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Head, Neck, and Shoulder Injuries in Ice Hockey: Current Concepts

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Head, Neck, and Shoulder Injuries in Ice Hockey: Current Concepts A Review Paper Head, Neck, and Shoulder Injuries in Ice Hockey: Current Concepts Charles A. Popkin, MD, Bradley J. Nelson, MD, Caroline N. Park, BA, Steven E. Brooks, MD, T. Sean Lynch, MD, William N. Levine, MD, and Christopher S. Ahmad, MD puck (body-checking). Not surprisingly, the potential Abstract risk for injury in hockey is high. At the 2010 Winter Ice hockey is a fast-paced contact sport Olympics, men’s ice hockey players had the highest that is becoming increasingly popular in rate of injury of any other competitors there—more North America. More than 1 million men, than 30% were affected.4 In the United States, an women, and juniors are playing hockey in estimated 20,000 hockey players present to the the United States and Canada. With play- emergency department (ED) with injuries each year.5 ers colliding forcefully with one another In some leagues, game-related injury rates can be as and with the boards surrounding the ice, high as 96 per 1000 player-hours (Table 1). injury rates are among the highest in all of Hockey is played and enjoyed by athletes ranging competitive sports. Physicians caring for a widely in age. Youth hockey leagues accept players hockey team should be aware of the more as young as 5 years. Hockey can become a lifelong common injuries, involving the head, the recreational activity. In North America, old timers’ neck, and the shoulder. In this review, we leagues have many players up to 6 discuss evaluation and treatment of these age 70 years. According to Inter- national Ice Hockey Federation data hockey injuries, return to play, and, where Take-Home Points applicable, prevention strategies. for 2016, more than 543,000 and 639,500 people play hockey in the ◾ Hockey is a high-speed United States and Canada, respec- collision sport with one tively.2 Most of the rules, protective of the highest injury rates among all sports. n a surface of ice in Windsor, Nova Scotia in equipment, skates, ice surfaces, and the middle of the 19th century, the modern goal sizes are the same in men’s ◾ Use of a helmet with 1 7 visors or full-face shields O game of ice hockey evolved. A blend of hur- and women’s hockey. The major significantly reduces the ley, a Gaelic sport, and lacrosse, from the native difference is in body-checking—this risk for eye injury. Mi’kmaq culture, the sport of ice hockey gained practice is not allowed at any age in ◾ Broken portions of teeth rapidly in popularity throughout Canada and is women’s ice hockey. should be found and now the country’s national sport. Hockey quickly In this article, we review the placed in a protective me- spread to the United States and then Europe. It is evaluation and management of dium such as saline, saliva, presently played in 77 countries across the world.2 common head, neck, and shoulder or milk for transport. Hockey players can reach speeds of up to 48 km hockey injuries for physicians who ◾ A player with unresolved (~30 miles) per hour on razor-sharp skates on an ice provide medical support and cover- concussion symptoms should not be allowed to surface surrounded by rigid plastic composite boards age for youth, amateur, and senior return to the ice. topped with plexiglass.3 They use sticks made of hockey teams. ◾ Shoulder dominance, wood, aluminum, or a composite material to advance which determines stick a 6-ounce vulcanized rubber puck on the opposing Evaluation and Management grip, is an important con- goal, and this puck sometimes reaches speeds over of Common Hockey Injuries sideration in the treatment 160 km (~100 miles) per hour. Older, male players Eye Injuries of shoulder instability in an are allowed to make physical contact with their Although eye injuries are less com- ice hockey player. opposing counterparts to separate them from the mon than musculoskeletal injuries Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. www.amjorthopedics.com May/June 2017 The American Journal of Orthopedics ® 123 Injuries in Ice Hockey: Current Concepts Table 1. Ice Hockey Injury Rates From Numerous Studies: Rates of Injury Per 1000 Player-Hours and 1000 Athlete Exposures, Depending on Study Design Injury Rate Practice: Game: Practice: Game: 1000 1000 1000 Athlete 1000 Athlete Study Play Level Player-Hours Player-Hours Exposures Exposures Lorentzon et al65 (1988), AJSM Swedish Elite 1.4 78.4 — — Stuart & Smith66 (1995), AJSM Junior A (USA) 3.9 96.1 — — Voaklander et al67 (1996), CJSM AMRL & OTL (Canada) — — 15.1 12.2 Mölsä et al68 (1997), AJSM Top 2 levels (Finland) 1.5 54 — — Ferrara & Schurr69 (1999), CJSM ECAC & Hockey East NCAA (USA) — — 2.5 14.7 Pinto et al70 (1999), CJSM Junior A (USA) 4 83 — — Flik et al3 (2005), AJSM ECAC & NCAA (USA) — — 2.2 13.8 Emery & Meeuwisse71 (2006), Minor/Youth Hockey (USA) Combined rate 4.13 — — AJSM practice & game Kuzuhara et al72 (2009), JAT Japanese Elite League 11.7 74.3 — — Rishiraj et al73 (2009), JSMPF Canadian College Hockey — — 1.1 8.2 Agel & Harvey7 (2010), CJS NCAA Men (USA) — — 2.2 18.7 Agel & Harvey7 (2010), CJS NCAA Women (USA) — — 2.9 12.1 Brooks et al6 (2014) High School Hockey (USA) — — 2-2.6 4.2- 6.1 Tuominen et al74 (2015), BJSM IIHF World Championships — 52.1 — 14.2 (game data) Abbreviations: AAP, American Association of Pediatrics; AJSM, American Journal of Sports Medicine; AMRL, Adult Men’s Recreational League; BJSM, British Journal of Sports Medicine; CJS, Canadian Journal of Surgery; CJSM, Clinical Journal of Sports Medicine; ECAC, Eastern Collegiate Athletic Conference; IIHF, International Ice Hockey Federation; JAT, Journal of Athletic Training; JSMPF, Journal of Sports Medicine and Physical Fitness; NCAA, National Collegiate Athletic Association; OTL, Old Timers League. and concussions in hockey, they are a serious Although most contusions cause only mild swell- risk for recreational and competitive players alike. ing and ecchymosis of the soft tissues around the Furthermore, recovery may be difficult, and eye in- eye, there is potential for serious consequences. In juries can have serious lifelong consequences.8 In a Scandinavia study, Leivo and colleagues10 found hockey, the most commonly reported eye injuries that 9% of patients who sustained a periocular are periorbital contusions and lacerations, hyphe- contusion also had a clinically significant secondary ma, corneal and conjunctival abrasions, orbital diagnosis, such as retinal tear or hemorrhage, eye- fractures, and ruptured globes (Table 2).9,10 Some lid laceration, vitreous hemorrhage, or retinal de- of these injuries have the potential to cause per- tachment. Although the study was hospital-based, manent ocular damage and loss of sight. A clear and therefore biased toward more severe cases, understanding of how to correctly evaluate, triage, its findings highlight the potential severity of eye and manage ocular trauma is therefore essential injuries in hockey. Furthermore, the study found for any physician providing primary medical care that the majority of players who sustained blunt for hockey players and teams. trauma to the eye itself required lifelong follow-up As a contact sport, hockey often involves because of increased risk for glaucoma. This is par- high-impact, blunt-force trauma. The trauma in ticularly true for hyphema, as this finding indicates hockey results from collisions with other players, significant damage to intraocular tissues.10 the boards, hockey sticks, and pucks. It is there- Players can also sustain fractures of the orbital fore not surprising that the most common ocular bones, including orbital blowout fractures. Typical injuries in this sport are periorbital contusions. signs and symptoms of blowout fractures include 124 The American Journal of Orthopedics ® May/June 2017 www.amjorthopedics.com C. A. Popkin et al Table 2. Common Ocular Injuries in Ice Hockeya Condition Description Treatment Return to Play Clinical Photograph Hyphema Rupture of blood vessels Remove player Do not return the player to the of the iris; gross blood from the game; use ice; ophthalmologist needs to or a clot in the anterior of corticosteroids clear the player to return chamber of the eye and cycloplegics is controversial Periorbital contusion One of the most Concern for secondary Because of high rate common facial injuries; eye injury; player’s of secondary injury, swelling and bruising glaucoma risk will be ophthalmologist needs to clear around the eye and eye higher the player to return socket Orbital blowout fracture Periorbital edema, Remove the player from Do not return the player to the ecchymosis and the game and send to the ice; ophthalmologist needs to restricted extraocular emergency department clear the player to return movements, and for ophthalmologic proptosis (abnormal evaluation; computed protrusion of the eye) tomography findings and clinical signs and symptoms guide treatment Ruptured globe High-velocity blunt Promptly refer the player Do not return the player to the trauma, hyphema, 360° to an ophthalmologist ice; ophthalmologist needs to conjunctival hemorrhage, (send player to the clear the player to return and leaking emergency department) and place shield en route Corneal abrasion Defect in the corneal Stop contact lens Player may return to play epithelial surface; use; topical diclofenac if there is no functional or tearing, sharp pain, and can be helpful for binocular loss of vision foreign body sensation pain; combination of are common complaints cycloplegic and antibiotic can expedite healing Corneal foreign body Foreign material in the Evert the eyelid and Player may return to play eye irrigate or use cotton bud; if there is no functional or use of topical antibiotics binocular loss of vision is controversial, but topical antibiotics may have role in athletic setting Subconjunctival Blood vessel ruptures Blood usually takes 7-10 Player may return to play if hemorrhage underneath conjunctiva days to resolve; do not there is no other ocular injury rub the eye; eyedrops and vision examination is can be used to soothe normal pain; use of nonsteroidal anti-inflammatory drugs is discouraged aOcular trauma images provided by Steven E.
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