Tibial Fractures in Alpine Skiing and Snowboarding in Finland: A Retrospective Study on Fracture Types and Injury Mechanisms in 363 Patients

Fracture distribution in alpine skiing - a national population based study of 7,110 fractures in adults and children from the Swedish fracture register

BACKGROUND

Alpine skiing is practiced with speed and forces which entails a risk of injury and fractures. Most studies focus on all injuries in the musculoskeletal system and fractures are only described briefly or lack comparison between children and adults. This study focuses on the national trends of skiing-related fractures in children and adults, detailing fracture localization characteristics and initial treatments.

METHODS

This is a population-based national cohort study using data from the Swedish Fracture Register. The study population includes children and adults with a fracture sustained by alpine skiing between January 2015 and April 2022. Variables of interest were age, sex, localization of the fracture and segment, the number of fractures per patient, injury date, open or closed fracture, energy level, and primary treatment.

RESULTS

In total 7,110 fractures were registered in 6,806 patients. 48.6 % of the fractures were in children The women had a statistically significant higher median age at fracture to men. In children, it was contrary with a statistically lower median age in girls compared to boys. Children most commonly fractured the tibia (48.4 %), the radius (22.2 %), and the hand (7.8 %). The most fractured segment in children was the tibial shaft (38.5 %). Adults most often fractured the tibia (27.6 %), the radius (13.9 %), and the humerus (13.6 %) and had the proximal tibia as the most fractured segment (18.8 %). 82 % (2724) of fractures in children were treated non-surgically. In adults, 54 % (1850) were treated non-surgically.

CONCLUSION

Tibia fractures were predominant, with children frequently experiencing shaft fractures and adults proximal tibia fractures. Younger, lighter children skiing at a slower speed would benefit from improved ski bindings for fracture prevention. Tailoring ski equipment to an individual's age and sex is crucial for enhancing preventive strategies.

Patient-reported outcomes after initial conservative fracture treatment in primary healthcare – a survey study

Background

Primary healthcare in Norway has first-line responsibility for medical emergencies, including traumas and fractures. Normally, patients with suspected fractures are referred to specialist care. However, some municipalities have X-ray facilities and handle minor fractures locally. We investigated patient-reported outcome measures after initial treatment of radiologically diagnosed fractures of the wrist, collarbone, and ankle at a primary healthcare centre in a rural municipality with a large ski resort. The patients’ general satisfaction with the treatment was also investigated.

Methods

Validated questionnaires were sent to patients with fractures of the wrist or collarbone (Quick DASH—Disability of Arm, Shoulder and Hand) or the ankle (FAOS -The Foot and Ankle Outcome Score). Patients with wrist and collarbone fractures also answered the Quality-of-life questions that are a subscale of the FAOS questionnaire for ankle fractures. Patient satisfaction was measured for all fracture groups. The Quick DASH scale ranges from 0 (no disability at all) to 100 (great disability), while for FAOS a score of 100 indicates no symptoms and 0 indicates extreme disabilities.

Results

A total of 148 of 238 patients answered the questionnaire (62% response rate). Patients with distal radius fractures had a mean Quick DASH score of 5.1 (median 0, range 0–77), and scores were significantly lower for males (p = 0.013) and increased with age (p = 0.024). Patients with collarbone fractures had a mean Quick DASH score of 2.1 (median 0, range 0–32) with no significant age or gender differences. Patients with ankle fractures had the following mean subscale-scores: Pain, 93.8; Symptoms, 71.4; Activities of daily living, 97.4; Sport, 90.0; and Quality of life, 92.1. The scores did not differ significantly by specialization of the physician. A total of 88% of the patients were highly or very highly satisfied with the handling of their fracture.

Conclusions

The patients reported low rates of functional disability and high rates of satisfaction after initial radiological diagnosis and treatment of their fracture at the primary healthcare centre. Specialisation of the treating physician was not associated with the outcome in any of the fracture types.

Biceps femoris long head morphology in youth competitive alpine skiers is associated with age, biological maturation and traumatic lower extremity injuries

Lower extremity injuries are common in competitive alpine skiers, and the knee and lower leg are often affected. The hamstring muscles, especially the biceps femoris long head (BFlh), can stabilize the knee and the hip and may counteract various adverse loading patterns during typical mechanisms leading to severe lower extremity injuries. The aim of the present study was to describe BFlh morphology in youth competitive alpine skiers in relation to sex, age and biological maturation and to investigate its association with the occurrence of traumatic lower extremity injuries in the upcoming season. 95 youth skiers underwent anthropometric measurements, maturity offset estimations and ultrasound assessment, followed by 12-months prospective injury surveillance. Unpaired t tests showed that the two sexes did not differ in BFlh morphology, including fascicle length (Lf), pennation angle (PA), muscle thickness (MT) and average anatomical cross-sectional area (ACSA_avg). In contrast, U16 skiers had longer fascicles than U15 skiers (9.5 ± 1.3 cm vs 8.9 ± 1.3 cm, p < 0.05). Linear regression analyses revealed that maturity offset was associated with Lf (R² = 0.129, p < 0.001), MT (R² = 0.244, p < 0.001) and ACSA_avg (R² = 0.065, p = 0.007). No association was found between maturity offset and PA (p = 0.524). According to a binary logistic regression analysis, ACSA_avg was significantly associated with the occurrence of traumatic lower extremity injuries (Chi-square = 4.627, p = 0.031, R_Nagelkerke² = 0.064, Cohen f = 0.07). The present study showed that BFlh morphology is age- and biological maturation-dependent and that BFlh ACSA_avg can be considered a relevant modifiable variable associated with lower extremity injuries in youth competitive alpine skiers.

Better discrimination of the concomitant peri-ankle fractures in the spiral tibial shaft fractures by thin-slice axial and three-dimensional CT

The objective of this study was to examine the morphologic features of spiral tibial shaft as well as concomitant fibular and peri-ankle fractures on multidetector high-resolution CT and to speculate about the mechanisms underlying these combined fractures.This is a retrospective cohort study. A total of 197 tibial shaft fractures underwent multidetector high-resolution CT before intramedullary nailing. The presence and location of peri-ankle fractures were recorded using thin-slice axial CT. Tibial shaft fractures were classified as spiral or non-spiral. The morphologies of spiral tibial fractures and concomitant lateral malleolar fractures were delineated using three-dimensional CT.Seventy-five spiral and 122 non-spiral fractures were identified. Peri-ankle fractures excluding lateral malleolar fractures were found in 77.3% of spiral fractures and 18.9% of non-spiral fractures. The most frequent location of peri-ankle fractures in the spiral group was the posterior malleolus, followed by the anterolateral distal tibia, while the medial malleolus was the most frequent site in the non-spiral group. Of 75 spiral fractures, 72 showed a fracture morphology attributed to external rotation force. There were 13 lateral malleolar fractures that were defined as within 6 cm from the distal end of the fibula. No lateral malleolar fractures showed the typical morphology of isolated supination/external rotation-type ankle injuries. The displaced syndesmotic injuries commonly coexisting in pronation/external rotation-type ankle injuries were not observed.Most spiral tibial shaft fractures were caused by external rotation force. However, the morphology of concomitant peri-ankle fractures was inconsistent with typical mechanisms of isolated external rotation ankle injuries.

A 5-year-old Snowboarder with Boot Top Tibial Diaphysis Fracture

ABSTRACT

A previously healthy 5-year-old boy presented with an oblique fracture of the midtibial diaphysis at the top border of the snowboarding boot after falling from a standing position with both feet strapped to his snowboard. This case illustrates a snowboarding-specific variant of the torsion-tension boot top injury classically described in skiers. Unlike most snowboarding-related lower-extremity injuries, this fracture occurred in the absence of high-speed trauma or collision.

Ski and Snowboard - Related Orthopedic Injuries

Participation in skiing and snowboarding continues to increase. Both sports are associated with unique equipment and movement patterns, placing athletes at risk for several characteristic injuries. Although the axial skeleton and extremities are at risk for injury in both sports, skiing and snowboarding are associated with distinctive injury patterns. This article summarizes the epidemiology, risk factors, and specific injuries associated with skiing and snowboarding to better educate orthopedic surgeons regarding diagnosis and treatment of athletes partaking in these sports.

Different injury patterns after snowboard in children and adolescents

Background

Snowboarding is a very common sport especially among young adults. Common injuries are hand, wrist, shoulder and ankle injuries.

Purpose

of this study was to analyze different injury pattern in children and young adults comparing with adults.

Methods

Patients who were admitted for ambulant or stationary treatment as a result of injury practicing snowboard received a questionnaire and were divided into three groups (children, young adults and adults) according to their age. Between october 2002 and may 2007 1929 injured snowboard sportsmen were included in the study. Data such as location, date and time of accident as well as information about the slope were carried out. In addition snowboard skills were classified and patients were questioned whether they wore special protectors.

Results

32.5% of injured patients were female (n = 626) and 67.5% male (n = 1303) with a mean age of patients of 21.9 (7-66) years. 13% of all patients were in group I (children), 19.2% in group II (young adults) and 67.8% in group III (adults).Most common injuries with 60% of all accidents were injuries of the hand wrist especially in children beginning with snowboard sports. Injuries on the regular track were most common followed by jumps in the kicker park and rails in the fun-park. 20.6% in group I, 13.6% in group II and 12.8% group III did not wear any protectors.

Conclusion

Children and adolescents presented different injury patterns than adults. Young participants of up to 14 years of age are endangered especially during the first days of learning this sport. Further development of protectors with regard to biomechanical characteristics is important to achieve an optimal protective effect.

Level of evidence

2b.

Fractures diagnosed in primary care - a five-year retrospective observational study from a Norwegian rural municipality with a ski resort

Objective: The aim of this study was to characterize fractures recorded at a Norwegian primary care centre near a ski resort.Design: A retrospective five-year observational study in the period 2010-2014.Setting: A primary care centre equipped with an x-ray machine and located near a ski resort in a small rural municipality of 931 inhabitants in Norway. The X-ray images are digitalized and instantly transferred for assessment of a radiologist and/or an orthopedic surgeon both before and after treatment.Subjects: All patients with radiologically confirmed fractures.Results: A total of 1154 X-ray examinations were done, out of which 480 (41.6%) were fractures verified by a radiologist. The most frequent fractures were in the wrist (30%), collarbone (15%), shin (11%), humerus (9%) and ankle (8%). 316 (66%) of the fractures were in males and of these 225 were in age group 10-19 years. Males dominated among fractures in collarbone (92% males), finger (80% males), and foot (85% males). Women with fractures of the wrist, ankle, humerus and metacarpal bones, had a higher median age than men with similar fractures. Nonsurgical treatment with cast or braces was initially offered in 371 (77%) of the fracture-cases at the primary care level.Conclusion: Young men acquired most of the fractures, predominantly in the wrist, and mostly during the winter sport season. Nearly eight of ten fractures were treated locally in primary care centre.Key pointsA large seasonal variation was found in number of patients with fractures.More than 60% had fractures in the wrist, collarbone, shin or ankle.More than half of the patients with a fracture were males and below 20 years old.Most fractures were ski-related.

Alpine Skiing Injuries

Context:

Alpine skiing is a popular sport worldwide but has significant risk for injury. The epidemiology of skiing-related injuries has been described, which has led to the identification of risk factors for specific types of injuries.

Evidence Acquisition:

Pertinent literature from peer-reviewed publications was reviewed.

Study Design:

Clinical review.

Level of Evidence:

Level 5.

Results:

The adoption of international standards for ski-boot-binding systems has changed the profile of skiing-related injuries over time, as has the widespread use of helmets. An understanding of mechanisms of injury, risk factors, and preventative measures may decrease the incidence of skiing-related injuries.

Conclusion:

Advances in standards for skiing equipment have been effective at decreasing both the frequency and severity of skiing-related injuries, but additional efforts are required to improve the safety of the sport.

Extreme Sports Injuries to the Pelvis and Lower Extremity

Extreme sports are growing in popularity, and physicians are becoming increasingly aware of injuries related to these activities. Imaging plays a key role in diagnosing and determining clinical management of many of these injuries. This article describes general imaging techniques and findings in various injuries specific to multiple extreme sports.

Management of injuries in snowboarders: rehabilitation and return to activity

Snowboarding has seen a continuous increase in popularity, leading to an increase in the number of snowboarding injuries seen in orthopedic practice. Upper-extremity injuries are more common than lower-extremity, spine, and pelvis injuries. In this review, we focus on the most common snowboarding injuries of the extremities, spine, and pelvis and provide an overview of their respective rehabilitation and return-to-sport protocols. Despite many of the injuries seen in snowboarding also occurring in other sports, objective data about rehabilitation and return to sport are lacking for many injuries. This provides an opportunity for research in the area with regard to many sports and many different injuries.

Femur Fracture Associated with Knee Brace Wear in the Motocross Athlete: A Report of Two Cases and Review of the Literature

The sport of motocross entails off-road motorcycle racing and is associated with a high incidence of traumatic injury. While prophylactic knee braces are routinely worn, there has been anecdotal concern that brace use is linked to femoral shaft fractures. While this risk remains unreported in the medical literature, preventing this complication has played a role in new commercial knee brace designs. We present two cases in which two motocross riders sustained transverse femoral shaft fractures at the proximal portion of each respective knee brace. The fracture locations measured on anterior-posterior radiograph were 22 and 21.1 cm proximal to the center of the knee, which is also the recommended proximal extent of motocross knee braces. We propose that the rigid knee brace protects the ligamentous knee structures but may focus undue force on the proximal aspect of the brace. New knee brace designs have incorporated features to dissipate the potentially injurious force to prevent femur fracture. While knee braces undoubtedly help prevent ligamentous knee injury, these cases question the safety of standard brace design and highlight the need for further brace development to better protect the patient's bony structures, in addition to the knee joint.

Skiers and snowboarders have improved short-term outcomes with immediate fixation of tibial plateau fractures

Background

Tibial plateau fractures (TPFs) are frequently associated with motor vehicle accidents, auto-pedestrian crashes and falls. However, hospitals near ski resorts commonly treat TPF resulting from skiing. The soft tissue envelope and original mechanism of injury are important determinants in the decision to proceed with immediate or delayed fixation of the fracture. Our objective was to assess whether immediate (≤24 hours) versus delayed (>24 hours) open reduction internal fixation (ORIF) affected in-hospital outcomes among snow sport participants.

Methods

This was a retrospective study of patients with isolated TPF who were injured while skiing or snowboarding and treated at a Level III Trauma Center that serves four major ski resorts between 2010 and 2013. Clinical characteristics and in-hospital outcomes were obtained from an existing trauma database. Imaging was reviewed to classify the fracture as high (Schatzker IV–VI) or low (Schatzker I–III) energy. Differences in clinical characteristics and outcomes between immediate and delayed ORIF patients were analyzed with χ² and Wilcoxon two-sample tests. These analyses were also performed in the high-energy and low-energy fracture populations.

Results

ORIF was performed on 119 snow sport patients, 93 (78%) immediately. Patients had a median age of 49 years (range 19–70) and were predominantly male (66%). Forty percent sustained a high-energy TPF. No differences were observed between the demographic characteristics, injury severity, Schatzker scores or time from injury to hospital arrival for patients treated immediately versus delayed treatment. Compared with delayed fixation, patients treated immediately had less compartment syndrome (3% vs 27%), needed fewer fasciotomies (6% vs 31%) and had a shorter length of stay (3 vs 6.5 days), p<0.05 for all. These results persisted in the stratified analysis of high-energy fracture patients.

Discussion

Treating patients immediately led to more favorable in-hospital outcomes compared with delayed treatment, even among the patients with a high-energy fracture.

Level of evidence

Level IV, Therapeutic/Care Management.