Winter Skiing and Snowboarding Injuries

LESSON 2

By Katherine W.D. Dolbec, MD Dr. Dolbec is an emergency and sports medicine physician at the University of Vermont Medical Center and an assistant professor at the Larner College of Medicine in Burlington, Vermont. Reviewed by George Sternbach, MD, FACEP OBJECTIVES On completion of this lesson, you should be able to: CRITICAL DECISIONS 1. Identify the most common injuries sustained by skiers and n What injuries and mechanisms should be snowboarders. suspected when managing skiers and 2. Understand how to assess, image, and treat patients with snowboarders? skiing-related injuries. n How should skiing-related knee injuries be 3. Properly assess skiing-related thumb injuries and managed in the emergency department? understand their associated morbidity. n How should skiing-related thumb injuries be 4. Identify and manage common skiing- and snowboarding- managed in the emergency department? related shoulder injuries. n What unique factors should be considered when 5. Describe how to identify and treat unique snowboarding- related injuries. evaluating a snow sport-related shoulder injury? n What differential diagnoses should be FROM THE EM MODEL considered when evaluating a snowboarder with 18.0 Traumatic Disorders an ankle injury? 18.1.8 Extremity Bony Trauma

As the winter sports season reaches its peak, the number of skiing- and snowboarding-related injuries mounts. More than 100,000 injured skiers and snowboarders seek care in US emergency departments annually.1 Although nearly 50% of these presentations involve sprains and strains, these patients are at risk for a number of unique complications that can result in long-term sequelae. As such, emergency physicians must be prepared to recognize the mechanisms and nuanced signs of skiing- and snowboarding-related injuries, conduct appropriate diagnostic tests, employ splinting and bracing, and initiate rehabilitation and orthopedic follow-up.

January 2019 n Volume 33 Number 1 17 CASE PRESENTATIONS ■ CASE ONE posteriorly. His quadriceps strength and tenderness is noted on the is 4/5, and his hamstring strength ulnar side of the thumb. Although A 54-year-old man presents is 4+/5. The clinician performs the with knee pain resulting from a fall she has full active range of motion, Lachman test, which is positive sustained while skiing. He explains opposition movements cause her without an end point and with that he turned quickly to avoid pain. The emergency physician increased laxity in comparison to colliding with another skier, while orders x-rays of the patient’s thumb. the left knee. Increased excursion is shifting his weight toward the tails noted when varus and valgus stress ■ CASE THREE of his skis. He immediately heard is applied while the right limb is in A 25-year-old man arrives via a “pop” and felt a sudden, sharp full extension, but no frank knee ambulance after a snowboarding pain in his right knee. Although pain or gapping is noted. A posterior accident at a local terrain park. He the pain quickly abated after he drawer test is negative. The emergency fell, his knee felt “wobbly” when explains that he lost his balance physician orders x-rays. he tried to stand. Unable to bear and fell after landing a large jump. He complains of ankle pain and is weight and walk, the patient had to ■ CASE TWO having difficulty bearing weight. be carried down the mountain by A 22-year-old woman presents Mild swelling of the lateral ankle the ski patrol. with pain and swelling at the base of is noted, but there is no bruising. On examination, his right knee her right thumb after falling during is visibly swollen, with a palpable a skiing lesson. She explains that she Palpation reveals tenderness of the effusion. There is no tenderness to lost her balance on a beginner slope lateral ankle and lateral malleolus palpation along the patella or the and landed on outstretched hands; without crepitus. There is no pain medial or lateral knee lines. she was wearing her pole straps at at the proximal fibula or base of He has a limited range of motion the time. She has no history of prior the fifth metatarsal. The patient is (+5 degrees of extension and 100 thumb injuries and is right-hand able to plantar flex and dorsiflex degrees of flexion) with end-range dominant. his ankle with some discomfort. His flexion and extension. The patient has some mild swelling ankle strength and sensation are He complains of diffuse knee and discoloration around her first intact. Suspecting a fracture, the pain, which is most pronounced metacarpophalangeal (MCP) joint, clinician orders x-rays.

CRITICAL DECISION less severe. Experts, who typically move are the most common ski-related complaints, followed by trauma to What injuries and mechanisms at higher speeds, are far more likely to the head, face, shoulder, and thumb.1 should be suspected sustain head injuries, fractures, and high- grade sprains. Hard-packed Snowboarders are most inclined to when managing skiers and snow generally yields a greater number injure their wrists, shoulders, , 4 snowboarders? of high-speed and impact injuries than heads, faces, and . Although serious splenic injuries are rare, they Most snow-sport injuries are powder and heavy snow. occur more frequently in snowboarders traumatic, the result of moving at a high Other factors that predispose than they do in skiers.5 rate of speed on firm, slippery terrain patients to accidents include: while surrounded by other people and • Time skiing/snowboarding without Traumatic brain injuries, ranging obstacles. Falls account for 75% to 85% rest from concussions to intracranial of injuries, collisions cause 11% to 20%, • Skiing/snowboarding above one’s hemorrhages, are common in both and lift-related incidents prompt 2% to ability level skiers and snow­boarders (7.2%-17.9%) 9% of winter sport-related emergency • Improper or faulty equipment and are the most common cause department visits.2 • An inadequate adjustment to altitude of death and serious injury among both.1,6 Chest trauma (eg, rib fractures, Many variables affect injury rates, • Dehydration or fatigue pneumothoraces, hemothoraces) and including ability, age, gender, physical • Skiing/snowboarding off trail or in closed areas spinal injuries also occur.7 Ninety- fitness, and snow conditions. Patients • Failure to observe posted warning five percent of snow sport-related younger than 20 years and those older signs thoracic and lumbar spinal injuries 3 than 40 years are at greatest risk. While Skiers are prone to injuries that involve compression fractures, spinous beginners experience injuries three involve the lower extremities, while process fractures, or transverse process times more often than expert skiers and snowboarders are more apt to sustain fractures. In such cases, neurological snowboarders, their injuries tend to be upper-extremity trauma. Knee injuries sequelae are rare.8

18 Critical Decisions in Emergency Medicine CRITICAL DECISION drawer movement (Figure 3), in which rupture will disappear when the knee is How should skiing-related the skis continue downhill rapidly as placed in 30 degrees of flexion. the skier’s weight is shifted backward. The mechanism responsible for knee injuries be managed in These injuries often happen when most MCL injuries is valgus stress the emergency department? skiers land a jump with their weight placed on the knee during a fall. Knee injuries, which account for distributed in the “backseat.”10 These injuries are especially common approximately one-third of all injuries in beginners, who often spend Clinical Clues in adult skiers, are also common in considerable time skiing in a wedge A skier with an ACL injury may pediatric patients.9 Owing to the position, with their knees in a valgus report feeling or hearing a “pop” combination of gravitational and position and their and knees followed by a sensation of pain. centripetal forces inherent in the sport, internally rotated. On examination, in which a large lever arm is to attached Although the pain diminishes rapidly, these patients complain of medial to the , medial collateral ligament the affected knee will feel unstable when knee pain; there is tenderness to (MCL) sprains and anterior cruciate the patient attempts to stand or walk. palpation over the far medial knee ligament (ACL) sprains are particularly Effusion develops shortly thereafter, and joint and increased pain when valgus common, each accounting for with it, the pain returns. The Lachman stress is applied. Grade II and III approximately 25% of all skiing-related test, in which the examiner stabilizes the sprains are accompanied by a laxity knee injuries.9,10 patient’s femur with one hand and pulls of the ligament when valgus stress is Approximately 68% of ACL tears and pushes the anteriorly with the applied. Importantly, the laxity of the in skiers are associated with trauma other, is the most sensitive (80%-99%) affected limb should be compared to to the menisci or another ligamentous and specific (95%) method for detecting the contralateral, uninjured side, as structure.11 Lateral collateral ligament ACL ruptures. some patients inherently have greater (LCL) tears, posterior cruciate ligament Because the ACL is a primary ligamentous laxity. (PCL) tears, and knee dislocations are medial stabilizer, increased excursion Between 23% and 55% of relatively uncommon in this population. may be noted when varus and valgus skiing-related meniscal tears are The most common cause of ACL stress is applied to the knee in full associated with ACL ruptures.9,13 injuries in skiers is the “phantom extension. This finding should not be Lateral meniscal injuries accompany foot” (Figure 1), in which the knee is misinterpreted as a sign of trauma to the between 43% and 81% of ACL and simultaneously flexed and internally MCL or LCL, which can be identified MCL tears and are five times more rotated.9,12 ACL trauma can also be by tenderness with palpation over the common than coincident medial caused by valgus-external rotation and painful laxity with the meniscal tears in skiers with acute ACL (Figure 2), a mechanism frequently application of varus or valgus stress in insufficiency.9,11,13 These “shearing” associated with concomitant MCL full extension and 30% of flexion. The injuries are sustained when the tibia trauma, or a boot-induced anterior increased excursion caused by an ACL rotates on the femur. The diagnosis

FIGURE 1. Phantom Foot FIGURE 2. Valgus-External FIGURE 3. Boot-Induced Mechanism Rotation Mechanism Anterior Drawer Mechanism

This ACL injury occurs when a skier loses balance and transfers weight over the back of the skis. The hips drop below the knees and the uphill arm falls backward. With this mechanism, a skier lands from The uphill ski becomes unweighted, a jump, and the tails of the skis strike placing pressure on the inside edge of the These injuries are caused when the skier the snow first, which forces the elevated downhill ski, and the upper body rotates falls forward, catching the inner edge of to face the downhill ski, exerting an ski tips downward. The boot applies a the ski tip on snow. internal rotation force on the tibia. passive anterior drawer load to the tibia.

January 2019 n Volume 33 Number 1 19 FIGURE 4. Segond Fracture FIGURE 5. Initial ACL Injury Rehabilitation Exercises

Quad sets Heel slide

Passive knee extension

can be difficult to observe during the rotation of the tibia with respect to the allowed to do so. The placement of a physical examination, unless the patient femur.14,15 In addition, Segond fractures knee immobilizer should be avoided presents with a knee that is locked (a are associated with a high coincidence of whenever possible; these devices can complication of a bucket-handle tear, medial meniscal tears.14 significantly delay surgical management in which a portion of the has A reverse Segond fracture, or an avulsion and hinder rehabilitation by promoting flipped into the joint). fragment medial to the proximal tibia muscle atrophy and reducing range of Patients typically develop an (where the deep capsular component motion in the affected limb. Exceptions effusion within hours of injury. The of the MCL is attached), frequently to this rule include quadriceps and McMurray maneuver, in which a varus indicates trauma to the PCL, MCL, or ruptures, displaced force is applied to an internally rotated and is typically the tibial plateau fractures, tibial spine leg () as the knee is result of a high-energy valgus or external avulsion fractures, patellar fractures moved from flexion to extension and rotation mechanism.14,16 or dislocations, and knee dislocations. valgus force is applied to an externally It is also important to closely study In these instances, the knee should be rotated leg (medial meniscus) as the the tibial spines of any patient with a immobilized in extension and the patient knee is moved from flexion to extension, suspected ACL or PCL rupture. Tibial should refrain from bearing weight. An may be attempted. However, the test spine avulsions, rare injuries in which immobilizer may also be considered can be difficult to perform in a painful, the ligament remains intact but the bone for traumatic knee injuries in children, swollen limb. The test is considered is fractured at its tibial attachment, who sometimes require more aggressive positive when a palpable or audible require knee immobilization and a bracing for a comfortable and safe “clunk” can be appreciated when the prompt surgical consultation. All but discharge. Pediatric patients are more knee is moved from flexion to extension. the most minimally displaced of these likely to regain strength and range of 14 Suspicion can be confirmed by an fractures are managed surgically. motion post-injury than their adult outpatient MRI. Tibial plateau injuries are sustained counterparts. Any skier who presents with knee via the same mechanisms that precipitate Any patient with one of the above pain should undergo x-rays in the ligamentous injuries of the knee. indications for a knee immobilizer Clinicians should maintain a high emergency department (anteroposterior warrants urgent or emergent orthopedic suspicion for these diagnoses when [AP], lateral, and tunnel views). A management, and orthopedics should assessing x-rays; a CT scan should be sunrise view may be helpful if a patellar be consulted prior to emergency seriously considered if a displaced, pathology is suspected. The films should department discharge to determine the intra-articular tibial plateau fracture is be studied for evidence of a tibial plateau appropriate disposition and follow- suspected but not appreciated or fully or Segond fracture (Figure 4). Segond up plan. If a knee immobilizer is not assessed on plain film. Significant knee fractures, which represent an avulsion indicated, but the pain is unbearable or injuries should be promptly evaluated of the anterolateral ligament of the the knee is too unstable for the patient with outpatient MRI imaging to assess for knee, appear as small, cortical avulsion to walk unassisted, a hinged knee brace ligamentous, meniscal, and bony trauma. fractures lateral to the proximal tibia. and/or crutches can be supplied and the Although uncommon, Segond Management and Disposition patient can be instructed to bear weight fractures are pathognomonic for an Ambulation should be tested prior as tolerated. ACL injury in adults and likely represent to discharge, and patients who can Rehabilitation should be initiated a significant varus stress with internal walk unassisted should generally be upon discharge from the emergency

20 Critical Decisions in Emergency Medicine department, and patients should be be performed with the thumb in full Evaluation and Management encouraged to perform aggressive extension and at 30 degrees of flexion There is a theoretical concern range-of-motion exercises several to evaluate the proper and accessory that placing significant valgus stress times a day to prevent stiffness. In UCLs (Figure 6). on the MCP joint during ligamentous addition, an effort should be made to A UCL rupture should be considered stability testing could create a Stener preserve quadriceps and hamstring when assessing any thumb with a laxity lesion where one did not previously strength. Patients should be instructed of more than 30 degrees, laxity that exist. In practice, however, a relatively to perform quadriceps-flexion exercises is 15 degrees greater than it is on the gentle examination is unlikely to (performed in a seated or supine contralateral side, or laxity that has cause significant additional damage or position) and heel-slide exercises for no end point.17 UCL sprains, which increase the complexity of the probable hamstring strengthening (Figure 5) a can be graded I to III, are frequently impending surgical repair. minimum of three times per day. accompanied by trauma to the dorsal The differential diagnosis of a Knee injuries that do not fall capsule and the volar plate, potentially skiing-related injury to the base of the into the category of urgent/emergent leading to volar subluxation of the thumb includes a Bennett fracture, should be referred to orthopedics for proximal phalanx.17 Grade I injuries are Rolando fracture, and scaphoid further evaluation and management. evidenced by pain with palpation and fracture. Four-view x-rays of the Unfortunately, many skiing-related stress but no laxity; grade II injuries hand (AP, lateral, and oblique views) knee injuries, including displaced involve some laxity of the joint and should be obtained. Dedicated wrist tibial plateau and tibial spine avulsion a preserved end point; and grade III films, including a scaphoid view, can fractures, require surgical repair. ACL injuries are marked by significant laxity be obtained if a scaphoid fracture and meniscal injuries may warrant and no end point.17 is suspected. In addition, the x-rays surgery, depending on the patient’s age, Because of the significant force should be studied closely for evidence activity level, goals, and rehabilitation involved, grade III injuries are often of an avulsion fracture of the distal potential. MCL injuries are generally associated with Stener lesions, in which attachment of the UCL.17 Stress views treated nonoperatively. the distal end of the ruptured ligament can help clarify the degree of instability CRITICAL DECISION becomes displaced, resulting in the at the first MCP joint. Unstable grade interposition of the ulnar expansion III injuries require an outpatient MRI How should skiing-related of the dorsal aponeurosis between the for further evaluation and possible thumb injuries be managed ligament and its attachment site on surgical planning. In the hands of an in the emergency the proximal phalanx. These lesions experienced clinician, an ultrasound department? (Figure 7), which can manifest as a evaluation can also be effectively used painful lump at the site of the “balled up” to assess for a UCL rupture. An ulnar collateral ligament ligament, necessitate surgical repair to The patient’s thumb should be (UCL) sprain, or “skier’s thumb,” is avoid long-term functional compromise.17 immobilized in a spica splint, and the a common and deceptively serious injury typically caused by a fall onto an outstretched hand that is attached to FIGURE 6. Valgus Stress Test FIGURE 7. Stener Lesion a ski pole strap. Further valgus stress for the UCL of the Thumb is placed on the joint by the forward momentum of the skier, who may continue to travel downhill with the hand planted in the snow.9 Long-term disability can result from a chronic deficiency of the ligament; potential complications include a diminished grip and pinch, pain, and osteoarthritis.17 Injured hands should be thoroughly inspected for bruising and swelling, and the and bones should be carefully palpated to identify the point of maximal tenderness. UCL trauma should be suspected when maximal tenderness is noted over the ulnar aspect of the MCP joint. The stability of the ligament can be determined by placing valgus stress on the MCP joint. This maneuver should

January 2019 n Volume 33 Number 1 21 during falls in which the shoulder is FIGURE 8. Squared-Off Appearance of a Shoulder Dislocation abducted and externally rotated. These injuries can also occur when a skier or snowboarder catches an arm or ski pole on a stationary object while the remainder of the body continues its forward momentum. In snowboarders, anterior shoulder dislocations frequently result from jumps, aerial maneuvers, and falls backward.19 Luxatio erecta humeri is a rare form of dislocation in which the humeral head is displaced inferiorly and the arm becomes locked in a flexed, overhead position. Rotator cuff tears are closely associated with glenohumeral dislocations and greater tuberosity fractures. A skier older than 40 years who presents with a shoulder dislocation has a 35% risk of a concomitant rotator cuff tear. This risk increases to 40% in patients with greater tuberosity fractures and to 100% in those with neurological findings involving the axillary nerve.9,18 Weakness with resisted shoulder patient should receive close orthopedic biceps strains, glenoid fractures, scapula abduction in the scapular plane suggests follow-up. The interphalangeal joint fractures, humeral head fractures, a rotator cuff tear. These presentations should be left free to preserve optimal sternoclavicular separations, and are often delayed, however; as such, function and avoid stiffness. Patients acromial fractures. it is important to elicit a good history should be advised against removing the AC separations are the most regarding the onset of symptoms. splint until definitive care is sought. common snowboarding-related shoulder Patients with an anterior shoulder Grade I and II injuries can generally injuries, followed by glenohumeral dislocation present with pain and be treated nonoperatively, while grade joint dislocations, clavicle fractures, decreased passive and active range III injuries (with or without a Stener anterior and posterior sternoclavicular of motion in the affected limb. The lesion) typically require surgical repair.17 dislocations, rotator cuff strains, and shoulder will have a squared-off CRITICAL DECISION proximal humerus fractures.18 appearance (Figure 8), and there may be a palpable mass indicating the displaced What unique factors should Shoulder Dislocations humeral head. The neurovascular be considered when Anterior shoulder dislocations, examination may reveal numbness in evaluating a snow sport– which far outnumber posterior the axillary nerve distribution over the related shoulder injury? dislocations, most commonly occur lateral arm. Falls are the most common cause of shoulder trauma. The most common TABLE 1. Rockwood Classification of AC Injuries mechanisms are direct blows, eccentric Deltopectoral CC Interspace Radiographic Appearance muscle contractions with shoulder Type AC Ligaments CC Ligaments Fascia Difference* of an AC Joint I Sprained Intact Intact Normal Normal abduction and external rotation, and an axial load on an outstretched arm.18 II Disrupted Sprained Intact <25% Widened Rotator cuff tears, anterior III Disrupted Disrupted Disrupted 25% to 100% Widened glenohumeral dislocations, acro­ IV Disrupted Disrupted Disrupted Increased Clavicle posteriorly displaced (axillary) mioclavicular (AC) joint sprains, and V Disrupted Disrupted Disrupted 100% to 300% N/A† clavicle fractures are the most common 18 VI Disrupted Disrupted Disrupted Decreased Clavicle displaced shoulder injuries sustained by skiers. inferior to coracoid Less common shoulder injuries include *Distance between the superior aspect of the coracoid process and the inferior aspect of the clavicle, as greater tuberosity fractures, trapezius measured radiographically. strains, proximal humerus fractures, †N/A = information unavailable

22 Critical Decisions in Emergency Medicine Prereduction x-rays (including AP, been confirmed, reduction should be true AP, scapular Y, and axillary views) attempted promptly. The patient’s pain FIGURE 10. Lateral Process should be obtained to confirm the level and the difficulty of the procedure Talus Fracture dislocation and identify alternative or increase commensurate with the amount concomitant pathologies. X-rays can of time since the injury.20 An isolated, help confirm the position of the humeral uncomplicated shoulder dislocation can head in relation to the glenoid fossa and be successfully reduced using one of enable the identification of fractures. A many described reduction techniques. humeral neck fracture that accompanies Most anterior glenohumeral dislocations a shoulder dislocation can make closed can be reduced without sedation.19 reduction difficult or impossible. Greater The value of post-reduction films is tuberosity fractures are often seen controversial, and clinicians may be in patients with traumatic shoulder able to accurately assess these injuries dislocations and can be identified by clinically. In addition, a fracture that prereduction plain films. In rare cases, is identified after reduction was almost this fragment interferes with reduction certainly present before the reduction attempts. attempt and is unlikely to alter decisions Plain x-rays can also identify 21 alternative diagnoses such as AC joint regarding the pursuit of surgical repair. sprains, distal clavicle fractures, and Following reduction, patients should isolated humeral neck fractures. If a be discharged in a sling and instructed dislocation is suspected clinically but to avoid performing overhead activities is not identified on x-rays, the clinician and abducting, externally rotating, or should look for subtle signs of a extending the shoulder. However, they Courtesy of Matthew Gammons, MD posterior dislocation (eg, a light bulb should also be encouraged to begin sign) (Figure 9). The axillary view can gentle, passive range-of-motion exercises Shoulder Separations also help reveal these injuries. (eg, pendulum swings) as soon as can be Snowboarding-related AC Once a shoulder dislocation has tolerated. separations most often result from falls in which the patient lands directly 19 FIGURE 9. Light Bulb Sign of a Posterior Shoulder Dislocation on the lateral acromion. When managing a patient who has been injured in a snowboarding accident, the shoulders should be carefully inspected by palpating the joints and bony landmarks, noting any deformities and identifying the point of maximal tenderness. Range-of-motion testing should be attempted; however, due to the underlying pathology or secondary to pain, most shoulder injuries will be accompanied by a decreased range of motion. A thorough neurovascular examination should be performed. The AC ligaments are primarily responsible for the horizontal stability of the clavicle in relation to the acromion, while the coracoclavicular (CC) ligaments control vertical stability.19 Any trauma to these structures constitutes an AC sprain, the severity of which can be assessed using a variety of diagnostic tools. The Rockwood classification system (Table 1), the most widely used scale, can help facilitate communication between the emergency physician and the orthopedist.

January 2019 n Volume 33 Number 1 23 CASE RESOLUTIONS ■ CASE ONE to discuss management options. The The clinician diagnosed an X-rays of the skier’s injured knee clinician also showed him how to unstable grade III UCL injury and revealed a small avulsion fragment perform quadriceps sets and heel-slide placed the thumb in a spica splint. lateral and superior to the fibular exercises to maintain his muscle mass The patient was warned about the head, which was identified as a and stave off atrophy. In addition, he risks of long-term pain and disability Segond fracture. The emergency encouraged the patient to work hard and was advised to follow up with a physician suspected an ACL rupture on regaining full flexion and extension hand surgeon in 5 to 7 days. based on the mechanism of injury, of the knee by performing aggressive rapid development of an effusion, range-of-motion exercises multiple times ■ CASE THREE instability, positive Lachman test, per day. The snowboarder’s plain films increased varus-valgus excursion of revealed soft-tissue swelling without the knee in extension, and presence ■ CASE TWO any evidence of a fracture. The of a Segond fracture. X-rays of the patient’s thumb alignment of the osseous structures The patient was able to walk revealed no signs of a fracture, an was normal. Given the mechanism unassisted in the emergency avulsion fragment, or subluxation. of injury and ongoing exquisite department and did not require a Suspecting a rupture of the UCL, tenderness over the lateral aspect of brace or crutches. He was advised the clinician consulted with the the ankle, the emergency physician to take it slow, while contracting hand surgeon on call, who suggested obtained a CT scan, which revealed a his quadriceps and hamstrings performing a valgus stress maneuver nondisplaced LTPF. The patient was with each step to stabilize the knee, on the MCP joint. The test revealed placed in a splint, discouraged from and was urged to follow up with considerable valgus angulation without bearing weight, and advised to seek an orthopedist in the next week a ligamentous end point. orthopedic follow-up care.

Type I injuries involve partial to a suspected AC sprain. A cross-body to prevent stiffness. Shoulder pendulum tearing of the AC ligament. Type II adduction film, in which the hand on the exercises, which can often be initiated sprains are defined by a complete affected side is reached across to grasp within a week, should be demonstrated to tearing of the AC ligament and partial the contralateral shoulder, can accentuate the patient prior to discharge. disruption of the CC ligament, with the elevation of the clavicle in cases of Type IV to VI injuries warrant a slight elevation of the distal clavicle CC ligament disruption. an orthopedic consultation prior to in relation to the acromion. Type III AC separations warrant orthopedic discharge; these presentations are sprains are accompanied by a 25% to or sports medicine follow-up to ensure associated with significant soft-tissue appropriate healing without functional damage, and urgent surgical repair may 100% elevation of the distal end of the impairment. Patients with Rockwood type be required. In some cases, surgical repair clavicle in relation to the coracoid, as I to III fractures, who generally can be is warranted for unstable type III injuries, the CC ligaments and the AC ligament managed nonoperatively, should be placed particularly in patients with pain or are completely disrupted. in a sling for comfort and encouraged to disability that persists remote from the In types IV through VI, the CC mobilize the injured shoulder as tolerated initial trauma. and AC ligaments are completely disrupted and the trapezius and deltoid are detached from the distal half of the clavicle. In type IV injuries, the trapezius is impaled by the distal clavicle. Type V sprains are characterized by 100% to 300% superior displacement of the distal n Avoid the use of a knee immobilizer, unless it is truly indicated. clavicle in relation to the coracoid. In n Initiate physical therapy exercises in the emergency department for knee injuries type VI injuries, the distal clavicle is that do not require immobilization. Advise patients to begin aggressive range- of-motion and strength-preserving exercises immediately upon discharge. depressed into the subcoracoid space. n Ensure prompt hand surgery follow-up care for any patient with an injury of any X-rays should be performed on any grade to the UCL of the thumb. Surgery may be the only way to avoid long-term patient with a skiing- or snowboarding- pain and functional compromise. related shoulder injury. Weighted views, n Maintain a high index of suspicion for an LTPF in any snowboarder with an in which the patient holds a 10- to appropriate mechanism of injury. Additional imaging may be warranted, even if 15-pound dumbbell in the affected hand, the initial x-rays are negative. can help verify any instabilities related

24 Critical Decisions in Emergency Medicine CRITICAL DECISION to definitively diagnose or rule out these with snowboarding. Misdiagnosing What differential diagnoses fractures. MRI should not be the first-line these injuries as ankle sprains can result imaging modality for evaluating such in chronic pain and loss of function. A should be considered when cases, as it can fail to distinguish between CT scan is the imaging study of choice evaluating a snowboarder small avulsion fractures of the talus and in any patient with normal x-rays but with an ankle injury? adjacent ligamentous injuries.9 a suspicious mechanism and physical examination findings. Lateral talar process fractures Summary (LTPFs), which account for 32% of Despite the popularity of these REFERENCES snowboarding-related ankle fractures, winter past times for people of all ages, 1. 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LTPFs are fracture: a bony injury of the anterolateral ligament of the knee. Arthroscopy. 2014 Nov;30(11):1475-1482. examination findings, and there should well-described, albeit uncommon, injuries 16. Escobedo EM, Mills WJ, Hunter JC. The “reverse Segond” fracture: association with a tear of the posterior be a low threshold for initiating CT scans that are almost exclusively associated cruciate ligament and medial meniscus. AJR Am J Roentgenol. 2002 Apr;178(4):979-983. 17. Avery DM 3rd, Caggiano NM, Matullo KS. Ulnar collateral ligament injuries of the thumb: a comprehensive review. Orthop Clin North Am. 2015 Apr;46(2):281-292. 18. McCall D, Safran MR. Injuries about the shoulder in skiing and snowboarding. Br J Sports Med. 2009 Dec;43(13):987- 992. 19. Kocher MS, Dupré MM, Feagin JA Jr. Shoulder injuries from alpine skiing and snowboarding. Aetiology, treatment and prevention. Sports Med. 1998 Mar;25(3): n Placing a knee immobilizer on every patient with traumatic knee pain. This 201-211. 20. Kanji A, Atkinson P, Fraser J, Lewis D, Benjamin S. approach can impede rehabilitation, accelerate muscle atrophy, and diminish Delays to initial reduction attempt are associated with range of motion. If required for stability and comfort, other assistive devices higher failure rates in anterior shoulder dislocation: a retrospective analysis of factors affecting reduction failure. and methods of bracing should be considered. Emerg Med J. 2016 Feb;33(2):130-133. n Failing to recognize a possible UCL injury of the thumb. Unrepaired complete 21. Gottlieb M, Nakitende D, Krass L, Basu A, Christian E, Bailitz J. Frequency of fractures identified on post- ruptures lead to long-term pain and functional impairment. It is safe to apply reduction radiographs after shoulder dislocation. West J Emerg Med. 2016 Jan;17(1):35-38. firm but gentle valgus stress to the first MCP joint when evaluating such cases. 22. Mahmood B, Duggal N. Lower extremity injuries in n Failing to recognize mechanisms and examination findings consistent with snowboarders. Am J Orthop (Belle Mead NJ). 2014 Nov;43(11):502-505. an LTPF. These fractures are missed on as many as 50% of plain films; when 23. Miller, SJ. Fractures of the lateral process of the talus: possible, a CT scan should be obtained. snowboarder’s fracture. The Podiatry Institute Update. 2008;23.

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