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Review Article

Comprehensive Review of Skiing and Snowboarding Injuries

Owens, Brett D. MD; Nacca, Christopher MD; Harris, Andrew P. MD; Feller, Ross J. MD

Author Information
Journal of the American Academy of Orthopaedic Surgeons: January 1, 2018 - Volume 26 - Issue 1 - p e1-e10
doi: 10.5435/JAAOS-D-16-00832
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Abstract

In 2010, an estimated 11.5 million people in the United States participated in skiing, and 8.2 million engaged in snowboarding.1 Snowboarding has experienced a considerable increase in popularity since its inception in the 1970s.2 Given the increased popularity of the sport and the emergence of terrain parks, the incidence of snowboarding injuries has increased more than the incidence of skiing injuries. Made and Elmqvist3 found a threefold higher injury rate in snowboarders than in skiers. The authors found that from 1989 to 1999, the incidence of snowboarding injury as a component of all snow sport–related injuries increased from 4% to 56%.

Kim et al1 demonstrated that the most common injuries in snowboarders were wrist injuries, whereas the most common skiing injuries involved the lower extremity, predominately affecting the anterior cruciate ligament (ACL). However, no anatomic location is exempt from the potential for injury (Table 1). Compared with the incidence of snow sport–related injury to the upper extremities, the incidence of injury to the lower extremities has decreased substantially since the early 1970s.1 Improved equipment, such as newly developed bindings, may account in part for this considerable reduction in lower leg injuries.4 Some evidence suggests that wrist guards can successfully reduce serious upper extremity injury.5 Specific focus has been placed on the prevention of ACL injuries, resulting in injury prevention training programs and knee bracing.6

Table 1
Table 1:
The Most Common Skiing and Snowboarding Injuries by Anatomic Location

Head Injuries

Although not typically within the realm of orthopaedic medical practice, an understanding of the sequelae associated with snow sport–related head injuries is needed because these injuries may affect the overall surgical care of a patient, resulting in delays in definitive treatment and difficulty in complying with therapy for other treated injuries. Head injuries account for approximately 15% of all reported snowboarding injuries and are the most common cause of morbidity and death among snowboarders.7 In a study published in the year 2000, Levy and Smith8 reported that injuries to the head accounted for approximately 28% of all skiing injuries and 33.5% of all snowboarding injuries. Head injury also tends to be the leading cause of referrals to level I trauma centers after a snowboarding accident, which is why such an injury should be triaged appropriately in the initial trauma evaluation.9

Snowboarders have both feet securely fixed to the board, and they face sideways while riding, which inherently causes more ventrodorsal instability than does skiing. Because snowboarders tend to fall backward, they are more prone to occipital trauma, in contrast to skiers, who can use their upper extremities to brace themselves during a fall. Overall, 22% of head injuries are serious enough to cause clinical signs of concussion.10 Acute subdural hematoma was the most common intracranial injury pattern requiring intervention, a finding consistent with other published literature.11,12 Traumatic brain injury is fatal among snowboarders and skiers of all ages and is a contributing factor in up to 88% of all injury-related deaths.10

Axial Injuries

Spine trauma is among the most devastating injuries in winter sports, comprising 1% to 17% of all injuries in skiers and snowboarders.13,14 As freestyle skiing, which involves extreme jumping and aerial maneuvers, has become popular, spine injuries in skiers have increased.

Most spine injuries occur as a result of intentional jumps rather than collisions.15,16 A fall backward is the proposed mechanism of injury (which typically stresses the thoracolumbar junction), causing an axial load or a flexion-distraction moment. This mechanism of injury is important to consider during the initial assessment. Proper jumping and landing techniques should be taught and emphasized when the participant is young.

Spine injuries associated with skiing and snowboarding predominately affect the thoracic and lumbar spine.14,15,17 In a retrospective review conducted over a period of 5 years in Aspen, Colorado, Gertzbein et al14 reported on a cohort of 119 patients with a total of 146 thoracic or lumbar fractures. The AO Comprehensive Classification was used to categorize 114 fractures, and the remaining 32 fractures (22%) were isolated spinous or transverse process fractures. Of 114 fractures, 94.7% were categorized as compression injuries based the AO classification system; 71% of these were simple compression fractures, and the remaining 23% were classified as burst fractures. Distraction and rotational injuries were much less common, comprising 4.4% and 0.9% of injuries, respectively.

The development of back pain in young elite skiers should be investigated. Rachbauer et al17 radiographically evaluated elite skiers aged <17 years and compared the findings with those of recreational skiers of the same age. The average age at sport initiation was 6 years. Approximately 50% of the elite skiers had end plate lesions (with an anterior location being most common), compared with <20% in the recreational skiers. Persistently bending forward has been shown to increase intradiscal pressure greatly, subsequently causing fracture of the end plate and even disk herniation, which can be represented as Schmorl nodes that are sometimes identified on imaging. Greene et al18 coined the term atypical Scheuermann disease to describe the vertebral changes and development of mechanical back pain. The surgeon must consider such a diagnosis when evaluating competitive youth skiers and should take into account the high loads applied to the spine versus the actual loading capacity of an immature spine.

Ogawa et al19 performed a comprehensive review of 145 patients with snowboarding injuries over an 8-year period, focusing specifically on pelvic fractures. The incidence of pelvic fractures was 2%. Jumping was the main mechanism of injury observed; however, collisions—predominately with trees and ski towers—substantially correlated with unstable injury patterns. Using the Tile classification, those authors determined that, in patients with snowboarding-related pelvic injuries, the most common pelvic injury pattern was a type A (stable) fracture (85.5%), with isolated pubic or ischial fracture being most common, followed by isolated sacral fractures. Type B and C (unstable) fractures were less common than type A fractures, at 14.5%. Associated injuries were present in 20% of fractures, with a substantially higher prevalence of associated injuries found in the unstable fracture group compared with the stable fracture group. The authors of the study noted that, although sacral fractures are rare and typically are associated with pelvic ring fractures, isolated sacral fractures associated with snowboarding occur more often.19 Therefore, the surgeon must maintain a high level of suspicion for isolated sacral fractures in patients who present with buttock pain related to snowboarding injuries.

Shoulder Girdle Injuries

Shoulder girdle injuries are among the most common snow-sport injuries and more frequently occur in snowboarders than in skiers. Kim et al1 investigated snowboarding and skiing injuries that occurred at a resort in Vermont from 1988 through 2006 and found that shoulder injuries and clavicle fractures in adult snowboarders accounted for 11.7% and 4% of all reported injuries, respectively. The number of snowboarding-related clavicle fracture rates has increased greatly since the emergence of terrain parks. The prevalence of these injuries appears to be increasing as a result of the popularity of performing aerial stunts. Kim et al1 reported that 43.8% of clavicle fractures were sustained while snowboarding in terrain parks, 33.7% were associated with jumping activities, and 92.6% resulted from impact with the snow’s surface.

In a study of shoulder injuries associated with skiing and snowboarding, McCall and Safran20 reported that shoulder injuries account for 4% to 11% of alpine skiing injuries, with rotator cuff strains being the most common shoulder injury. Shoulder injuries associated with skiing are the result of four mechanisms: direct impact, axial load on an extended arm, resisted forced abduction of the arm, and external rotation forces resulting from a firmly planted ski pole in the grasp of a skier during a fall.

Ogawa et al21 retrospectively reviewed glenohumeral dislocations in snowboarders and skiers treated at a Japanese hospital over a 5-year period. In skiers, glenohumeral dislocations accounted for 5.5% of all injuries. Of all sites of dislocation, the glenohumeral joint was the most common at 49.3%, followed by the elbow at 23.4% and the acromioclavicular joint at 17.9%. The prevalence of fracture-dislocations was higher in skiers than in snowboarders (33.9% and 12.4%, respectively). One common mechanism is secondary engagement of the leading toe-side edge of the snowboard, resulting in a fall forward. A high incidence of recurrent dislocations has been documented in younger patients (especially those aged <25 years) with a prior dislocation.

As in the general population, rotator cuff pathology is of primary concern in skiers and snowboarders aged >40 years with a prior dislocation.20 Pevny et al22 found that the incidence of concomitant rotator cuff tear was 35% after first-time dislocations in patients aged >40 years; therefore, radiologic assessment with MRI should be considered in these patients.

Wrist Injuries

The wrist is the most common location of upper extremity injury related to snowboarding.23,24 Idzikowski et al23 conducted a survey of upper extremity snowboarding injuries that occurred during 10 seasons in Vail, Colorado, from 1988 through 1998. Wrist injuries accounted for 44% of all upper extremity injuries and 21.6% of all snowboarding injuries. Fractures accounted for 78% of wrist injuries. Sasaki et al24 reported similar results in their comparative study of wrist injuries sustained during snowboarding and Alpine skiing; snowboarding wrist injuries accounted for 36.4% of all upper extremity injuries, compared with 9.1% of skiing injuries. Physeal fractures associated with snowboarding were found to occur at twice the rate of that associated with skiing. The mean age of snowboarders who sustained distal radius fractures was 21.7 years, compared with 30.8 years for skiers. The age-matched rate of distal radius comminution was found to be 49.4% for snowboarding and 23.8% for skiing in patients aged 18 to 32 years.24 Scaphoid fractures and perilunate injuries often are associated with high-energy injury; thus, these injuries are more commonly found in more experienced skiers and snowboarders. Idzikowski et al23 reported that perilunate dislocations or lunate fracture-dislocations accounted for 2% of wrist injuries in their study. Of the injuries sustained by beginner snowboarders, 34% were injuries to the wrist, and wrist fractures were common. Overall, 92% of injuries were the result of a fall. A fall forward (ie, toe side) was more predictive of a shoulder injury, whereas a fall backward (ie, heel side) was more likely to result in a wrist injury.

Hand Injuries

The incidence of hand injuries varies considerably among skiers and snowboarders. In a study of 7,430 snowboarding-related injuries, Idzikowski et al23 noted that hand injuries accounted for 8.4% of upper extremity injuries. Of the hand injuries, 50% were fractures, 31.5% were sprains, and 5.6% were dislocations. Ulnar collateral ligament (UCL) injuries accounted for only 1.8% of reported hand injuries among snowboarders.23 In contrast, UCL injuries are among the most common skiing injuries. Van Dommelen and Zvirbulis25 found that UCL injuries accounted for up to 80% of all upper extremity injuries in skiers.

Watson-Jones26 initially studied the UCL and its effect on thumb stability in 1943. Campbell27 first reported chronic laxity of the UCL in gamekeepers, a condition that later was termed gamekeeper’s thumb. Frequently encountered in skiing, acute traumatic rupture of the UCL popularized the term skier’s thumb to describe this injury (Figure 1). The typical mechanism of injury involves a fall while the skier holds a ski pole or when a skier continues forward while the pole is planted firmly, resulting in forced thumb metacarpophalangeal abduction and extension.28,29

Figure 1
Figure 1:
Illustration showing the mechanism of thumb metacarpophalangeal ulnar collateral ligament injury, known as skier’s thumb. (Copyright Rick Sargent, Sargent Illustration and Design.)

Knee Injuries

Knee injuries are some of the most common injuries in snow sport athletes, especially in skiers, accounting for approximately one third of all reported injuries.23,30-32 Soft-tissue injuries account for most reported cases, and the ACL is involved in approximately 50% of all serious knee injuries. As in other sports, noncontact ACL injuries in skiing occur more frequently in females than in males. Ruedl et al30 found a twofold increased risk for ACL tear in a female recreational skier’s nondominant leg. This injury most commonly involved the left leg, because >90% of skiers preferred the right leg as their kicking leg. In addition to soft-tissue injuries, fractures secondary to high-energy trauma also are observed. In children, it is not uncommon to discover Salter-Harris fractures of the distal femur associated with downhill skiing.33 In adults, the incidence of tibial plateau fracture is on the rise, with lateral plateau fractures being the most common variant.28

Multiple proposed mechanisms exist for ACL injuries related to snow sport activity. In a study by Bere et al,34 20 videos of World Cup skiers sustaining ACL injuries were analyzed. Three main mechanisms of injury were identified: back-weighted landing, slip-catching, and dynamic snow plowing. The ultimate cause of failure in the dynamic snow plowing and slip-catching mechanisms was knee internal rotation and/or valgus loading. Most injuries (50%) were in the slip-catching category and occurred as the outer ski was reestablishing contact with the snow. The inside ski edge suddenly caught the surface of the snow, forcing the knee into excessive valgus and internal rotation (Figure 2). This combination of valgus and internal rotation loading of the knee is consistent with biomechanical studies simulating ACL injuries in skiers. Other mechanisms have been described, such as valgus and external rotation loading of the knee, as well as the classic phantom foot phenomenon, which occurs as the skier falls backward in between the skis as the inside edge of the downhill ski catches the snow’s surface, ultimately resulting in internal rotation of the flexed knee.28,32 Secondary to the previously described mechanisms, especially valgus load, it is not uncommon to discover concomitant injuries, such as medial collateral ligament sprains, meniscal tears, and even tibial plateau fractures.28 The previously described mechanisms of injury are unique to skiing and differ substantially from those experienced in other sports. Failure of ski bindings to release as these injuries occur has been noted, as demonstrated in 24.6% of skiers in the series by Koehle et al32 and in 17 out of 20 skiers in the series by Bere et al.34 Although ligamentous injuries of the knee tend to occur less frequently in snowboarders than in skiers, experienced snowboarders who perform large jumps and tricks are at risk for these injuries. A proposed mechanism for ACL injury in snowboarders is eccentric quadriceps contraction on a flexed knee while landing on a flat surface, forcing the knee into internal rotation.7

Figure 2
Figure 2:
Photographs showing a slip-catch mechanism of injury, causing left knee anterior cruciate ligament injury. A, The skier is out of balance backward and inward during a right-hand turn. B, The skier loses pressure on the outer ski, which drifts away from the body’s center of mass. C, The outer ski catches the inside edge abruptly. D, The skier falls backward toward her left. (Reproduced with permission from Bere T, Mok KM, Koga H, Krosshaug T, Nordsletten L, Bahr R: Kinematics of anterior cruciate ligament ruptures in World Cup Alpine skiing: 2 case reports of the slip-catch mechanism. Am J Sports Med 2013;41[5]:1067-1073.)

Overall, management of knee injuries related to winter sports does not differ greatly from that for injuries related to other sports. Oates et al35 evaluated the risk for further injury in skiers with native, ACL-deficient, and reconstructed knees. Compared with knees that had intact ligaments, ACL-deficient knees exhibited a 6.2-times higher risk of injury than intact knees did, and reconstructed knees demonstrated a 3.1-times higher risk of injury. Only 13% of the native knees ultimately required surgery, whereas 39% and 41% of the ACL-deficient and reconstructed knees, respectively, required surgery. The authors also found that skiers who were treated with hamstring autograft were considerably more likely to experience rerupture than were those who were treated with patellar tendon autograft.

Foot and Ankle Injuries

With the advent of improved ski boots and bindings, the increase in ACL injuries has corresponded to a reduction in foot and ankle injuries in skiers. In a prospective study of skiing injuries sustained at two ski areas from 1972 through 1994, Deibert et al36 noted an overall 43% reduction in the number of ankle injuries sustained at the beginning of the study compared with the number of injuries at the end of the study. In contrast, foot and ankle injuries are the most prevalent type of lower extremity injury associated with snowboarding, and one study found that injuries to the ankle comprised approximately 15% of all injuries.7 Ankle fractures and sprains, associated with either snowboarding or skiing, constituted most of the injuries. Fracture of the lateral process of the talus, which is commonly referred to as the snowboarder’s fracture, is an injury relatively unique to snowboarding (Figure 3). Leach and Lower37 reported that peroneal tendon dislocations and Achilles tendon ruptures typically result from a forward fall and are commonly seen in skiers.

Figure 3
Figure 3:
A, Illustration showing the proposed mechanism of injury for the snowboarder’s fracture, including eversion and dorsiflexion of the left ankle. B, CT of both ankles demonstrating a normal ankle and an ankle with a displaced fracture of the intra-articular lateral process of the talus (arrow). (Panel B reproduced with permission from Kirkpatrick DP, Hunter RE, Janes PC, et al: The snowboarder’s foot and ankle. Am J Sports Med 1998;26[2]:271-277.)

In a study of snowboarding injuries that occurred in Japan over the 2004 to 2005 and 2008 to 2009 snowboarding seasons, Ishimaru et al38 found that most ankle fractures were supination-external rotation injuries as defined by the Lauge-Hansen classification system, with supination-external rotation type II injuries being the most common. The leading lower extremity, which tends to be contralateral to the upper extremity injury site, was most commonly injured. Ishimaru et al38 found that collision with other participants or obstacles was the mechanism responsible for most lower extremity injuries. However, other series have reported that falls were the most common mechanism of injury.39

Tibial plafond injuries and pilon fractures are common, especially in skiers, secondary to vertical impact and axial load. When the athlete lands on a slope, the energy tends to dissipate while downhill motion continues. Energy does not dissipate when the athlete lands on a flat surface, and this can result in tibial plafond injury.37

Although ankle fractures and sprains account for most of the injuries in skiers and snowboarders, Kirkpatrick et al39 found that metatarsal fractures were the most common foot fracture sustained by the snowboarders in their study, accounting for 29 of 33 foot fractures (88%). This type of fracture is the result of an impact mechanism rather than the rotation mechanism associated with ankle injuries.

In contrast, fracture of the lateral process of the talus is relatively uncommon, accounting for approximately 1.2% to 6.3% of all lower extremity injuries in snowboarders.39 The mechanism for this injury initially was believed to be ankle dorsiflexion, hindfoot inversion, and axial loading (typically occurring after a jump).7,39 However, in a cadaver study of talus fractures produced by eversion and dorsiflexion, Funk et al40 reported that all of the axially loaded and dorsiflexed ankles that were subjected to eversion sustained a fracture, whereas no fractures occurred in axially loaded and dorsiflexed ankles subjected to inversion. Suspicion for fracture of the lateral process of the talus warrants assessment with CT because the fracture can be missed easily on plain radiography (Figure 3, B). The consequences of delayed detection of the injury, which is commonly misdiagnosed as an ankle sprain, can lead to osteonecrosis, nonunion, and subtalar osteoarthritis. The goal of treatment is to maintain joint surface congruity. Open reduction and internal fixation often is warranted for larger displaced fractures (>2 mm), whereas smaller displaced fragments may be excised, with early weight bearing allowed.7,39 In a study of talus fractures in snowboarders, Valderrabano et al41 assessed treatment outcomes in 20 patients over a 3.5-year period. American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale scores were considerably higher in patients who underwent surgical treatment for type II injuries with >2 mm of displacement, compared with those who underwent nonsurgical treatment. Subtalar arthritis developed in three patients; however, no statistically significant difference was found between patients who underwent surgery and those who did not. The authors concluded that anatomic reduction and fixation led to better outcomes, particularly in the setting of type II displaced fractures, allowing patients to return to their previous level of sport activity.

Injury Prevention

Helmets

The deaths of Michael Kennedy and Sonny Bono prompted advocacy of mandatory helmet use; however, no mandate and universal recommendations on helmet use during winter sport participation are available. The American Medical Association found insufficient evidence to officially endorse helmet use in 1997; however, it did recommend voluntary use for children and adolescents while participating in winter sports.10 Hasler et al11 observed a large increase in helmet use in Switzerland, from 10% in the 2001 to 2002 season to 69.2% in the 2010 to 2011 season. In a recent study of skiing- and snowboarding-related injuries treated at a level I pediatric trauma center in Colorado from January 1999 through December 2014, it was discovered that 57% of children injured were helmeted.42 In patients who were admitted to the intensive care unit, the mean injury severity score and abbreviated injury severity score were considerably lower for those who were helmeted, compared with those who were not. Although the authors of the study demonstrated a trend of increased use, a substantial number of patients (40%) elected not to use a helmet. In a systematic review of the efficacy of helmets in reducing head injuries in snowboarders and skiers, Haider et al10 found overwhelming evidence that helmet use reduces the risk and severity of head injuries in these athletes. An increased risk of cervical spine injury or compensating “risky” behavior was not observed in those who were helmeted.

Wrist Guards

As the prevalence of upper extremity injuries has increased, especially in snowboarders, attention has turned to the possible protective effect of wrist guards.1 In a survey of snowboarding-related upper extremity injuries, Idzikowski et al23 determined that in 5.6% of injuries, the snowboarders had been wearing wrist guards. Women, older participants, and less experienced riders were more likely to wear wrist guards. Overall, wrist-guard wearers were approximately 50% as likely to sustain wrist injuries as those who did not wear wrist guards. The authors of the study were unable to correlate fracture severity with the use of guards; however, they concluded that wrist guards provided considerable protection against wrist injury. Russell et al5 also examined the effect of wrist guard use on wrist and arm injuries in snowboarders and found that the risk of wrist injury, sprain, and fracture was substantially reduced with the use of wrist guards. The authors of the study found that one wrist injury was prevented for every 50 snowboarders wearing wrist guards. Although these studies suggest that the use of wrist guards is beneficial, there is no consensus on which type of wrist guard design offers optimal protection against injury.

Knee Bracing and ACL Injury Prevention

A paucity of literature exists regarding knee braces and their ability to prevent skiing and snowboarding injuries in native knees; most of this research has focused on ACL-deficient or reconstructed knees.6,43 Kocher et al43 studied a cohort of 180 professional alpine skiers with ACL deficiency and found that those who did not use braces were 6.4 times more likely to sustain an injury to the knee than those who did use braces. Injuries included meniscal tears and osteochondral and medial collateral ligament pathology. They concluded that, in the ACL-deficient knee, bracing can be beneficial. In a prospective cohort study by Sterett et al,6 the effect of bracing on ACL-reconstructed knees was evaluated. Similar to the study by Kocher et al,43 Sterett et al6 found that the risk for subsequent knee injuries was 2.7 times higher in recreational skiers who did not use braces than in those who used braces. Of 61 total injuries, 28 required surgery, 11 of which were revision ACL reconstructions. Overall, functional knee bracing seems to provide some degree of stability in the setting of rotational stress in skiers. Additional studies are needed to evaluate the effectiveness of bracing in preventing ACL injuries in native knees.

In addition to bracing, the focus of research has turned to other modifiable risk factors that may prevent initial knee injuries, especially in elite skiers. Raschner et al44 studied ACL injuries in relation to physical fitness over a 10-year period in skiers aged 14 to 19 years. The authors of the study found that decreased core strength strongly correlated with higher rates of ACL injury, especially in female skiers. In a study of elite Alpine skiers, Jordan et al45 compared the quadriceps and hamstring strength of ACL-reconstructed knees versus noninjured knees. They found substantial differences in quadriceps and hamstring maximal and explosive strength between ACL-reconstructed knees and both the contralateral extremities and the noninjured knees. Also of interest, uninjured male ski racers displayed bilateral deficits in hamstring maximal and late-phase explosive strength, demonstrating the need to focus on specific resistance training, not just when rehabilitating injured skiers, but also when training young elite skiers.

Ski Bindings

Improvements in ski bindings began in the 1970s, with no important advancements occurring after 1980.4 Modern ski boots are designed to provide excellent control and support, thereby restricting range of motion. Current ski bindings are adjusted based on weight, height, age, trail difficulty, and speed. Each season, bindings must be inspected and checked for proper calibration of the heel and toe pieces using the Deutsches Institut für Normung international standard to ensure disengagement. These design changes have improved the skiing experience; however, they simultaneously increase the number of situations that may place the ACL at risk for sprain or tear.4

In a retrospective study of 498 recreational skiers who sustained an ACL injury, Ruedl et al46 reported that the bindings failed to release in 78% of cases, with a much higher incidence in female than male skiers. Falls at slow speed and falling backward resulted in a higher incidence of failed binding release than did falls at higher perceived speeds. Overall, failure of the binding to release was substantially associated with female sex, slow perceived speed, and complete rupture of the ACL.

Bindings and Boots

Snowboard bindings, unlike the typical recreational ski binding, are not releasable. An exception is the telemark ski, which lacks a heel binding, and is lighter and more flexible overall. Three different kinds of snowboard boots are available: soft, hybrid, and hard. Soft snowboarding boots are traditional and generally are constructed of leather or synthetic material that allows maneuvering and comfortable riding. Hybrid boots have gained popularity with new snowboarders. Typically, they are constructed of leather or an outer synthetic shell with a rigid inner boot. Hard snowboard boots, which are primarily worn by racers, provide increased ankle control and support. Each style of boot places different forces on the foot and the lower extremity.47

Lower extremity snowboarding injury patterns have changed as the design of boots and bindings has evolved. Many studies have demonstrated that <50% of snowboarding injuries affect the lower extremity and are related to the type of boot used. Hard snowboard boots place snowboarders at risk for fracture of the fibula and tibia at the top of the boot, known as boot top fracture47 (Figure 4). Telemark ski boots, which contain an open heel, effectively can prevent these fractures in a forward fall.48 Hard snowboard boots have been shown to place snowboarders at approximately two times the risk of knee injury compared with soft boots; however, soft snowboard boots place these athletes at approximately two times the risk of ankle injuries compared with hard snowboard boots.47

Figure 4
Figure 4:
Illustration demonstrating the mechanism of injury for a tibia and fibula fracture (ie, boot top fracture), which is the result of a bending moment secondary to the more rigid boot.

Although releasable ski bindings are thought to prevent lower extremity injuries, the bindings often do not actually release under applied stress and falls. In a review of telemark skiing injuries, the type of bindings and boots and the skier’s experience level were the most important risk factors for injuries.48 The authors noted a reduced injury rate overall for telemark skiing compared with alpine skiing. They attributed this finding partly to the increased stability provided by telemark boots. Increased stability can reduce falls caused by a ski edge catching the snow during a turn, which is a common mechanism of injury. Additional improvements in binding technology and release mechanisms is a possible area of future focus to further reduce injury rates.

Summary

Skiing and snowboarding are among the most popular winter sports worldwide, and snowboarding has experienced the largest recent increase in participation.1 Although injuries sustained by skiers and snowboarders can occur in other sports, the environment, equipment, and pathomechanics of skiing and snowboarding lead to a unique spectrum of injuries. Recent developments in equipment and prevention measures have helped to reduce the incidence of injuries related to skiing and snowboarding. Improvements in wrist guards, knee braces, and binding design have contributed to this reduction in upper and lower extremity trauma. Future research likely will be focused on injury prevention training programs and the continued evolution of equipment with protective properties.

References

Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, references 5 and 10 are level I studies. References 6, 9, 36, 39, and 41 are level II studies. References 1, 11, 17, 30, 35, 38, and 42-46 are level III studies. References 2, 3, 12-16, 18, 19, 21-25, 29, 31, 34, 40, and 48 are level IV studies. References 4, 7, 8, 20, 27, 28, 32, 33, 37, and 47 are level V expert opinion.

References printed in bold type are those published within the past 5 years.

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Keywords:

skiing; snowboarding; anterior cruciate ligament; ACL; injury prevention; bindings

Copyright 2017 by the American Academy of Orthopaedic Surgeons.