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

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

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

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

5. 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

6. Outdoor Emergency Care, 4th Edition AAOS/NSP

7. 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, (2):
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

8. 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

9. Statistics: Snowsport Deaths
Occurrence of death in USA from 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

10. 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

11. 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

12. 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

13. 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

14. Outdoor Emergency Care, 4th Edition AAOS/NSP

15. 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

16. 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

17. 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

18. 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 )
Outdoor Emergency Care, 4th Edition AAOS/NSP

19. 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

20. 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

21. 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

22. 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

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

24. 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

25. Outdoor Emergency Care, 4th Edition AAOS/NSP
Skiing: Knee Braces
Oates et al:
Three groups of skiers: (1) No previous ACL injury (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

26. 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

27. Outdoor Emergency Care, 4th Edition AAOS/NSP

28. 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

29. 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

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

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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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

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

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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

65. 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

66. 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

67. 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

68. 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

69. 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

70. 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

71. 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

72. 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

73. 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

74. 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

75. 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

76. 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

77. 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

78. 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

79. 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

80. 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