Common ski injuries involve these areas of the body:

• Head
• Shoulder
• Arm
• Wrist
• Thumb
• Knee
• Ankle

Head

10-15% of all ski injuries are head injuries with over 43% occurring in younger children. However, head injuries can range from a minor bump on the head, with no residual symptoms, to major life-threatening trauma. Severe injuries and in particular deaths are rare but well publicised. Fatal accidents usually involve high speed collisions with larger solid objects (tree, rock or pylon) or falls from a height. Wearing a helmet at all times while skiing or riding is a sensible precaution. It may help reduce the incidence of minor to moderate head injury - it will certainly take the sting out of minor bumps.

Helmets are an essential component of any snowboarder's protective gear, regardless of ability. They seem to have been more readily accepted snow-boarders than skiers. In some countries children are required to wear helmets at all times when skiing or snowboarding. When choosing a helmet, look for the ASTM Logo which means the helmet has met a set of minimum manufacturing standards.

Shoulder

Incidence: Shoulder injuries account for about 10% of all alpine ski injuries and 15% of all snowboard injuries. Joint injury includes dislocation and subluxation (the joint hasn’t quite come out of joint) of the shoulder and AC joint.

Cause and prevention: Not surprisingly, the two commonest mechanisms leading to shoulder injuries on the slopes are falls and collisions. When skiing in trees if skier uses poles straps and a pole gets caught in a passing trees the shoulder can be literally pulled out of joint!
Falls can injure the shoulder in one of two ways -

• The casualty falls directly onto the shoulder joint itself
• In the process of a fall, the casualty lands onto an outstretched hand and the force of the fall is transmitted up the arm to the shoulder joint

Try to avoid falling on to the outstretched hand if possible.       

Dislocation of the Shoulder

This occurs when your shoulder pops out of the socket.  An acute dislocation of the shoulder is an extremely painful injury. It usually occurs as a result of a fall onto an outstretched hand, or on your elbow with the momentum of the fall twisting the body round and wrenching the shoulder out of joint.

Diagnosis: the diagnosis can usually be made easily by an experienced ski patrol or doctor. The shoulder is very painful and impossible to move. The contours of the shoulder are different. Sometimes the shoulder cuff muscles can be injured and may require surgical repair.

Radiology: An x-ray may be required to confirm diagnosis and to exclude fracture.
Treatment: The shoulder needs to be put back into place (reduced). This may be done with painkillers alone, gas and air or anaesthesia. Usually a first time dislocation will be treated in a sling followed by physiotherapy. After reduction, the patient usually experiences rapid relief of their pain. Shoulder fractures and dislocations may require prolonged rehabilitation. In some, the shoulder has been damaged and so the joint will never be as strong as it once was and will go on to have further dislocations that may require surgery.

Acromio-clavicular (AC) joint

The AC joint sits between the outside end of the clavicle (collar bone) and the bit of the shoulder blade known as the acromion. A ligament connects the two and holds the joint together.

Cause and prevention:  A fall with direct impact on the outside of the upper arm may lead to this ligament being damaged and tearing, allowing the joint to distort (a so-called subluxation, also known as a "sprung" AC joint) or become completely separated (a dislocation).
Diagnosis: As with all ligament sprains, damage to the ACJ can be graded 1 to 3 depending on the degree of damage. A visible bump is obvious with A-C joint dislocations.
Radiology: An x-ray is usually required.
Treatment:   Grade 1 & 2 ACJ sprains can usually be treated conservatively with the arm in a sling and good analgesia. Most grade 3's can be treated in a similar manner but need careful follow-up - as with a collar bone injury usually there is good recovery of function in the shoulder. Exercising the shoulder to rehabilitate it should take place ideally under the expert guidance of a physiotherapist. If the shoulder is not settling, it's possible again that internal fixation of the shoulder joint may be required.

Fracture of the Clavicle (collar bone)

 The clavicle is the commonest fracture site of the shoulder joint seen in both skiers and snowboarders and the commonest upper limb fracture in skiers (in snowboarders it comes second to the wrist).

Cause: Fractures usually result from the transmission of force in a fall up the arm which is absorbed in the collar bone which finally breaks as a result.
Diagnosis: They are fairly easy to diagnose with localised pain at a specific site along the bone, usually accompanied by obvious swelling over the fracture site. The bone can be divided into three segments - inner, middle and outer. Fractures usually occur at the weakest point of the bone, which is the junction of the middle and outer thirds.
Radiology: An x-ray will be required.
Treatment: Usually all that is required is a sling. You can start to get the shoulder moving straight away, if pain allows.

Arm

Fracture of the Humerus

Cause: A fractured humerus (upper arm bone) can result from (usually) a direct blow but sometimes a fall onto the outstretched hand. 
Diagnosis: Palpation will reveal tenderness along the line of the bone (best done gently on the inside aspect of the arm where there is less fat and muscle to get in the way). These breaks can be across the shaft of the bone or off the head of the bone at the actual shoulder joint. The radial nerve is at risk with this injury, damage to this nerve can result in a ‘wrist-drop’
Radiology:  X-rays are needed here.
Treatment:  Treatment is usually non-operative with a sling and analgesia. Surgery is needed occasionally.

Wrist

Fracture of the Wrist

These are the most common snowboarding injury (23%).
Incidence: An estimated 95,000 snowboard wrist fractures world-wide per season!
Cause and prevention: These usually occur as a result a fall onto an outstretched hand. Unlike skiers, who can step out a leg when they lose balance, snowboarders are more likely to topple over and the natural tendency is to fall onto an out stretched hand. One simple technique that may protect your upper limb in the event of a fall is to learn to fall correctly. Wrist guards may help prevent wrist sprains and fractures. There is now overwhelming evidence to support their effectiveness in reducing the incidence of wrist injuries. The Colorado Snowboard Injury Survey collected information from over 7000 snowboard injuries. Their findings indicated that snowboarders wearing wrist guards were half as likely to injure their wrists as those not wearing guards
Diagnosis: The wrist is usually very painful and may be deformed by the fracture.
Radiology: An x-ray is required.
Treatment:  Displaced fractures will need to be reset under anaesthetic and held in plaster. Some of these fractures will require surgery.

Learning to fall properly
The most popular technique involves simulating a "parachute fall" - tucking the forearms in towards the chest, with the fists clenched. Knees should be bent as you fall so that your buttocks or knees take the brunt of the impact rather than your wrist.

Thumb

Skier's Thumb

'Skier's thumb' is a term coined for an injury affecting the ulnar collateral ligament (UCL) at the metacarpophalangeal joint of the thumb. It’s an important injury that is often mis-diagnosed, under-treated and its functional importance not appreciated by both doctors and patients - at least initially. It is quite unique to skiing. If your ski pole gets planted and twisted as it gets stuck in the snow, this ligament can easily get injured. If you are falling, do not hold onto your poles, as they are more likely to harm you rather than help you. Do not have straps.

Knee

The knee joint, with its associated ligaments, menisci and bones, currently account for 30-40% of all alpine ski injuries. The most commonly injured structures within the knee include the medial collateral ligament (MCL), anterior cruciate ligament (ACL), and meniscus. The top of the tibia (shin bone), or the tibial plateau, is the most common site of knee fracture in skiers. The majority of lower extremity injuries are due to a twisting injury of the leg. This is particularly so if bindings are not set correctly which then do not release.

Ligament – Medial Collateral Ligament

The MCL is a tight ligament on the inner side of the knee. It prevents the knee opening on the inner side and is put on a stretch as the knee falls in to a knock-knee position.  When excessively stretched the ligament is sprained. A sprain is a tear in the ligament and can be partial or complete.
Incidence:    MCL injuries account for 20-25% of all ski injuries and occur in skiers of all levels, but mostly occur in beginner and intermediate skiers.
Cause and prevention of injury: The higher prevalence among less experienced skiers is largely due to the position that beginner and intermediate skiers adopt, with the knee joint in a knock knee position, (feet wider apart than the thigh). When skiing in a snow plough the knees are forced, intentionally, into a knock-knee position. Intermediate skiers, (and some advanced skiers) ski with the knee falling into a knock- knee position, (A-frame). In an A frame the MCL is vulnerable to injury. In the A frame or snowplough position the MCL is under tension and even a strong skier will find it difficult to have enough control to prevent the knees being driven in further towards each other resulting in MCL sprain. A widening snow plough, crossing skis or a fall when in the A frame position, will easily sprain the MCL. Experienced skiers injure their MCL by 'catching an inside edge' causing the knee to suddenly twist outwards and fall in towards the opposite knee.  Immediately following a grade 1 injury the skier may find they can ski down but will find that hours later the knee becomes painful. The skier is very vulnerable to further injury if they ski with this injury.
Diagnosis: A description of the injury will often give the diagnosis of MCL sprain which is then confirmed by examination.

Grades of severity of MCL sprains
MCL injuries are graded from one to three depending on the degree of damage and associated ligament laxity.

• Grade 1 - No laxity ('give') in the ligament when stressed. Few, if any, ligament fibres torn. Often very painful. Relatively little swelling and later some bruising over the inner side of the knee. The knee is very tender on the inner side.
• Grade 2 – Some, but not all, ligament fibres torn. The ligament is stretched but if the examiner tensions the MCL eventually it tightens but with increased opening on the inner side of the knee. Blood collects quickly within the knee. (haemarthrosis) swelling knee usually appears within a few hours of injury.
• Grade 3 – The ligament has been stretched until it completely ruptures. If the ligament is tensioned by the examiner it cannot be felt to tighten as the knee is opened up on the inner side. All ligament fibres torn. The knee will feel unstable if an attempt is made to weight bear. Grade 3 injuries are usually accompanied by injuries to the Anterior Cruciate Ligament (ACL) and the capsule at the back of the knee. Due to the major disruption there may be surprisingly little swelling and pain in these because the swelling leaks out of the knee.
  

Radiology: An ordinary x-ray is normally arranged by the resort doctor to exclude fracture. It should be given to you to bring home. It is almost never necessary to do an MRI prior to travel. The quality of MRI’s offered in the resort is often poor. Definitive investigations such as MRI are usually best done on your return to the UK.

Treatment:

• Grade 1. These are usually very sore particularly on twisting or forcing the knee in to a knock knee position. You are advised not to ski as the risk of further injury is very high. However, it is often possible to walk. Self management includes control of swelling. For the return journey, the resort doctor will usually advise some form of splint and crutches. Do NOT crook the knee over a pillow at night although it may initially feel comfortable it will stiffen the knee in a bent position. Most grade one injuries should expect to return to sport at 4-6 weeks, with few long term consequences. For the small proportions that do not settle, an ultrasound-guided steroid injection may be required.
• Grade 2. The MCL has stretched significantly and requires protection against being further stretched and will require a brace. Ideally a hinged knee brace is worn to permit movement whilst also protecting the inner part of the knee. This may be worn for 4-6 weeks. Crutches may be required. Without a brace the knee may be felt to gap open on the inner side whilst walking. This injury will usually settle without surgery, and with appropriate physiotherapy, return to sport at 8-12 weeks.
• Grade 3. The ligament is completely ruptured. These more serious injuries should have an early expert assessment.  This is a major knee ligament injury. These require splintage for a period of time and crutches. Many of these will require surgery.

                                     
Anterior cruciate ligament (ACL)
The ACL is the major stabilising ligament in the centre of your knee, which helps to prevent sliding movement of the tibia on the femur.
Incidence:    ACL injuries account for 10-15% of ski injuries. ACL injuries occur in skiers of all abilities and can be attributed to specific falling patterns. Improvements in ski equipment have reduced the rate of lower limb fractures but not the rate of ACL rupture. In fact, there is an alarming increase in ACL injuries (almost a 240% increase).
Cause: The most comprehensive study of ACL rupture in skiers has been carried out in Vermont. The following is based on the research carried out by Vermont Safety Research and is the result of studying their ski worker population and video of skiers falling and rupturing their ACL. For more information see their website Vermont Ski Safety.
Injury Mechanism:

1. Phantom-foot ACL Rupture: The skier falls backwards with their weight going onto the back of the downhill ski, the ski whips round and as the skier continues to fall the calf is forced against the back of the boot levering the tibia (shin bone) forward. The ACL is particularly likely to rupture if the skier resists the fall as this increases the forward displacement of the tibia. Similarly if the skier has fallen he or she should not attempt to get up until they have stopped sliding. A skier who attempts to sit down whilst skiing or is out of control may induce the same combination of events that lead to ACL rupture.
2. Boot-induced ACL: if a skier falls backwards whilst attempting a jump they will land on the back of the skis this is made worse if the legs straighten As they land on the tails of the ski the back of the ski boot forces the calf forwards which drives the tibia out from under the femur and the ACL tears.
3. Another skier/snowboarder: There are two common scenarios. One whereby a stationary skier is hit from behind on the lower leg by another skier or snow-boarder - this again applies sudden extreme pressure to the back of the calf, forcing the tibia forwards with resultant ACL damage. The second of these is a combination of the boot induced ACL and a twisting injury that is frequently seen as a skier exits a chairlift, and the person next to them falls on to their skis, pushing the victim backwards, causing them to fall and at the same time causing their skis to cross.

Diagnosis:   Often the individual describes feeling or hearing a ‘pop’ or a ‘snap’, with the knee ‘giving way’ beneath. Attempting to stand on the leg will often result in the leg giving-way. It is rare to be able to continue skiing following ACL rupture. Significant swelling from bleeding within the knee, (haemarthrosis) usually develops within an hour of injury. The knee is usually quite painful and difficult to assess unless the examiner is very experienced - resort doctors usually are! Increased movement in the knee can be detected on performing Lachman test. The examiner gently tries to assess the amount that the tibia can be slid forwards on the femur, when the ACL is ruptured the amount the tibia can be slid forwards is increased.
Radiology: An ordinary x-ray is normally arranged by the resort doctor to exclude fracture. It should be given to you to bring home. It is almost never necessary to do an MRI prior to travel. The quality of MRI’s offered in the resort are often poor. Definitive investigations such as MRI are usually best done on your return to the UK.

Treatment:  The resort doctor will usually advise that you wear a splint and use crutches. This is mainly for safety and comfort. Many resort doctors will advocate blood thinning injections to reduce your risk of Deep Vein Thrombosis (DVT). In addition to this keep your leg elevated and regularly move your foot up and down from the ankle.

There is no evidence to support immediate surgery for ACL rupture. It is preferable to let the swelling settle before operating, this may take 4 to 6 weeks. If you have immediate surgery consider who you will turn to if there are problems after return home. Clearly the best person to consult in these circumstances is the person who carried out the surgery, which is unlikely to be practical. Travelling home immediately following surgery may result in an increase risk of complication such as DVT.

 It is generally agreed that if you wish to continue skiing at the level of a good intermediate or above, you will probably need to consider reconstructive surgery to your ACL. For carefully selected patients, if the knee feels stable with physiotherapy, this may be avoided. Others advocate a knee brace to avoid surgery, but this will not provide the stability of an ACL reconstruction, but may be suitable for occasional intermediate skiers.

Preventing ACL Injury

Skiing is a vigorous sport, and as such, to participate safely, you are advised to be in good physical shape. At particular risk are once a year skiers who do little exercise the rest of the year. There is good evidence that appropriate strength and conditioning will reduce the risk of injury, particularly if combined with good technique. Ideally regular conditioning work should be performed for 2-3 months prior to your ski trip. Your equipment should be appropriate for your height, weight and ability, and set for the same. Of particular importance is the DIN setting for your bindings. Do not borrow equipment that may not be well suited to your ability, weight and condition, injury rates are greatly increased.

Avoiding High Risk ACL Behaviour:

1. Don't ski if you have not fully recovered from an earlier injury.
2. Beware that on day 3 your muscles may be at their most fatigued, (beware after 3pm 3rd day!).
3. Alcohol affects your performance, and thus increases your risk of injury.
4. Be vigilant when getting off a chair lift as it is a common site for knee injuries to occur.
5. Advanced skiers pay attention on easy runs where you may allow your guard to drop. Advanced skiers often injure themselves by being inattentive in easy conditions!
6. Don't fully straighten your legs when you fall, since a straight leg provides a longer lever force against the knee. Keep your knees flexed.
7. When you're down, stay down; do not try to stop the fall as you cannot always predict which direction your leg is going to twist.
8. Fall forwards, as falling backwards places abnormal forces across the ACL. Don't land on your hand backwards. Keep your arms up and forward.
9. Don't jump unless you know where and how to land. Land on both skis and keep your knees flexed.

Meniscus Injuries

Incidence: 5-10% of ski injuries involve the meniscus. The meniscus is comprised of cartilage and it sits between the femur and tibia.
Cause and prevention: Sudden twisting can tear the meniscus, usually occurring when the knee is bent with the full body weight on it. Commonly occurs when skiing on moguls, or in deep powder especially if poor technique. Failure to absorb a bump in moguls and uneven weighting of the skis in powder may cause a tear of the meniscus.
Diagnosis: There is immediate pain when standing or walking, but may have little swelling initially though swelling the day after is more common. A large tear may get stuck between the bones preventing straightening of the knee. This is known as a 'locked knee'. The knee is usually tender at the join between the femur and the tibia (the joint line)
Radiology: An ordinary x-ray is normally arranged by the resort doctor to exclude fracture. It should be given to you to bring home. It is almost never necessary to do an MRI prior to travel. The qualities of MRI’s offered in the resort are often poor. Definitive investigations such as MRI are usually best done on your return to the UK.

Treatment: Following an acute tear there is little that can be done in the resort to get you back skiing the same week. Occasionally it may be possible to get the pain and swelling sufficiently under control to allow some cautious skiing. This is however more likely if the tear is longstanding. Self management of swelling is advised.

On return to the UK you should seek advice. Following confirmation of the tear by a specialist you may be advised to consider arthroscopy, (keyhole surgery), particularly if the knee is locked. Isolated tears in the older population may occasionally settle without surgery. You should discuss this with your specialist.

Ankle
Modern ski boots have greatly reduced the incidence of ankle injuries in skiers. Sprains do occur but the once commonplace fractured ankle is now a rarity. This is not the case in snowboarding.

Snowboarder’s ankle

Incidence: These account for almost 17% of snowboarding injuries.
Cause: The mechanism of injury is a forcing of the ankle into dorsiflexion and inversion, which may occur during a landing from an aerial manoeuvre or a jump, especially when the landing has been over-rotated.
Prevention: The risk of sustaining an ankle injury as a snowboarder is related to the kind of boot worn. Snowboarding boots come in three styles: soft, hard and hybrid.
Hard shell boots tend to worn by more experienced boarders and (as with ski boots) tend to protect the ankle joint. Traditionally, beginner snowboarders use soft boots. The current soft snowboard boot is made of leather or synthetic material that allows moderate stability yet is balanced by moderate flexibility. The advantages of soft boots are increased maneuvering ability and comfort. Unfortunately they do not offer the ankle as much in the way of protection. Any forces transmitted back from the board tend to be absorbed by this joint. This is especially so when the ankle is either compressed or turned in (as can happen after a jump).Increasingly popular are the relatively new hybrid snowboard boots.
Hybrid boots are constructed either:-
a) with soft leather or synthetic outer shell and a stiff inner boot.
b) or combining a hard shell base with a softer upper component. The idea is to combine the comfort and manoeuvering ability of a soft boot with the stability and protection of a hard boot.

Some beginners wear moon boots or hiking boots, both of which lack stability and may lead to a higher injury rate. These types of boots should not be used for snowboarding.
Diagnosis and radiology: Almost 50 percent of the ankle injuries are fractures, which are usually easily diagnosed.  However, "snowboarder's ankle," a fracture of the lateral talus may be difficult to see on a standard ankle x-ray series. This common injury should be considered to be a "severe ankle sprain" that is persistently painful, has limitation of motion and fails to improve with appropriate management. They may require a scan to accurately diagnose them.

Treatment:   Treatment for un-displaced fracture is a short-leg cast for six weeks. Advice regarding weight bearing will be given. Crutches will be required. Patients with more severe fractures may require surgery. 

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Ski Injury Clinic (In Specialist Clinics)