Outdoor Emergency Care, 4th Edition AAOS/NSP1 SKI AND SNOWBOARD INJURIES

Outdoor Emergency Care, 4th Edition AOutdoor Emergency Care, 4th Edition AAOS/NSPAOS/NSP

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SKI AND SNOWBOARD SKI AND SNOWBOARD INJURIESINJURIES


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Statistics: Statistics: (Scottish Snow Sports Safety Study)(Scottish Snow Sports Safety Study)

** Skiers mainly injure Knee, then head/face, then limbs


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** Skiers injure knees and snowboarders injure wrists


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** Skiers sprain more and snowboarders fracture more


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Conclusion Conclusion (Scottish Snow Sports Safety Study)(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


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Statistics:Statistics:((Geddes, R et al. Boarder Belly: splenic injuries reslting from Geddes, R et al. Boarder Belly: splenic injuries reslting from ski and snowboarding accidents. Emergency Medicine ski and snowboarding accidents. Emergency Medicine Australia. April, 2005.17 (2): 157-162Australia. 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.


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Statistics:Statistics:((1995 - U.S. Consumer Product Safety Commission)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.


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Statistics:Statistics:Snowsport DeathsSnowsport 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!


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Statistics: Statistics: Final ConclusionsFinal 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


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Common Common RecommendationsRecommendations•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.


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Recommendations are helpful but is there any evidence on protective

equipment- Helmets, wrist guards, knee braces?


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Helmets:Helmets:Hagel, I et al.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


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Helmets:Helmets:Hagel, I et al.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


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Helmets:Helmets:Sulheim, et al.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


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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

Helmets:Helmets:Sulheim, et al.Sulheim, et al.


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Helmets:Helmets:Macnab, et al.Macnab, et al.

Results

1. No difference in serious neck injury between groups (helmet vs non-helmet)

2. Failure to use helmet increase head injury (RR 2.24; 95% CI 1.23-4.12)


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Snowboarding Injury:Snowboarding Injury:EpidemiologyEpidemiologyResults

1. Ratio of upper extremity injury to all types of injury was significantly higher in snowboarders than skiers by three times

2. Snowboarders fracture wrists and skiers fractures clavicles

3. Snowboarders dislocate elbows and skiers dislocate shoulders

4. In snowboarders, the left upper extremity was more frequently affected due to their orientation on the board


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Snowboarding:Snowboarding:Wrist GuardsWrist Guards

O’Neill et al.

1. Studied rate of injury in first time snowboarders

2. Compared 551 wore wrist guards and control was more than 1800; no wrist guards.


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Results

1. 40 wrist injuries in Control (unguarded) and 0 injuries in experimental (guarded) in first timers

2. No higher rate of other upper extremity injury in guarded group

Should they have stopped and given everyone wrist guards?


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Ronning et al. - Results

1. Significant difference between the two groups

2. Wrist guards were protective

3. More injuries if first-timers and those who rented equipment


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Statistics:Statistics:Boarder BellyBoarder Belly


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Skiing:Skiing:BindingsBindingsVery poor evidence for studies on bindings

• Finch et al:

1. Review article based on 15 low level evidence studies

2. 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

3. Adjustments, especially in children, tends to be inadequate

4. Suggests that a binding testing device should be used to optimize and standardize adjustments


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Skiing:Skiing:Knee BracesKnee BracesOates et al:

1. Three groups of skiers: (1) No previous ACL injury- 4748 (2) ACL deficient- 138 (3) ACL reconstruction- 274

2. Put them all in knee braces

3. Ligament deficient knees had 6.2x higher rate of injury than intact knees

4. Ligament reconstructed knees had 3.1x higher rate than intact

5. Injuries in intact knees were also less severe


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Skiing:Skiing:Knee BracesKnee 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


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Classic Injuries:Classic Injuries:Skier’s ThumbSkier’s Thumb

Background•Skier’s thumb, aka gamekeepers thumb

•Ski pole injuries and football injuries are now most common cause


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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


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Classic Injuries:Classic Injuries:Skier’s ThumbSkier’s ThumbPrevention


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Conclusions:Conclusions:GeneralGeneral

Skier, think knee sprain then ACL or ligament disruption

Snowboarder think wrist fracture of left hand


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Conclusions:Conclusions:Skiing InjuriesSkiing 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


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Conclusions:Conclusions:Snowboard InjuriesSnowboard 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


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• 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.

ObjectivesObjectives (1 of 5)(1 of 5)


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• 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.



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• 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.



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• 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.



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• Demonstrate securing a patient to a long backboard.

• Demonstrate the procedure for rapid extrication.

• Demonstrate helmet removal techniques.



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Spinal ColumnSpinal Column


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Assessment of Spinal InjuriesAssessment 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


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Questions to Ask Questions to Ask Responsive PatientsResponsive 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?


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Assessment of Spinal InjuriesAssessment 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.


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Signs and Symptoms of Signs and Symptoms of Spinal InjurySpinal 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


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Emergency Medical CareEmergency 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.


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Stabilization of the Cervical Stabilization of the Cervical Spine Spine (1 of 3)(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.


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• 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.


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• 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


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Preparation for Transport:Preparation for Transport:Supine PatientsSupine Patients (1 of 2)(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.


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Preparation for Transport:Preparation for Transport:Supine PatientsSupine Patients (2 of 2) (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.


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Preparation for Transport: Preparation for Transport: Sitting PatientsSitting 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.


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Preparation for Transport: Preparation for Transport: Standing PatientsStanding 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.


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Head InjuriesHead Injuries

• All head injuries are potentially serious.

• Types include: – Scalp lacerations– Skull fractures– Brain injuries – Medical conditions– Complications of head injuries


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Scalp LacerationsScalp 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.


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Skull FractureSkull Fracture

• Indicates significant force

• Signs:– Obvious deformity– Visible crack in skull– Raccoon eyes– Battle’s sign– Cerebrospinal fluid


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Concussion Concussion (1 of 2)(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


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Concussion Concussion (2 of 2)(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.


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Intracranial BleedingIntracranial Bleeding

• Major TBI• Laceration or

rupture of blood vessel in brain– Subdural– Intracerebral– Epidural


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Other Brain InjuriesOther 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.


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Complications of Head InjuryComplications 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.


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Assessing Head Injuries Assessing Head Injuries (1 of 2)(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


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Assessing Head Injuries Assessing Head Injuries (2 of 2)(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.


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Signs and Symptoms Signs and Symptoms (1 of 3)(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


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Signs and Symptoms Signs and Symptoms (2 of 3)(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


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Signs and Symptoms Signs and Symptoms (3 of 3)(3 of 3)

• Seizures

• Numbness or tingling in the extremities

• Irregular respirations

• Dizziness

• Visual complaints

• Combative or abnormal behavior

• Nausea or vomiting


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Level of ResponsivenessLevel 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.


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Change in Pupil SizeChange in Pupil Size• Unequal pupil size may indicate increased

pressure on one side of the brain.


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Emergency Medical CareEmergency 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.


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Managing the Airway 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.


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CirculationCirculation

• 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.


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Cervical Collar 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


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Applying a Cervical CollarApplying 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.


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BackboardsBackboards• 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


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Helmet Removal Helmet Removal (1 of 5)(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?


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Helmet Removal Helmet Removal (2 of 5)(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.


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• 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.


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• 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.


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• 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.


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Pediatric Needs Pediatric Needs (1 of 2)(1 of 2)

• Children will need additional padding to prevent neck flexion.

• Blanket rolls can be used in place of cervical collars.


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Pediatric Needs Pediatric Needs (2 of 2)(2 of 2)

• Children may need extra padding to maintain immobilization.

• Car seats can be used as immobilization devices.

Documents

Outdoor Emergency Care, 4th Edition AAOS/NSP1 SKI AND SNOWBOARD INJURIES