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Thousands of people participate in winter sports and recreational activities each year. Although the sports themselves are quite different, some common themes lead to injuries.
Most winter sports and recreational activities occur in low-friction environments—on snow or ice—that can result in slips, falls, and high-speed collisions. Bobsledding, sledding, figure skating, snowboarding, skiing, curling, ice climbing, and ice hockey are all popular in winter. Are you familiar with the injuries common in these activities?
Image courtesy of Science Source/Dr P Marazzi. Icons courtesy of Dreamstime/Nadezhda Khvatova.
Bobsledding involves two to four people on a four-runner sled (bobsled or bobsleigh) sliding down an ice-covered incline or tunnel.[1] The body experiences extremely high "g-forces" during turns—up to four or five times the force of gravity.[2] In addition, the sleds can reach speeds of up to 90 miles per hour (mph) during elite-level competition[3]; even during recreational races, speeds can easily approach 60 mph.[4,5] Crashes can lead to severe multisystem trauma and long-bone fractures, and fatalities have been reported.[6-9]
Image courtesy of United States Army/Tim Hipps.
The violent forces of turning and bumping on a bobsled over imperfections in the ice can lead to compression fractures or, more often, sprains and strains of the spinal musculature. Although it is much more common to experience blunt-force traumatic injuries during a crash, it is important to note that with increasing age, it is possible to sustain spinal fractures even without a crash. There are reports of older recreational bobsledders sustaining spinal compression fractures during routine participation without crashing.[2]
Plain x-rays, such as the one shown, demonstrate anterior "wedging" in large compression fractures, with significant height loss. When compared to computed tomography (CT) scans, plain x-rays have poor sensitivity for detecting spine fractures in blunt trauma. Therefore, if there is clinical concern for spine fractures, CT scanning should be considered.
For more information about spine sprains/strains and compression fractures, see the Medscape Drugs & Diseases articles Cervical Spine Sprain/Strain Injuries, Lumbosacral Spine Sprain/Strain Injuries, and Lumbar Compression Fracture.
Adapted images of an L4 vertebra compression fracture courtesy of Wikimedia Commons/James Heilman, MD.
An estimated 230,000 children and teens aged 19 years or younger present annually to US emergency departments (EDs) for sledding-related injuries.[11] Fractures are the most common injuries (26.3%), closely followed by abrasions and contusions (25.0%), and the head is the most frequently injured site (34.1%). Possibly due to the lack of control and inability to steer to avoid collisions, snow tubes and disks are associated with more traumatic brain injuries (TBIs) than other types of sleds.[11]
Sledders should avoid areas where they may slide into the path of motor vehicles or other sledders. In particular, careful selection of appropriate slopes/hills is important, as collisions with trees and stationary objects are responsible for a significant number of injuries. In addition, sledding feet first and sitting up may reduce the risk of head injuries.
For more information about head injuries, see the Medscape Drugs & Diseases articles Head Trauma and Head Injury.
Image courtesy of Pixabay.
These images were obtained from a 19-year-old male who presented to the ED with a Lisfranc fracture-dislocation of the foot associated with a high-velocity sledding injury. He underwent immediate open reduction and internal fixation (ORIF).
The radiograph on the left reveals lateral displacement of the first, second, and third metatarsals (tarsometatarsal or Lisfranc joint) with associated fracture of the middle cuneiform.
The CT scan on the right shows disruption of the tarsometatarsal (Lisfranc) joint with associated soft-tissue swelling.
Images courtesy of Benejam CE, Potaczek SG. J Med Case Rep. 2008;2:266. [Open access.] PMID: 18694504, PMCID: PMC2527576.
Wrist fractures
Falling onto an outstretched hand (FOOSH) is one of the most frequent injuries encountered in many winter activities.[12,13] Figure skaters and snowboarders (much more commonly than skiers) are particularly at risk for wrist fractures,[13] although these injuries are fairly common in most winter sports that involve sliding on frozen surfaces.[12,13]
Images courtesy of Xavi (left) and TimOve (right), both via Flickr.
Colles fractures often result from FOOSH and typically present with the classic "dinner fork" or dorsiflexion deformity (shown), in which the fracture fragments of the distal wrist are displaced dorsally.[14] Less common are Smith fractures ("garden spade deformity"), wherein the distal fracture fragments are displaced in the volar direction (ie, reverse Colles fracture).
Physical examination of wrist injuries includes assessment for pallor or duskiness of the hand or the presence of a compromised radial pulse; each sign suggests vascular compromise.[14] Patients with a high-energy mechanism of injury may also have other associated injuries; therefore, careful evaluation of the shoulder, elbow, and hand is critical. Tenderness in the anatomic snuffbox is of special concern for fracture of the scaphoid bone, which is at high risk for avascular necrosis owing to its blood supply.[14]
One of the most serious early complications of wrist fracture is acute carpal tunnel syndrome due to swelling and increased compartment pressure.[15] If there are signs of neurovascular compromise, urgent reduction of the fracture may restore function and should be considered in the field if there will be significant delay in reaching a medical facility.
Image courtesy of Wikimedia Commons/D Sprenkels.
Radiographic evaluation of wrist injuries should include anteroposterior (AP), lateral, and oblique views.[16] Normal anatomic alignment of the radiocarpal joint viewed on the lateral film is 11° of palmar angulation with a range of 1°-23°. Ulnar angulation on the AP film is normally 15°-30°. Special scaphoid views can help detect fractures, as many scaphoid fractures are not easily visualized on plain film x-rays.[16]
Patients with tenderness in the anatomic snuffbox, even in the absence of other obvious fractures should be immobilized in a thumb spica splint. Follow-up imaging (often CT scanning) as soon as 3 days later may reveal a scaphoid or other fracture(s).
For more information about wrist fractures, see the Medscape Drugs & Diseases article Wrist Fracture in Emergency Medicine.
Images of a characteristic Colles fracture courtesy of Wikimedia Commons/Ashish j29.
Alpine skiing involves sliding down a snow-covered hill on skis with fixed-heel bindings, whereas cross-country (or Nordic) skiing uses skis with free-heel bindings.[17]
Knee injury: ACL tear/rupture
The most common injuries sustained by alpine skiers are to the knee(s).[17,18] Acute tears of the anterior cruciate ligament (ACL) occur when a twisting force is applied to the ski, such as when skiing moguls (bumps), landing jumps, or falling at an angle.[17] If the fixed-heel bindings on the ski do not release, an immense force is placed on the ACL when the knee is rotated by the strong mechanical advantage of the ski. Patients will often hear an audible "pop" and experience a brief, severe pain in the knee; they are usually unable to bear weight, often develop a large hemarthrosis, and feel notable instability of the knee.[19,20]
Image courtesy of Flickr/Jibber Team.
The anatomy of an ACL tear/rupture is shown on the left.
The sagittal magnetic resonance image (MRI) on the right demonstrates a partial ACL tear that involved nearly 75% of the ligamentous body as revealed at arthroscopy.
Images courtesy of Wikimedia Commons/Bruce Blaus (left) (adapted) and Yaqoob J, Alam MS, Khalid N. Pak J Med Sci. 2015;31(2):263-8. [Open access.] PMID: 26101472, PMCID: PMC4476323. (right).
The Lachman test is the most sensitive physical examination for diagnosis of acute ACL tear/rupture.[17,20] It is performed with the patient supine, knee flexed to 30°. The examiner grasps the patient's tibia with one hand, stabilizes the thigh with the other hand, and then pulls the tibia anteriorly.
The test is considered positive for an ACL tear if there is no firm "endpoint" to the anterior translation of the tibia when compared to the unaffected knee.[17] This corresponds to approximately a 2-3 mm greater translation than the unaffected knee[20] or greater than 10 mm in total.[21]
Adapted image courtesy of Lam MH, Fong DT, Yung PSh, Ho EP, Chan WY, Chan KM. Sports Med Arthrosc Rehabil Ther Technol. 2009;1(1):20. [Open access.] PMID: 19712449, PMCID: PMC2744659.
The majority of ACL tears may be diagnosed on the basis of clinical history and physical examination findings alone.[17] MRI is the most sensitive imaging modality for diagnosis and characterization of ACL tears, but it should not be obtained emergently to make the diagnosis. Plain films are inadequate to identify ACL rupture; however, they may reveal associated injuries,[17] such as a lateral tibial plateau fracture.
Patients with suspected acute rupture of the ACL should initially be managed conservatively with immobilization and weight bearing as tolerated.[17] They should return for reevaluation once the pain and swelling have improved, as these otherwise make the physical examination difficult and less reliable. Patients with ligamentous injuries should remove knee immobilizers and begin range-of-motion exercises within 48-72 hours.
The proton-weighted density MRIs reveal ACL rupture (left), medial collateral ligament (MCL) rupture (center), and a complex internal meniscus tear at the posterior horn (right).
For more information about ACL injuries, see the Medscape Drugs & Diseases articles Anterior Cruciate Ligament Injury, Anterior Cruciate Ligament Pathology, and MRI for Anterior Cruciate Ligament Injury.
Images courtesy of Wikimedia Commons/Hellerhoff.
Upper extremity injuries: skier's thumb
Skier's thumb (also gamekeeper's thumb) is the most common upper extremity suffered by skiers.[13] It often occurs as a result of a FOOSH, when the thumb is forcefully bent backward, thereby injuring the ulnar collateral ligament (UCL). The straps from ski poles can transmit the forces from falling or colliding with stationary objects directly across the thumb joint.[22] Partial or complete UCL rupture can occur. Patients experience pain and weakness with pinching and grasping motions of the affected thumb.[22]
Obtain x-rays to rule out associated fractures and dislocations of the thumb. MRI and ultrasonography may be helpful in determining the extent of the injury.
Patients presenting acutely with skier's thumb should be immobilized in a thumb spica splint, as well as evaluated for potential surgical intervention.[22]
The x-ray on the left reveals a bony skier's thumb. The MRI on the right shows an old avulsion fracture of the UCL insertion.
Images courtesy of Mahajan M, Rhemrev SJ. Int J Emerg Med. 2013;6(1):31. [Open access.] PMID: 23938194, PMCID: PMC3765347.
Frostbite
Cross-country (Nordic) skiing places participants at risk for frostbite due to the potential for extended exposure to extreme cold conditions.
Frostbite occurs when the chilling effects of the environment outpace the body's ability to stay warm, resulting in freezing and subsequent tissue damage.[23,24] When the body's core begins to cool, peripheral blood vessels constrict to selectively shunt blood to the vital organs in the body's core. This leaves the distal extremities as well as exposed tissues vulnerable to frostbite, as these regions become even more cold due to the reduced warm blood flow.[23] Individuals with poor peripheral perfusion owing to vascular disease or diabetes as well as those who wear tight-fitting gloves or boots are at an increased risk for frostbite.
The body loses heat through three primary processes: conduction, convection, and radiation.[24] Exposed fingers, nose, and ears can develop frostbite very quickly in windy conditions. Preventing core heat loss by wearing insulating layers is critical to maintain good peripheral blood flow and warmth. Wearing a hat significantly reduces the body's radiant heat loss and keeps the core warm. Having dry gloves available and minimizing the time bare skin is exposed to the air is also essential, as this prevents convective heat loss.
Image of a cross-country skier courtesy of Flickr/Daniel A Leifheit.
Frostbite is classified similarly to burns, as follows[25]:
Unfortunately, it can be very difficult to differentiate these degrees of frostbite prior to rewarming; moreover, during the rewarming process, the ischemic tissue is further damaged by the reperfusion inflammatory response, which disrupts the microcirculation.[25]
For simplicity, experts have recommend the following simplified, two-tiered classification system after the initial rewarming process[25]:
Images of grade IV frostbite of the feet of a middle-aged male on day 2 (left) and after 3 weeks (right) courtesy of Ramdass MJ. Cases J. 2009;2:6635. [Open access.] PMID: 20181167, PMCID: PMC2827043. The patient's condition required bilateral below-the-knee amputations.
The Wilderness Medical Society recommends the following for management of frostbite[25]:
The images of a frostbitten toe on the left foot are from the same individual. The top left image was obtained 2 days after rewarming. The top right image reveals the same toe 12 days later. The bottom center image was taken 3 weeks after the initial frostbite.
Images courtesy of Wikimedia Commons/ Dr S Falz.
Frostnip and chilblains
Less severe exposures to the cold can result in nonfreezing cold injuries such as "frostnip" or "chilblains" (pernio).
Patients with frostnip present with erythema, numbness and, sometimes, pain of the affected site with rewarming.[25,26] There is no freezing of the tissues resulting in cell death or edema; therefore, signs/symptoms rapidly resolve with rewarming. The development of frostnip should be a warning sign for impending frostbite.[25]
Patients with chilblains (shown) present with often-painful erythematous digits after being exposed to cold, wet conditions.[26,27] Chilblains may also be associated with underlying rheumatologic disease. There is no freezing of the tissues; therefore, blisters or edema do not develop. Chilblains are self-limited, usually resolving within 3 weeks.[26,27]
For more information about cold injuries, see the Medscape Drugs & Diseases articles Frostbite, Pernio, and Cold Injuries.
Image courtesy of Wikimedia Commons/Sapp.
Ice climbing is a sport that has been steadily growing in popularity.[28,29] Climbers ascend frozen waterfalls (left) or alpine walls with the use of two handheld sharp metal ice axes or ice tools and metal shoe spikes known as crampons, as well as other equipment.[30]
The majority of injuries sustained by ice climbers are minor,[28,29] although there is a high potential for severe or fatal injuries. Most injuries are abrasions and contusions to the head and face or other body parts (right), which typically occur from chunks of ice that are broken loose by tools swinging into the ice, or lacerations and puncture wounds to the lower legs from the crampons.[28,29] Helmets and eye protection greatly reduce the risk and severity of injury to the head and face.[29]
During an uncontrolled descent such as a fall, an ice climber may lose control of one or both ice axes/tools, which can then bounce off the ice and strike the climber's face. The sharp crampons can also stick into the ice during a fall, thereby applying huge forces to the climber's knee(s). Fortunately, falling is uncommon in ice climbing, possibly owing to the high level of caution exercised by most climbers.
Injuries are significantly more common in less experienced ice climbers than in advanced climbers, with one study reporting an injury odds ratio of 2.55 in the less-experienced group.[29]
Images courtesy of Wikimedia Commons/Ramon Marin (ice climber) (left) and Flickr/Niki (ice chunk injury) (right).
Curling is a relatively obscure winter sport, unless one lives in Canada: 80% of all curlers worldwide are Canadian.[31] This sport consists of two teams of four players pushing 44 lb (19.96 kg) granite stones across a sheet of ice with a brush or "push broom."[32]
Although this activity may not look strenuous to the casual observer, the repetitive sweeping motion requires a considerable amount of strength[33] and can lead to sore forearms and overuse injuries to the shoulders, hips, and back.[31,33] Many curlers also complain of sore knees from the deep lunging position used to send the curling stone down the ice (right).
The majority of injuries sustained during curling are related to slipping and falling on the ice, with head injuries the most common, followed by upper extremity sprains/strains.[31] Minor head injuries such as bruises and contusions occur most frequently, followed by more serious head injuries, including concussion; intracranial hemorrhage may also occur (left).[31] Wearing proper footwear designed for curling may be key to injury prevention.[31]
Images courtesy of James Heilman, MD, (left) and Bjarte Hetland (right), both via Wikimedia Commons.
Traumatic brain injuries
TBIs are common in most winter sports. Concussion is the mildest form of TBI and results from a sudden high-energy impact to the head.[34,35] The disruption to the brain is functional, with changes on the cellular level; there is no structural damage to the brain on the macroscopic level.[35,36] Thus, standard neuroimaging will appear normal in concussion.[35,36]
One study identified concussion as the predominant injury suffered by high school ice hockey players, with nearly half caused by body checking (46%).[37] Research findings suggest that the actual number of concussions is likely to be significantly underestimated owing to routine underrecognition and underreporting.[35,38] Many young hockey players feel the need to hide their concussion symptoms for fear of being removed from play.[38,39]
Adapted images courtesy of Tyler CW, Likova LT, Mineff KN, Elsaid AM, Nicholas SC. Front Neurol. 2015;5:282. [Open access.] PMID: 25691880, PMCID: PMC4315029 (left); and Dreamstime/Matthew Swartz (right).
It is essential to rule out more serious TBIs such as subdural or subarachnoid hemorrhage in athletes with acute TBIs. Concussions may be graded on a scale of 1 to 3, with 3 being the most severe. The Canadian CT head rule (CCHR) and the New Orleans criteria (NOC) are two validated and widely used decision rules that help guide the use of CT scanning in adults with TBI.[40] Although both rules have been shown to have a 100% sensitivity in identifying clinically important brain lesions requiring surgical intervention, the Canadian head CT rule has a higher specificity.[40,41]
CT scan of a bilateral subdural hemorrhage courtesy of Wikimedia Commons/James Heilman, MD.
Canadian CT head rule
The CCHR indicates that any one of the following findings is a high risk factor for neurologic interventions[40]:
Medium risk factors for brain injury detection on CT scanning, per the CCHR, include the following[40]:
NOTE: The CCHR does not apply in nontrauma cases and in those who: have a GCS below 13, are younger than 16 years, are taking warfarin or have a bleeding disorder, or have an obvious open skull fracture.[40]
The images show fluid-attenuated inversion recovery (FLAIR) MRI sequences in three TBI cases depicting different levels of burden of white matter damage. Top left: Solitary, focal white matter hyperintensity (WMH) (arrow) in a child with mild TBI. Top center: Admission CT scan from a 62-year-old male with severe TBI (GCS = 7) but no white matter anomalies. Top right: CT scan from a 17 year old with an admission GCS of 3 revealing prominent, extensive, and widely distributed WMHs. Bottom left: A child with mild TBI and hemosiderin in the corpus callosum (arrow). Bottom center and bottom right: Images from the same patients, respectively, as the top center and right. Both patients show some generalized atrophy and ventricular dilation as a reflection of generalized brain volume loss that was a consequence of severe TBI, along with multiple hemosiderin deposits.
Images courtesy of Bigler ED. Front Hum Neurosci. 2013;7:395. [Open access.] PMID: 23964217, PMCID: PMC3734373.
New Orleans criteria
The NOC indicate that the presence of any one of the following findings requires CT scanning of the head[40]:
Patients should be advised to be aware of symptoms of postconcussive syndrome, which can develop over the weeks following an event.[35] Diagnostic criteria include at least three of the following eight symptoms: headache, dizziness, fatigue, irritability, insomnia, concentration problems, memory difficulty, and/or stress/emotional/alcohol intolerance.[42] If the patients play contact sports such as ice hockey or are at risk for a second impact, they should be counseled not to return to play until cleared by their primary physician to avoid secondary impact syndrome.[43]
The T1-weighted coronal MRIs are those of a male adolescent with TBI (left) and an age-matched control subject (right). Top left: The upper left arrows indicate a prominent interhemispheric fissure and cortical sulci, indicating whole brain-volume loss and generalized cerebral atrophy in the TBI patient. The lower arrow indicates an atrophic hippocampus and dilated temporal horn, seen bilaterally.
Middle row: Dorsal view of a three dimensional (3-D) reconstruction of the ventricle (blue) superimposed on the brain surface 3-D reconstruction. The ventricle-to-brain ratio (VBR), a global measure of brain integrity, in the TBI brain is markedly deviant from normal.
Bottom row: Frontal view of the 3-D reconstructed brain. In the TBI brain, there is global frontal atrophy with visibly larger cortical sulci compared to that of the age-matched control subject, reflective of generalized cerebral atrophy. An increased VBR reflects this type of global brain-volume loss, ventricular enlargement, gyral shrinkage, and sulcal enlargement.
Image courtesy of Bigler ED. Front Hum Neurosci. 2013;7:395. [Open access.] PMID: 23964217, PMCID: PMC3734373.
Due to the increased risk of iatrogenic malignancy when exposing pediatric patients to ionizing radiation from CT scans, researchers developed an algorithm (partially shown) to aid in the determination of which children presenting with TBI should undergo neuroimaging.[44]
The majority of children with mild symptoms and no dangerous mechanism of injury do not require CT evaluation and can be observed for the development of concerning signs/symptoms, such as altered mental status, intractable vomiting, or worsening symptoms.[44]
Adapted image courtesy of Kuppermann N, Holmes JF, Dayan PS, et al, for the Pediatric Emergency Care Applied Research Network (PECARN). Lancet. 2009;374(9696):1160-70. PMID: 19758692.
As noted earlier, many young athletes in competitive sports, such as ice hockey, may try to minimize or hide their concussion symptoms from coaches, parents, and clinicians.[35] Thus, standardized patient assessment tools can be helpful in identifying concussion. Although none of these tools are particularly well validated, their use is recommended.
The Centers for Disease Control and Prevention's (CDC's) "Heads Up" initiative provides many tools and resources for parents, schools, coaches, and clinicians to prevent, recognize, and respond to concussions and other TBIs[45] at https://www.cdc.gov/headsup/index.html. These tools/resources include information sheets, posters/infographics, stickers, and palm cards, as well as free online applications (apps), embeddable microsites, and training.
Removing athletes from play following a concussion or other TBI is crucial, as they are more susceptible to repeat head (or other) injury due to slowed reaction times. Repeat concussion prolongs symptoms, and there is growing concern that postconcussive symptoms are associated with long-term cognitive dysfunction and other neurologic sequelae.[35,36,46] The American Medical Society for Sports Medicine (AMSSM) indicates that athletes should be free from concussion symptoms before being cleared to return to play.[46]
Emerging evidence suggests that early return to physical activity may be helpful in reducing the severity and chronicity of postconcussive symptoms.[47] The activity should not be one that is high risk for repeat head injury.
The images are from an adult male who sustained a severe TBI (GCS = 3), demonstrating differences in the brain before (MRI) and after his head injury (CT scans). The VBR in the CT scans progressively increases over time, reflecting parenchymal degeneration. DOI = day of injury; VBR = ventricle-to-brain ratio.
For more information about concussions and TBIs, see the Medscape Drugs & Diseases articles Traumatic Brain Injury (TBI) - Definition and Pathophysiology and Classification and Complications of Traumatic Brain Injury, as well as the slideshow Pediatric Concussion and Other Traumatic Brain Injuries.
Images courtesy of Bigler ED. Front Hum Neurosci. 2013;7:395. [Open access.] PMID: 23964217, PMCID: PMC3734373.
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