emergency resources should be familiar with protocols for emergent transport of critical patients to a higher level of care.
Initial Evaluation, Resuscitation, and Acute Management
Evaluation of an acutely injured athlete on a slope or at the nearby medical facility starts with triage and use of the primary and secondary survey to assess for life-threatening injuries (23). A brief history with inquiry about the mechanism of injury, if possible, is important in understanding the injury (22,23). A focused physical examination and assessment using appropriate imaging studies can help determine the urgency of the condition and need for further care. FAST and eFAST should be performed on all patients with possible intra-abdominal and chest injuries (e.g., rib and pelvis fractures) (23). Risk of hemorrhagic shock is significant with pelvic and femur fractures. Intravenous access and adequate pain management should be achieved as soon as possible (24). On slope, intravenous access is rarely indicated as the risk of hypothermia and delay in transportation should take top priority.
Removal of sport-specific equipment, particularly boots, can be a challenge in these athletes. The medical provider with the highest level of experience with ski and snowboard equipment should handle equipment removal. If ski patrol personnel are available, their expertise in this area may be utilized.
Stabilization, Immobilization, and Transportation
Patients with critical conditions should be stabilized and transported to a facility with capability for higher level of care as soon as possible (23,24). Athletes with open fractures (Figure) should be transported as soon as possible (e.g., muscle necrosis usually occurs with inadequate arterial blood flow for more than 6 h) for follow-up care and surgical intervention in most cases. Transportation should not be delayed to conduct additional assessments. If there is no life- or limb-threatening injury present after initial evaluation, appropriate stabilization and follow-up care can be arranged. The appropriate mode of transportation from the slope to medical facility and to higher level of care depends on availability and severity of the athlete's injury. Attempt to reduce joint dislocations or displaced fractures should be conducted under appropriate analgesia or anesthesia. Following reduction, the injured body part should be immobilized, decreasing rates of complications (24). Most injuries seen in these athletes will be nonemergent (e.g., nondisplaced clavicle fracture, acromioclavicular joint sprain, ACL rupture), and need initial immobilization, pain management with oral medications, and follow up within 2 d to 5 d.
Figure: Open distal tibia fracture in a 38-year-old female skier. Any fracture with a break in the skin continuity over a fracture is an open fracture. Oftentimes, the fractured bone pulls back after breaking the skin, so there would be no exposed bone.
Musculoskeletal Injuries
Upper-extremity Injuries
Injuries of the shoulder, elbow, forearm, and wrist are more prevalent in snowboarders than skiers (13,25). In snowboarders, the most common upper-extremity fractures are distal radius fractures, followed by clavicle fractures and proximal humerus fractures (13,25). In skiers, clavicle fractures are the most prevalent type of fracture, followed by distal radius and proximal humerus fractures, all of which account for a minority of all skiing injuries (13). Glenohumeral is the most common joint dislocation in both skiers and snowboarders (13,26). This is followed by AC joint injuries and elbow dislocations (13).
Wrist fractures are the most common fracture in snowboarders and are commonly seen in skiers as well (2,7,13,25). These are typically of the distal radius, and usually sustained from a fall, landing onto an outstretched hand (5,13). This injury is commonly seen in younger, more inexperienced snowboarders (2,5,7,27,28). As with any fracture, initial assessment of a distal radius fracture should include skin integrity and neurovascular status, along with plain radiography if possible (29). Many distal radius fractures can be treated with immobilization alone, but significantly angulated, displaced, or open fractures are treated operatively (29).
Injuries to the thumb ulnar collateral ligament (UCL), sometimes referred to as “skier's thumb,” are more commonly seen in skiers than snowboarders (5,28). The mechanism of this injury is typically a sudden valgus force to the thumb after a fall, such as when a skier falls to the ground with a ski pole still in hand (5,27,28). The patient will be tender to palpation over the injured ligament and may have instability with passive valgus stress of the MCP joint (29). Management is guided by X-rays, presence of an avulsion fracture, as well as the degree of laxity of the UCL (29). A patient with a partial tear with minimal laxity can be treated nonoperatively (29,30), while operative treatment is necessary for injuries that involve high-grade tears or avulsion fractures with displacement (29).
Clavicle fractures in snow sports are commonly the result of jumping and subsequent impact with the snow surface, particularly increased in those who frequently use terrain parks (2). These most commonly involve the middle third of the clavicle (5,30,31). Acutely, there may be an obvious deformity, swelling, and bruising over the fracture site, with guarding of the affected shoulder (31). Exam should include neurovascular assessment, signs of skin breakdown, skin tenting, and assessment for concomitant upper-extremity injuries, visceral injuries, or cervical spine injuries (31). If the fracture is stable and not widely displaced, without significant skin tenting, the patient can be treated nonoperatively (30,31). There has been ongoing debate about operative versus nonoperative treatment of displaced mid-shaft clavicle fractures, which is beyond the scope of this review.
AC joint injuries are more common in advanced snowboarders who sustain a fall onto the shoulder with their arm adducted (30). The patient typically presents with tenderness of AC joint and a positive cross arm test, with or without visible deformity (31). Most of these injuries can be managed nonoperatively (30).
Dislocations of the glenohumeral joint are most commonly anterior and can acutely present with loss of contour of the lateral shoulder and anterior fullness, with the patient holding their arm in abduction (31). After assessment of neurovascular status and plain radiography, if available, the dislocation should be reduced as soon as possible (31). There are a wide variety of techniques to reduce these types of injuries, a topic which is beyond the scope of this review. Postreduction management will be based on age, history of recurrent dislocations, or accompanying injuries (31).
Proximal humerus fractures result most commonly from high-energy impact in younger, novice snowboarders. The most common type of proximal humerus fracture in this population is an avulsion of the greater or lesser tuberosity (31). Patients typically present with pain, swelling, bruising, and inability to move the shoulder (31). If plain radiography indicates minimal displacement without associated dislocation, the patient can be treated nonoperatively (30,31). Proximal humerus fractures also are relatively common among older female skiers with low bone density.
Lower-extremity Injuries
Lower-extremity injuries are more common in skiing than in snowboarding (2,5,12,19,20,30). This is in large part due to differences in equipment, overall stance, and fall mechanisms (5). Skiers tend to undergo more torsional forces, placing the knee at increased risk for ligamentous knee injuries (2,5). Snowboarders do not experience as much lower-extremity torque due to the nature of the equipment (2,26–28,32). While lower-extremity fractures are not as common in skiing, both tibial plateau fractures and tibial plafond fractures have been seen, as well as tibia shaft (“boot-top”) fractures (5,30). Foot and ankle injuries are the most common lower-extremity injuries seen in snowboarders (5,7,9,27,28).
Ligamentous knee injuries are the most common lower-extremity injuries in skiers, typically resulting from a valgus load with internal rotation (5). Experienced snowboarders attempting tricks and jumps have a higher rate of ligamentous knee injuries than inexperienced snowboarders (2,5,7). ACL injuries commonly cooccur with MCL and meniscal injuries (4,5). Most athletes and active individuals with ACL rupture undergo surgical reconstruction to preserve knee stability (30,33).
Ankle sprains are seen more commonly in snowboarding, likely due to use of softer boots compared with ski boots (27,28,30). Fractures of the lateral process of the talus (FLPT), also known as a “snowboarder’s fracture,” is relatively unique to this sport (4,7,9,30). This injury typically presents with anterolateral ankle pain, and the typical mechanism is dorsiflexion, inversion of the hindfoot, axial loading, and internal rotation (5,7,30). This injury may be mistaken as a sprain of the anterior talofibular ligament. There are potential complications, such as avascular necrosis, subtalar arthritis, and nonunion, if this fracture goes untreated (5,7,9,30). FLPT may be missed on plain radiography, so CT should be considered if there is a high suspicion for this injury (2,5,7,12,30). Nondisplaced fractures can often be treated nonoperatively, but attention should be paid to assessing for any degree of displacement (9,30).
Metatarsal fractures also are common in snowboarding, usually resulting from a hard landing on a flat surface. Most isolated metatarsal fractures can be treated nonoperatively (30).
Midshaft tibia and fibula (“boot top”) fractures may be seen in both skiers and snowboarders who wear hard boots (5,30). These injuries typically require urgent surgical fixation.
Nonmusculoskeletal and Severe Injuries
While musculoskeletal injuries are the most common type of injury in snow sports, severe injuries are more likely to affect the head, face, spine, chest, and abdomen (34). Of severe injuries presenting to United States Emergency Departments, 47% to 57% were to the head, 29% to the spine, 37% to the chest, and 35% to the abdomen (34). For both skiing and snowboarding, severe injuries are more likely to occur on days with 5 cm or less of snowfall (20). More severe injuries, including injuries to the spine, thorax, and kidneys, are more likely to occur from collisions rather than falls (20).
Facial Injuries
Facial injuries occur more often at the recreational level in both skiers and snowboarders and typically result from falls or collisions (35). Typical facial injuries in skiers and snowboarders include facial fractures, dental injuries, and dentoalveolar soft tissue injuries (21,35,36). In both skiing and snowboarding, males are more likely to sustain facial fractures. Snowboarders tend to have more maxillofacial injuries than skiers (36). For any suspected facial fracture, acute management should include assessment of the ABC (airway, breathing, and circulation), securing the airway, and assessment for associated cervical spine or head injury (37). Physical examination should include assessment for missing teeth, facial asymmetry, or uneven pupils that may indicate further underlying trauma (37). Any individual with a suspected facial fracture or unstable dental injury should be managed at an emergency facility (37).
Head Injuries
Head injuries are the leading cause of death and critical injury in skiing and snowboarding and range from concussion to severe traumatic brain injury (5,21,38–40). Concussions are the most prevalent type of head injury in both skiing and snowboarding (21,40). Acute assessment and management of head injury in these sports should include a full neurological examination, including a Glasgow Coma Scale score, and assessment for visual disturbances (18,41). A comprehensive head trauma assessment can include standard sideline concussion assessment tools, such as The Sport Concussion Assessment Tool, 5th edition (SCAT5) (41). An individual should not be allowed to return to participation the same day if they experience any head injury that causes symptoms. In stable and nonemergent head injuries, the athlete can be observed for worsening symptoms, but any skier or snowboarder with suspected cervical spine injury, deteriorating symptoms, altered mental status, or signs of intracranial bleeding should be transferred immediately to a tertiary care facility (39,41).
It is critical to recognize early any serious head injury that will necessitate transfer to a tertiary care center. In both skiing and snowboarding, falls are the primary cause of traumatic brain injury (18,19). Collision with an obstacle (tree, rock, lift pole), while the least frequent mechanism of injury, is associated with higher severity head injuries (18). Skiers have higher rates of skull fractures than snowboarders (19). In snowboarding, serious head injuries including subdural hematomas can be seen as a result of aerial moves and landing failures and are more frequent at terrain parks (5,18,19,30,40).
Spine
Spinal injuries account for 1% to 17% of all injuries in alpine sports (5,26,42). For both skiers and snowboarders, the lumbar spine is the most common site of spine injury, and it is not uncommon for more than one spinal level to be affected (42). The majority of severe spinal injuries occur in skiers, while spinal injuries in snowboarders tend to be more stable. Low-risk injuries, such as isolated transverse process fracture, spinous process fracture, or thoracolumbar compression fracture, are seen more often in snowboarders (26,30,42). This difference is likely due to the different injury mechanisms in each sport. Injuries in skiing are more often due to high speed collision leading to a distraction and rotation injury, whereas injuries in snowboarding are more often due to jumps and falls (30,42).
Spinal injuries in skiing that involve the cervical spine are higher risk and may have permanent neurological consequences (42). Initial assessment of spinal injuries should include motor and sensory function, as well as assessment for concomitant injuries (cerebral, pulmonary, vascular, or visceral) (43). If a cervical spine injury or unstable spine injury is suspected, the patient will need to be transported to a tertiary care center. Stable injuries, such as isolated spinous process/transverse process fractures without neurological deficits or spine instability, can be treated with supportive care (30,43).
It also is important to be aware of the latest evidence on cervical and spinal immobilization and discussing with ski patrol and emergency services on their current protocol and available on-site equipment. Although immobilization procedures have been the norm in the trauma setting for years, there is a lack of high quality studies to support rigid spinal immobilization and cervical collars (44). According to the most recent evidence out of Denmark, there is weak recommendation against rigid immobilization in ABCDE stable patients (44). The prior guidelines regarding cervical collar immobilization were based on anatomical and mechanical considerations and not backed by high quality evidence (44). There is additional evidence showing that if the cervical collar or rigid spineboard is placed incorrectly or inappropriately, there may be increased harms at the same time there is a lack of evidence showing improved neurological outcomes (44). With all of that being said, one must still know when it is appropriate to use these procedures (as mentioned in the above paragraph), while also keeping in mind that rigid immobilization may not be appropriate for all injuries.
Chest Wall
Chest trauma is more common in skiing than in snowboarding (34). The most frequent ski- and snowboard-related chest injuries presenting to U.S. emergency departments are rib fractures, lung injury, pneumothorax, hemothorax, and clavicle fractures (34). Isolated rib fractures can be treated with supportive care and careful return precautions. Given the possibility for underlying pulmonary injury from the same mechanism, injuries to the chest wall should be evaluated the same day, preferably at a facility that has X-ray capabilities. Any pulmonary injury, such as pneumothorax or hemothorax, should be transported to an emergency department for further assessment and management. Children may suffer pulmonary contusion without rib fractures. There is minimal data on air travel (with vast changes in altitude and subsequent air pressures) and acute pneumothorax. Based on the evidence that we do have, it would be advisable to postpone commercial air travel until at least 2 wk after radiographic resolution of a traumatic pneumothorax to prevent further complications (45).
Abdomen and Pelvis
Abdominal trauma is more common in snowboarding than skiing (34). The most frequent abdominal injuries in these sports are to the spleen, kidney, pelvis, liver, and gastrointestinal tract (34). Intra-abdominal injuries are most commonly lacerations of solid organs, while pelvic injuries are most commonly fractures (20). Splenic injuries specifically are more likely to occur in snowboarders than skiers, and more likely in male snowboarders than female snowboarders (46). While the majority of severe injuries in skiers and snowboarders occur from collisions, a prospective study of splenic injuries showed that these were more likely to occur as a result of a fall or jump in snowboarders, and more likely to occur as a result of a collision in skiers (46). Ultrasound is an invaluable tool for identifying these injuries in a prehospital setting. Any intra-abdominal injury or pelvic fracture identified on the slope or a smaller clinic should be emergently transferred to a higher level of care.
Environmental Injuries (Altitude, UV radiation, Cold Injury)
Altitude illness is an important environmental consideration in these sports, given that most recreational skiers and snowboarders travel to high-altitude resorts from lower altitudes. Typically seen in unacclimatized individuals ascending above 2500 m, Acute Mountain Sickness (AMS) is the most common form of acute altitude illness (47). Symptoms of AMS are nonspecific, and include headache, gastrointestinal symptoms (poor appetite, nausea, vomiting), fatigue, and dizziness, with change in activity due to these symptoms (47). Other altitude-related illnesses include high-altitude pulmonary edema and high-altitude cerebral edema, which are rare. The primary treatment for all types of altitude illness is descent to a lower altitude (47). Prevention measures against altitude illness include primarily gradual ascent to altitude and may include use of medications, such as acetazolamide and dexamethasone (47).
Levels of UV radiation also can be high at ski resorts, with increases in ambient UV radiation 2% to 3% for every 100 m of altitude gained, and increase up to 40% due to reflection from snow (48). It is recommended that alpine athletes be educated on need for UV protection and use sun-protection factor 30 sunscreen or more, especially on those parts with highest exposure, such as the nose and lips (48).
Skiers and snowboarders are at risk of environmentally associated cold-induced injury, including accidental hypothermia, which is defined as an unintentional drop in core temperature to or below 35°C (49). Hypothermia is not reported frequently in the context of resort located skiing and snowboarding, but should be considered in backcountry skiers particularly due to the association of this condition with trauma (49). The two signs that can guide prehospital clinical assessment of the severity of hypothermia are shivering and any change in mental status (49). Most patients diagnosed with hypothermia will need treatment and monitoring in a hospital setting, though individuals who are shivering, alert, and uninjured may be able to be treated outside of the hospital. Treatment should include protection from further cooling, shelter, calorie replacement to support shivering, and active warming if possible (49).
Frostbite is a local cold-induced freezing injury primarily of peripheral body parts, which progresses along a spectrum of injury severity. Frostbite can occur due to cold exposure of isolated body parts, so may be seen in recreational skiers and snowboarders both in the front and backcountry. Prevention of frostbite should be approached with the goals of maximizing blood flow and minimizing heat loss from soft tissues (50). The primary approach to treatment of early frostbite in the field should include treatment of concomitant injury, rewarming rapidly in water or other environment between 37°C and 39°C, air drying of damaged tissue, protection from refreezing or trauma, dressing the injured tissue, and systemic hydration (50). Subsequently, individuals should be transported to an emergency medical facility for further treatment (50).
While not typically a concern in-bounds of ski and snowboard resorts, avalanche safety is an important consideration for backcountry skiers. Avalanche injuries can be fatal, as a result of both polytrauma, and asphyxia (51). Evidence shows lower risk of avalanche for backcountry skiers traveling in groups of two rather than groups of four or more (52). Education efforts are important in increasing adherence of backcountry skiers and snowboarders with recommended safety practices (53).
Injury Prevention
Both skiing and snowboarding place athletes at risk of a variety of musculoskeletal injuries, and it is important to understand the utility of various prevention strategies. Beginners are at the highest risk of injury, and so proper education, sports-specific instruction, and education on risk awareness is important for novices (28,32,34). Education should include use of protective equipment, and proper chairlift technique (25,28,32,34). Helmet use has been shown to decrease risk and severity of head injuries in both skiing and snowboarding, without increasing risk of cervical spine injury or risk taking (5,15,21). Multiple studies have shown a protective effect of wearing wrist guards, especially in beginners (2,32). Other prevention techniques that show possible benefit include neuromuscular training and improving core strength, but these need further study (2,7).
Conclusions
Snowboarding and skiing place winter athletes at risk for a multitude of injuries. Upper-extremity injuries, especially wrist injuries, are the most common injuries seen in snowboarders. Lower-extremity injuries, specifically ligamentous knee injuries, are the most common injuries seen in skiers. It is important that sports medicine physicians are able to both recognize and acutely treat the most common musculoskeletal, head, body, and environmental injuries seen in these athletes. Helmets, wrist guards, and proper instruction prior to activity have all been shown to reduce injury rates in skiing and snowboarding. More research needs to be done on fall prevention strategies and the most effective types of protective equipment.
The authors declare no conflict of interest and do not have any financial disclosures.
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