Snowboarding Injuries

Transcription

1 Sports Med 2004; 34 (2): INJURY CLINIC /04/ /$31.00/ Adis Data Information BV. All rights reserved. Snowboarding Injuries Current Trends and Future Directions Christopher Bladin, 1 Paul McCrory 2 and Anita Pogorzelski 2 1 Eastern Melbourne Neurosciences, Monash University, Melbourne, Victoria, Australia 2 Centre for Sports Medicine, Research and Education, Melbourne University, Melbourne, Victoria, Australia Contents Abstract Demographics Cause of Injury Spinal Cord Injuries Major Trauma Snow Drowning Population-Based Studies Conclusions Abstract Snowboarding has become one of the premier alpine sports. The past decade has seen the popularity of snowboarding increase dramatically and the recent Winter Olympic Games at Salt Lake City, USA, showcased the strong visual appeal of the sport and the youth-oriented lifestyle and culture that accompanies it. The injury profile of the sport has also undergone change along with technological advances in boot and binding systems and the changing demographics of the sports participants. Central to the development of injury-prevention strategies is knowledge of the profile of injuries that occur, understanding those who are at particular risk and, if possible, the biomechanical factors involved in each injury type. Snowboarding was initially considered a dangerous, uncontrolled, alpine sport an opinion based on little or no scientific evidence. That evidence has rapidly grown over the past decade and we now know that snowboard injury rates are no different to those in skiing; however, the injury profile is different. The purpose of this review is to give some perspective to the current snowboard injury literature. It discusses not only the demographic profile of those injured and the type of injuries that occur, but also gives some insight into the progress that has occurred in determining the impact of specific prevention strategies, such as splints to prevent injuries to the wrist/forearm. The next decade will also see a greater understanding of the biomechanical forces involved in snowboard injuries, which may well impact on future technological advances. As the literature indicates, however, some things will not change, e.g. injuries are more likely to occur in beginners and lessons need to be reinforced as a fundamental aspect of any injury-prevention strategy.

2 134 Bladin et al. From humble beginnings in the 1970s, snow- ployed by other authors is to obtain similar data by boarding has become one of the key growth areas in surveying a broad cross-section of snowboarders at alpine sports and is now prominent as an Olympic a point in time. [6,7] The pros and cons of differing sport. Recent reports indicate that snowboarders epidemiological approaches are discussed elseconstitute between one-third and one-half of partici- where, [8] but they can yield differing results and this pants at most alpine resorts. [1,2] needs to be considered when interpreting published The sport is predominantly youth oriented. data on alpine injury rates. Two-thirds of participants are under the age of 25 The following review will examine a number of years and up to 80% of children who participate in aspects of snowboarding injuries, including snow sports have ridden snow boards by their 12th demographics of the injured snowboarder, the range birthday. [3,4] Snowboarding equipment accounts for and nature of injuries, biomechanical issues, and the one-third to one-half of all purchased alpine sport influence of equipment and skill level as potential equipment. [4] risk factors for snowboarding injuries. At the time of Technological advances have resulted in lighter, writing, there are more than 80 different injury faster snowboards with boots and binding systems studies and case reports in the English language that allow quick entry and exit. Although releasable medical literature alone. This review is not designed snowboard bindings have been developed, they have to encompass all of these studies but rather to give a not become widespread as it is perceived that it is broad overview of the patterns of snowboarding safer for the rider to remain attached to the injuries that may then be used to assist in devising snowboard. This is an obvious distinction to skiing strategies for injury prevention and treatment. where releasable bindings are a key safety requiresentative of the range of international studies over The data presented in table I are broadly repre- ment. The growth in the popularity of snowboarding the past decade. Over time, there have been many has been accompanied by an increasing number of changes in boot/binding technologies and variations studies into snowboarding injuries. These range in the mix of novice/expert snowboarders that will from small case series through to large database lead to differences in some injury rates, but overall, studies with many thousands of snowboarding injuries the injury trends remain consistent. that come from Australia, Europe and North America. Methodological issues common to all alpine 1. Demographics sports injury studies are that case ascertainment The typical profile of a snowboarder is a male is problematic and accurate measurement of expo- (>70%) aged in his late teens or early twenties. Over sure is limited. It is well documented that many recent years, however, this has changed with many injured skiers or snowboarders do not seek medical older individuals involved in the sport and with an attention with up to 40% of alpine sport injuries increasing number of women. Beginner or novice going unreported. [5] During a recent alpine season in snowboarders constitute 40 60% of those injured Colorado, USA ( ), 31% of skiers and 29% compared with 18 34% in skiing. [1,2,10,15] In some of snowboarders refused medical attention after an studies, more than half of the injured beginners had encounter with the ski patrol. [5] In this context, no never had lessons. [2] Injury rates in alpine sports are study is going to be able to identify all alpine inju- traditionally measured as the rate of injury per 1000 ries. Publications on snowboarding injuries will skier (i.e. slope user) days. Overall, for snowvary from injury databases at large alpine medical boarding, this is estimated at about 4 per 1000 skier centres (often focusing more on selected injury days, [1,10,16] although some studies have put this as types) through to compilations of ski patroller acci- high as 16 per 1000 skier days. [7,9] dent reports (which have a greater range of injuries but less accurate injury diagnosis). Most of these are descriptive cohort studies focusing on the injured 2. Cause of Injury snowboarder to determine their demographics, and The majority of injuries occurring in snowthe type of injuries. An alternative strategy em- boarding are related to human error with equip-

3 Snowboarding Injuries 135 Table I. Injury profile from a representative sample of snowboard injury studies Study Year n Country Mean Head/neck/ Upper limb Lower limb Abdomen/ Chest Other age (y) face back upper shoulderarm/ wrist/ lower thigh knee ankle/ lower limb elbow hand limb foot leg Abu-Laban [9] Canada Bladin et al. [10] Australia Calle & Evans [11] US Chow et al. [12] US Davidson & US Laliotis [1] Sutherland et Scotland al. [13] Pigozzi et al. [14] Italy Idzikowski et al. [5] US Kirkpatrick et al. [4]a Machold et al. [7] Austria Langran & Scotland < Selvaraj [2] a These studies were linked and the results have been combined for display purposes. ment failure reported to be responsible for less than 1% of all injuries. [1] Compared with skiers, snowboarders are injured three times more frequently from jumping. [1] Contrary to perception, collisions with objects or other slope users account for only about 10% of snowboard injuries, which is less frequent than that in skiers. [1] The majority of snowboarders (>75%) use soft shell boots but few (<10%) use protection devices (e.g. for wrist, elbow or knee) even when they are available. [4,12] Just under half (44%) of those injured have less than 1 year of experience in snowboarding with 20 36% of injuries occurring while trying snowboarding for the first time. [6,9] However, studies focusing specifically on first-time snowboarders and skiers having lessons indicate that only 4% of participants sustain an injury (be it in skiing or snowboarding) suggesting that initial involvement in the sport through lessons represents a better risk management strategy. [6] As table I indicates, there is variation in the ratio of upper to lower limb injuries. Case ascertainment may be a factor in this as many of those injured will self triage to other medical facilities especially those with less severe injuries. Studies with reliable case ascertainment demonstrate a 2- to 3-fold greater risk of upper to lower limb injuries, with approximately two-thirds of all injuries involving the upper limb and upper body and one-third of injuries involving the lower limbs. The converse is typically seen in alpine skiing injuries. The most common injury site in snowboarders is the wrist, which accounts for 22% of all snowboarding injuries. About two-thirds of wrist injuries are fractures. [11,16] Overall, compared with skiers, there is up to a 10-fold increase in wrist injuries in snowboarders, with one-third of injuries in beginner snowboarders occurring to the wrist. [1,12] Wrist fractures and sprains are more common in snowboarding novices, in women, and in the younger age groups. Intermediate and more experienced snowboarders, particularly men, were more likely to sustain hand, elbow and shoulder injuries. Preventive strategies have also been investigated with some studies reporting that snowboarders who wear protective wrist guards are significantly less likely to sustain wrist injuries as those who do not, [17] but the design of the protection device is also an important

4 136 Bladin et al. element. [18] This view is also supported by cadaveric biomechanical data [19] using thermoplastic wrist guards during low energy impact situations. However, other cadaveric studies using in-line skating wrist guards demonstrated no protective benefit. [20] Other studies have suggested that while protecting the distal forearm, wrist guards may, however, increase the risk of injury to the shoulder. [12] The overall prevalence of wrist injury is low (<2% of all snowboarders) and indeed less than 10% of snowboarders currently use wrist guards. [4,12,17,21] In contrast to skiing, injuries to the lower limb, particularly the knee, are less likely in snowboarders. This is thought to be related to the biomechanics of snowboarding injuries. The snowboarder is fixed to the board and, when falling, the board is unable to act independently as a lever exerting torque on one or other knee. This is a common biomechanical basis for lower limb injuries in skiing where, and as a consequence, knee injuries are much more prevalent and often more severe. Most lower limb injuries in snowboarding occur to the leading leg, usually the left. Assessment of the severity of an alpine knee injury is limited by the level of medical expertise available at the time. Those studies based at fully equipped alpine medical centres are able to provide a more accurate diagnosis; in contrast, reports derived solely from ski patroller data are much less accurate in grading injury severity. Soft tissue knee injuries account for about 34% of all ski injuries. Approximately 60% involve the medial collateral ligament, the most common type of ski injury, which overall accounts for 16% of ski injuries. Conversely, snowboarders experience about 17% of all injuries to the knees and a similar rate to the ankles (see table I). Ankle injuries in snowboarding are variable with more sprains (52%) than fractures (48%). [4] The style of boot does not appear to significantly affect the ankle injury rate. [4] An unusual injury, a fracture of the lateral process of the talus, has also been reported in snowboarding related to inversion and compression forces on landing after jumps. [4,22,23] A large database from Colorado of 7000 patients indi- cate that fracture of lateral process of the talus may account for 15% of ankle injuries or 2.3% of all snowboarding injuries. [4] Clinical diagnosis can be quite difficult and is often misdiagnosed as a severe ankle sprain. Radiological diagnosis of this injury can also be quite difficult, requiring sophisticated imaging techniques, e.g. computed tomography/ magnetic resonance imaging scan. Unfortunately, conservative management can result in significant disability, unless anatomic alignment is appropriate- ly maintained. Successful management requires ac- curate diagnosis, including the degree of displace- ment and comminution. [4] If many displaced frag- ments are detected, most authors favour early excision with weight bearing as tolerated. If there is large displacement of the lateral process talus frac- ture, open reduction internal fixation is the preferred treatment with no weight bearing for 4 6 weeks. [4,23] Biomechanic studies have been undertaken on cadaveric ankles on a testing machine in a position of fixed dorsi-flexion and inversion. No fractures occurred after axial loading and dorsi-flexion inver- sion, but the majority of specimens sustained frac- tures of the lateral process of the talus when loaded with external rotation, supporting the hypothesis that external rotation combined with dorsi-flexion and inversion is a key component of the mechanism of injury. 3. Spinal Cord Injuries There is an increasing occurrence of spinal injury in snowboarding, partly due to the enthusiasm that snowboarders have for performing jumps and various aerial manoeuvres. Overall, however, the sea- sonal incidence of spinal injuries in snowboarders is low. A large study from Gifu, Japan, reported 238 of 7188 (3.3%) snowboarding injuries involved the spine compared with 86 of 6302 (1.4%) spinal injuries in skiing. [24] Half of the snowboarding spinal injuries involved jumping, whereas there were few skiing spinal injuries associated with this activity. The majority of spinal injuries were fractures to the transverse process of the vertebra. Increasing confi- dence and expertise allows participants to attempt jumps. In keeping with this, intermediate or expert snowboarders were more likely to have spinal injuries than beginners, whereas about 70% of spinal injuries caused by skiing resulted from a simple fall. [24]

5 Snowboarding Injuries Major Trauma lower limb injuries and snowboarders more upper limb injuries. Fortunately, severe, life-threatening injuries in [6] A recent Austrian study surveyed 2745 students snowboarding are infrequent. Data from Colorado riding snowboards participating in an Austrian indicate that the severe injury rate in snowboarding school winter sports programme. [7] By definition, is approximately 0.03 injuries per 1000 snowthis population was school-age (average age 14.7 boarding days with the mechanism of injury evenly years) and were predominantly male (68%). Unique divided between falling onto the snow and collision to this study is that incomplete questionnaires were with another object (e.g. trees, other skiers). [25] able to be followed up and that the diagnosis and Traumatic brain injury and intra-abdominal injuries treatment of injuries was able to be confirmed by accounted for over 80% of severe injuries that occontacting the relevant medical facilities. The large curred. In comparison, the majority (70%) of serious numbers of young snowboarders in this study were injury in skiers related to skeletal trauma. [16,25] Overunique. There was a relatively high level of beginall, serious snowboarding injuries occurred at rates ners with little previous snowboarding experience similar to those of serious ski injuries, although the within the overall group of snowboarders. injury profile appears to be different. [25] Of 2579 respondents to the survey, 152 students 5. Snow Drowning reported snowboard injuries. As with other studies, injuries to the wrist were the most common (32%), Drowning would seem to be a rather unlikely followed by the hand (20%) and head (11%). Of the mechanism of injury and death in snowboarding but 152 snowboarding injuries, 107 required medical has been well described. [26] This phenomenon may care, which is on a par with medical clinics dealing occur during off-piste activities or following heavy with alpine sporting injuries. As with other studies, snowstorms, which result in deep, soft powder snow the upper body was affected in approximately twoaccumulating on the slopes and particularly around thirds of injuries, the lower body in one-third of the base of trees. A typical sequence of events is that injuries. the snowboarder is found buried head-down in snow The injury-prone nature of beginner at the base of a tree (or tree well). Often there are snowboarders was all too evident. There was an associated head injuries that may have occurred just 8-fold risk of injury in beginners compared with prior or at the time of collision with the tree. Resus- experienced snowboarders; 67% of all injuries and citation may be difficult given the terrain, limited 72% of all wrist injuries occurred within the first 7 access, and the fact that hypothermia has also often days of learning to snowboard; 35% of all accidents occurred. [26] occurred within the first 4 days of commencing 6. Population-Based Studies snowboarding and 51% occurred within the first week. The benefit of wrist protection devices was A number of studies attempt to determine also evaluated. Not using a wrist protection device snowboard injury rates and injury profiles via popuinjury. was associated with an almost 3-fold higher risk of lation-based studies using injury surveys. [6,7] This However, the distribution of injuries to the can present methodological difficulties in terms of arm and shoulder remained the same in case ascertainment of those injured it is often a snowboarders with and without wrist protection. As snap-shot of a days worth of trauma. However, part of the instruction for this winter sports school when efficiently performed upon a large captive programme, 1522 snowboarders received special population, the reliability of the sampling signifihowever, training in how to deal with the impact of a fall; cantly improves. despite this training, there was no real First time skiers or snowboarders (over reduction in wrist injuries. [7] participants) enrolling in a Learn to Ski/ Another aspect of this study [7] was analysis of Snowboard programme in the US were followed risk-taking behaviour by snowboarders. Students for the day of the lesson. Injuries occurred in 4% of were asked to report on all previous sports-related each group with skiers having significantly more injuries (i.e. not only snowboarding injuries). A

6 138 Bladin et al. 8. Sackett DL, Haynes RB, Guyatt GH, et al. Clinical epidemiolo- gy: a basic science for clinical medicine. 2nd ed. Boston (MA): Little, Brown and Company, Abu-Laban R. Snowboarding injuries: an analysis and compari- son with alpine skiing injuries. CMAJ 1991; 145 (9): Bladin C, Giddings P, Robinson M. Australian snowboard injury data base study: a four-year prospective study. Am J Sports Med 1993; 21 (5): number of snowboarders had sustained previous sporting injuries and analysis revealed that there was a 35% increase in risk of snowboarders with previous sport injuries experiencing an injury during the first week of snowboarding. 7. Conclusions 7. Machold W, Kwasny O, Gaeler P, et al. Risk of injury through snowboarding. J Trauma 2000; 48 (6): Calle S, Evans J. Snowboarding trauma. J Pediatr Surg 1995; The injury profile of snowboarding is different to 30: alpine skiing and, as such, can influence the devel- 12. Chow T, Corbett S, Farstad D. Spectrum of injuries from snowboarding. J Trauma 1996; 41 (2): Pigozzi F, Santori N, Di Salvo V, et al. Snowboard traumatolo- opment of injury-prevention programmes. Injuries to the upper limb, in particular fractures to the wrist snowboarding and alpine skiing. Injury 1996; 27 (6): and forearm, may represent up to a 10-fold increase over those in skiers. This would suggest that some gy: an epidemiological study. Orthopedics 1997; 20: intervention may be of benefit and there is some evidence that prevention using wrist guards may be beneficial. However, ensuring that an intervention is beneficial is entirely dependant on it being used. Med 1999; 105 (1): 83-8 Even when offered, the acceptance rate of an injury- prevention strategy is often low (4% in one study) Med 2001; 29 (5): and even snowboarders do not rate the risk of injury as a significant concern. [5] This may be due to vari- ous factors from socio-cultural issues to poor safety equipment design but clearly further research with interventional studies are needed to progress developments in this area. Acknowledgements 20. Giacobetti F, Sharkey P, Bos-Giacobetti M, et al. Biomechanical analysis of the effectiveness of in line skating wrist guards for preventing wrist fractures. Am J Sports Med 1997; 25: Janes P. The Colorado Snowboarding Injury study: eight year results. In: Johnson R, editor. Skiing trauma and safety. Phila- delphia (PA): American Society for Testing and Materials; 1999: Fujioka K, Janes PC. Snowboard injuries. Sports Med Digest 1989; 11: McCrory P, Bladin CF. Fracture of the lateral talar process: snowboarder s ankle. Clin J Sports Med 1996; 6: No sources of funding were used to assist in the preparation of this manuscript. The authors have no conflicts of interest that are directly relevant to the content of this manuscript. References 13. Sutherland A, Holmes J, Myers S. Differing injury patterns in 15. Chissell H, Feagin Jr J, Warme W, et al. Trends in ski and snowboarding injuries. Sports Med 1996; 22 (3): Bindner S, Geiger K. The downside of snowboarding. Postgrad 17. Ronning R, Ronning I, Gerner T, et al. The efficacy of wrist protectors in preventing snowboarding injuries. Am J Sports 18. Machold W, Kwasny O, Eisenhardt P, et al. Reduction of severe wrist injuries in snowboarding by an optimized wrist protection device: a prospective randomized trial. J Trauma 2002; 52: 19. Greenwald R, Janes P, Swanson S. Dynamic impact response of human cadaveric forearms using a wrist brace. Am J Sports Med 1998; 26: Davidson T, Laliotis A. Snowboarding injuries: a four-year 24. Yamakawa H, Murase S, Sakai H, et al. Spinal injuries in study with comparison with alpine ski injuries. West J Med snowboarders: risk of jumping as an integral part of snow- 1996; 164 (3): boarding. J Trauma 2001; 50 (6): Langran M, Selvaraj S. Snow sports injuries in Scotland: a casecontrol study. Br J Sports Med 2002; 26: Prall J, Winston K, Brennan R. Severe snowboarding injuries. 3. Sacco D, Sartorelli D, Vane D. Evaluation of alpine skiing and Injury 1995; 26 (8): snowboarding injury in a northeastern state. J Trauma 1998; Kizer K, MacQuarrie M, Kuhn B, et al. Deep snow immersion (4): deaths: a snowboarding danger. Physician Sports Med 1994; 4. Kirkpatrick D, Hunter R, Janes P, et al. The snowboarder s foot 22 (12): and ankle. Am J Sports Med 1998; 26: Idzikowski J, Janes P, Abbott P. Upper extremity snowboarding injuries: ten-year results from the Colorado snowboard injury Correspondence and offprints: Professor Christopher Bladin, survey. Am J Sports Med 2000; 28 (6): Eastern Melbourne Neurosciences, Box Hill Hospital, Nel- 6. Fulham O Neill D, McGlone M. Injury risk in first-time snowboarders versus first-time skiers. Am J Sports Med 1999; son Road, Box Hill, VIC 3128, Australia. 27 (1): chris@bladin.com