SKI AND SNOWBOARD INJURIES Outdoor Emergency Care, 4th Edition AAOS/NSP

Statistics: (Scottish Snow Sports Safety Study) ** Skiers mainly injure Knee, then head/face, then limbs Outdoor Emergency Care, 4th Edition AAOS/NSP

Statistics: (Scottish Snow Sports Safety Study) ** Skiers injure knees and snowboarders injure wrists Outdoor Emergency Care, 4th Edition AAOS/NSP

Statistics: (Scottish Snow Sports Safety Study) ** Skiers sprain more and snowboarders fracture more Outdoor Emergency Care, 4th Edition AAOS/NSP

Conclusion (Scottish Snow Sports Safety Study) Injury rate in Scotland is 2.24 injuries per 1000 skier days Over the four years of the study there was a trend toward less injury Attributed this to increased use of helmets, wrist guards, awareness No mention of skiers using knee braces for primary prevention of joint injury Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Statistics: (Geddes, R et al. Boarder Belly: splenic injuries reslting from ski and snowboarding accidents. Emergency Medicine Australia. April, 2005.17 (2): 157-162 Ten year retrospective review on splenic injury in skiers and snowboarders (boarder belly). Snowboarders are six times more likely to sustain splenic injury than skiers Males 21 times more likely than females to sustain such injury Most injury in snowboarders resulted from falls or jumps. Outdoor Emergency Care, 4th Edition AAOS/NSP

Statistics: (1995 - U.S. Consumer Product Safety Commission) Through the National Injury Information Clearinghouse the looked at head injury from skiing. 42% of head injuries were concussions 24% of head injuries were lacerations CPSC estimates that each year more than 7,000 head injuries could be prevented or reduced in severity with helmet use. Outdoor Emergency Care, 4th Edition AAOS/NSP

Statistics: Snowsport Deaths Occurrence of death in USA from 1991-2004 is 469 58 snowboarders. 401 Skiers. 1 death/ 1.4million skier days Average 35 deaths per season No decrease in mortality despite increased helmet use! Outdoor Emergency Care, 4th Edition AAOS/NSP

Statistics: Final Conclusions Skiers: lacerations, boot-top contusions, thumb injuries, and complex knee injuries. Snowboarders: distal radius fractures, foot or ankle injuries Serious injuries: equal rates of closed head injuries but snowboarders suffer more intra-abdominal injuries (boarder belly) Snowboarders suffer from falls or jumps while skiers from collision. Unique pattern of injuries. Accident prevention must focus on sport specific education and equipment design Outdoor Emergency Care, 4th Edition AAOS/NSP

Common Recommendations Make sure items such as bindings and boots are adjusted to fit properly. Don't ski or snowboard beyond your ability. Ski and snowboard in control, and follow the rules of the slopes. Never ski or snowboard alone. Get in shape before you hit the slopes *Wear warm, close-fitting clothing. Loose clothing can become entangled in lifts, tow ropes and ski poles. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Recommendations are helpful but is there any evidence on protective equipment- Helmets, wrist guards, knee braces? Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Helmets: Hagel, I et al. Assumption that they are helpful is based on bicycle helmet data that does prove usefulness Children have large head:body ratio Could helmets exert excessive bending or twisting on the neck in simple falls Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Helmets: Hagel, I et al. Conclusions: Wearing helmet may reduce risk of head injury by 29-56% Although not statistically significant, there was a trend toward helmet use causing an increase in neck injuries. Limitations: Snowsport participants that fell but were not injured as a result of wearing a helmet could not have been reported Benefits of wearing a helmet may have been underestimated Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Helmets: Sulheim, et al. Norwegian study in skiers and snowboarders Methods Case control study at 8 major alpine resorts during 2002 season 3277 injured and 2992 non-injured controls interviewed Multivariate logistic regression analysis Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Helmets: Sulheim, et al. Results 578 (17.6%) head injuries. Helmet use reduced head injury by 60% even after adjusting for other factors like skill level, equipment, et cetera The risk for head injury was higher in snowboarders Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Helmets: Macnab, et al. Results No difference in serious neck injury between groups (helmet vs non-helmet) Failure to use helmet increase head injury (RR 2.24; 95% CI 1.23-4.12) Outdoor Emergency Care, 4th Edition AAOS/NSP

Snowboarding Injury: Epidemiology Results Ratio of upper extremity injury to all types of injury was significantly higher in snowboarders than skiers by three times Snowboarders fracture wrists and skiers fractures clavicles Snowboarders dislocate elbows and skiers dislocate shoulders In snowboarders, the left upper extremity was more frequently affected due to their orientation on the board Outdoor Emergency Care, 4th Edition AAOS/NSP

Snowboarding: Wrist Guards O’Neill et al. Studied rate of injury in first time snowboarders Compared 551 wore wrist guards and control was more than 1800; no wrist guards. Outdoor Emergency Care, 4th Edition AAOS/NSP

Snowboarding: Wrist Guards Results 40 wrist injuries in Control (unguarded) and 0 injuries in experimental (guarded) in first timers No higher rate of other upper extremity injury in guarded group Should they have stopped and given everyone wrist guards? Outdoor Emergency Care, 4th Edition AAOS/NSP

Snowboarding: Wrist Guards Ronning et al. - Results Significant difference between the two groups Wrist guards were protective More injuries if first-timers and those who rented equipment Outdoor Emergency Care, 4th Edition AAOS/NSP

Statistics: Boarder Belly Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Skiing: Bindings Very poor evidence for studies on bindings Finch et al: Review article based on 15 low level evidence studies Bindings currently have one pivot point to release for rotational forces exerted on the ski from the front, but this does not account for rotational forces from the back Adjustments, especially in children, tends to be inadequate Suggests that a binding testing device should be used to optimize and standardize adjustments Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Skiing: Knee Braces Oates et al: Three groups of skiers: (1) No previous ACL injury- 4748 (2) ACL deficient- 138 (3) ACL reconstruction- 274 Put them all in knee braces Ligament deficient knees had 6.2x higher rate of injury than intact knees Ligament reconstructed knees had 3.1x higher rate than intact Injuries in intact knees were also less severe Outdoor Emergency Care, 4th Edition AAOS/NSP

No evidence on knee braces for primary injury prevention Skiing: Knee Braces Kocher et al: Cohort study of 180 ACL deficient skiers who were a mix of braced and non-braced knees Unbraced knees had higher injury rates (P=0.005) No evidence on knee braces for primary injury prevention Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP

Classic Injuries: Skier’s Thumb Background Skier’s thumb, aka gamekeepers thumb Ski pole injuries and football injuries are now most common cause Outdoor Emergency Care, 4th Edition AAOS/NSP

Classic Injuries: Skier’s Thumb Presentation Acute trauma or repeated stress typically results in ulnar collateral ligament tendonopathy or disruption Leads to swelling, pain, tenderness and/or loss of stability Outdoor Emergency Care, 4th Edition AAOS/NSP

Classic Injuries: Skier’s Thumb Outdoor Emergency Care, 4th Edition AAOS/NSP

Classic Injuries: Skier’s Thumb Prevention Outdoor Emergency Care, 4th Edition AAOS/NSP

Conclusions: General Skier, think knee sprain then ACL or ligament disruption Snowboarder think wrist fracture of left hand Outdoor Emergency Care, 4th Edition AAOS/NSP

Conclusions: Skiing Injuries If points to knee Think ACL tear or sprain and consider brace in future If points to hand Think skier’s thumb and search and qualify avulsion fracture and/or ligament disruption If points to arm Think clavicle fracture and/or shoulder dislocation Outdoor Emergency Care, 4th Edition AAOS/NSP

Conclusions: Snowboard Injuries If points to knee Think sprain If points to hand/wrist Think distal radius fracture and give them a brace to use in future If points to arm Think elbow dislocation If points to foot/ankle Think snowboarder’s ankle If points to abdomen Think boarder belly Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Objectives (1 of 5) List the functions of the central nervous system. Define the structure of the skeletal system as it relates to the nervous system. Relate mechanism of injury to potential injuries of the head and spine. State the signs and symptoms of a potential spinal injury. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Objectives (2 of 5) Describe the method of determining if a responsive patient may have a spinal injury. Relate the airway emergency medical care techniques to the patient with a suspected spinal injury. Describe how to stabilize the cervical spine. List the steps in performing rapid extrication. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Objectives (3 of 5) Explain the rationale for immobilization of the entire spine when a cervical spine injury is suspected. Explain the rationale for utilizing rapid extrication approaches only when they indeed will make the difference between life and death. Demonstrate opening the airway in a patient with a suspected spinal cord injury. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Objectives (4 of 5) Demonstrate evaluating a responsive patient with a suspected spinal cord injury. Demonstrate stabilization of the cervical spine. Demonstrate the four-person log roll for a patient with a suspected spinal cord injury. Demonstrate how to log roll a patient with a suspected spinal cord injury using two people. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Objectives (5 of 5) Demonstrate securing a patient to a long backboard. Demonstrate the procedure for rapid extrication. Demonstrate helmet removal techniques. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Spinal Column Outdoor Emergency Care, 4th Edition AAOS/NSP

Assessment of Spinal Injuries Vehicle crashes (snowmobile, car, motorcycle) Snow rider collisions with fixed objects Snow rider collisions with other snow riders Falls from heights Blunt or penetrating trauma Blunt trauma Hangings Diving accidents Outdoor Emergency Care, 4th Edition AAOS/NSP

Questions to Ask Responsive Patients Does your neck or back hurt? What happened? Where (specific location) does it hurt? Can you feel me touching your fingers? Your toes? Can you move your hands and feet? Outdoor Emergency Care, 4th Edition AAOS/NSP

Assessment of Spinal Injuries Assess DCAP-BTLS. Avoid any excessive motion. Assess strength in each extremity and compare. Absence of pain does not rule out injury. Ability to move or walk does not rule out injury. Outdoor Emergency Care, 4th Edition AAOS/NSP

Signs and Symptoms of Spinal Injury Pain or tenderness of spine Deformity of spine Tingling and/or weakness in the extremities Loss of sensation or paralysis Incontinence Soft-tissue injuries to head, neck, back Outdoor Emergency Care, 4th Edition AAOS/NSP

Emergency Medical Care Follow BSI precautions. Manage the airway. Perform the jaw-thrust maneuver to open the airway. Consider inserting an oropharyngeal airway. Administer oxygen. Stabilize the cervical spine. Outdoor Emergency Care, 4th Edition AAOS/NSP

Stabilization of the Cervical Spine (1 of 3) Hold patient’s head firmly with both hands. Support the lower jaw. Move to patient’s head to eyes-forward position. Maintain position until patient is secured to backboard. Outdoor Emergency Care, 4th Edition AAOS/NSP

Stabilization of the Cervical Spine (2 of 3) Assess and monitor CMS functions. Cervical collars do not replace manual stabilization. Improperly fitted collars may be harmful. Towel rolls and/or blanket rolls can be substituted for cervical collar. Outdoor Emergency Care, 4th Edition AAOS/NSP

Stabilization of the Cervical Spine (3 of 3) Do not force the head into a neutral, in-line position if the following develop: Muscles spasms Increase in pain Numbness, tingling, or weakness Compromised airway or breathing Outdoor Emergency Care, 4th Edition AAOS/NSP

Preparation for Transport: Supine Patients (1 of 2) Maintain in-line stabilization. Assess and monitor distal CMS functions in each extremity. Apply a cervical collar, sized appropriately. Have other team members position immobilization device. Log roll patient; quickly assess the back. Outdoor Emergency Care, 4th Edition AAOS/NSP

Preparation for Transport: Supine Patients (2 of 2) Center patient on device. Secure upper torso to device. Secure pelvis, legs, and feet. Immobilize and secure the head. Check and adjust all straps. Reassess distal CMS functions. Outdoor Emergency Care, 4th Edition AAOS/NSP

Preparation for Transport: Sitting Patients Maintain manual in-line stabilization. Assess CMS functions, apply a cervical collar. Place a short board or short immobilization device behind patient. Position device around patient and secure. Turn and lower patient to long backboard. Secure short and long backboards together. Reassess distal CMS functions. Outdoor Emergency Care, 4th Edition AAOS/NSP

Preparation for Transport: Standing Patients Stabilize the head and neck from behind and apply a cervical collar. Position board upright behind patient and secure. A rescuer stands at each side, facing the patient. Reach under each arm, grasp board near patient’s shoulder. Carefully lower patient to ground. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Head Injuries All head injuries are potentially serious. Types include: Scalp lacerations Skull fractures Brain injuries Medical conditions Complications of head injuries Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Scalp Lacerations Scalp has a rich blood supply. There may be more serious, deeper injuries. Follow BSI precautions. Fold skin flaps back down onto scalp. Control bleeding by direct pressure. Watch for skull fractures Add additional dressings as needed. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Skull Fracture Indicates significant force Signs: Obvious deformity Visible crack in skull Raccoon eyes Battle’s sign Cerebrospinal fluid Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Concussion (1 of 2) Minor traumatic brain injury (TBI) Temporary loss or alteration in brain function May result in unresponsiveness, confusion, or amnesia Retrograde amnesia: forgetting events leading up to injury Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Concussion (2 of 2) Anterograde (posttraumatic) amnesia: forgetting events after the injury Perseveration: repetitive speech patterns Brain can sustain bruise when skull is struck. There will be bleeding and swelling. Bleeding will increase pressure within skull. Outdoor Emergency Care, 4th Edition AAOS/NSP

Intracranial Bleeding Major TBI Laceration or rupture of blood vessel in brain Subdural Intracerebral Epidural Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Other Brain Injuries Brain injuries are not always caused by trauma. Medical conditions may cause spontaneous bleeding in the brain. Example: high blood pressure Signs and symptoms of nontraumatic injuries are the same as those of traumatic injuries. There is no MOI. Outdoor Emergency Care, 4th Edition AAOS/NSP

Complications of Head Injury Cerebral edema is one of the most serious complications. Ensure airway and provide oxygen. Seizure (convulsion) may occur. Vomiting may occur. Common in children Leakage of cerebrospinal fluid may occur. Do not pack ears or nose. Outdoor Emergency Care, 4th Edition AAOS/NSP

Assessing Head Injuries (1 of 2) Common causes: Skier-object (fixed or moving) collisions Direct blows (deformed or dented helmet) Falls from heights Sports injuries, especially involving speed Evaluate and monitor level of responsiveness Outdoor Emergency Care, 4th Edition AAOS/NSP

Assessing Head Injuries (2 of 2) Blunt injuries are associated with trauma. Consider MOI. Assess and monitor level of responsiveness. Evaluate and compare pupil size, shape, and reaction to light. Injury may be closed or open. Outdoor Emergency Care, 4th Edition AAOS/NSP

Signs and Symptoms (1 of 3) Lacerations, contusions, hematomas to scalp Soft areas or depression upon palpation Visible skull fractures or deformities Ecchymosis around eyes and behind ear Clear or pink CSF leakage Failure of pupils to respond to light Outdoor Emergency Care, 4th Edition AAOS/NSP

Signs and Symptoms (2 of 3) Unequal pupils (anisocoria) Occurs naturally in 5% of the population Loss of sensation and/or motor function Period of unresponsiveness Respiratory distress due to bleeding or swelling of the airway Amnesia Outdoor Emergency Care, 4th Edition AAOS/NSP

Signs and Symptoms (3 of 3) Seizures Numbness or tingling in the extremities Irregular respirations Dizziness Visual complaints Combative or abnormal behavior Nausea or vomiting Outdoor Emergency Care, 4th Edition AAOS/NSP

Level of Responsiveness Change in level of responsiveness is the single most important observation. Use the AVPU scale or Glasgow Coma Scale (depending on local protocols). Reassess level of responsiveness: Every 15 minutes if patient is stable. Every 5 minutes if patient is unstable. Levels may fluctuate or progressively deteriorate. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Change in Pupil Size Unequal pupil size may indicate increased pressure on one side of the brain. Outdoor Emergency Care, 4th Edition AAOS/NSP

Emergency Medical Care Protect the cervical spine. Follow these three principles: Establish an adequate airway, provide high-flow oxygen. Control bleeding, provide adequate circulation. Assess baseline vital signs and monitor patient’s level of responsiveness. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Managing the Airway First priority! Use jaw-thrust maneuver. Maintain neutral, in-line stabilization. Use suction and remove foreign bodies. Provide high-flow oxygen. Assist ventilations as needed. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Circulation Start CPR in patients with cardiac arrest. Control bleeding. Shock is usually due to bleeding. Patients with a medical condition or nontraumatic brain injury should be placed on side to avoid aspiration. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Cervical Collar Provides preliminary, partial support Applied to every patient with a suspected spinal injury Used with manual stabilization until patient is secured to spinal immobilization device Must be correctly sized Outdoor Emergency Care, 4th Edition AAOS/NSP

Applying a Cervical Collar One rescuer provides continuous manual in-line support of head. Measure proper size collar. Place chin support snugly under chin. Maintain manual support. Wrap collar around neck. Ensure that collar fits. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Backboards Short backboards, vests Used on patients found in sitting position Used in extrication Long backboards Provide full-body immobilization Can be used to splint many injuries Instructors: refer back to slides 19—24 for review. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Helmet Removal (1 of 5) Is airway clear and is patient breathing adequately? Can airway be maintained and ventilations assisted with helmet in place? How well does helmet fit? Can patient move within helmet? Can spine be immobilized in a neutral position with helmet on? Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Helmet Removal (2 of 5) A helmet that fits well prevents the head from moving and should be left on, as long as: There are no impending airway or breathing problems. It does not interfere with assessment and treatment of the airway. You can properly immobilize the spine. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Helmet Removal (3 of 5) Remove a helmet if: It makes assessing the airway difficult. It interferes with spinal immobilization. It allows excessive head movements. Patient is in cardiac arrest. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Helmet Removal (4 of 5) Remove glasses or goggles. Stabilize head and loosen strap. Place hands at the jaw and back of head. Begin to gently slide helmet up and off. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Helmet Removal (5 of 5) Slide hand up the back of head to prevent it from moving. Rotate helmet all the way off head. Manually stabilize cervical spine as normal. Apply cervical collar. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Pediatric Needs (1 of 2) Children will need additional padding to prevent neck flexion. Blanket rolls can be used in place of cervical collars. Outdoor Emergency Care, 4th Edition AAOS/NSP

Outdoor Emergency Care, 4th Edition AAOS/NSP Pediatric Needs (2 of 2) Children may need extra padding to maintain immobilization. Car seats can be used as immobilization devices. Outdoor Emergency Care, 4th Edition AAOS/NSP