Alpine Skiing and Snowboarding
Devin P. McFadden
Alpine skiing and snowboarding are two of the most popular winter sports throughout the world.
Injury patterns are distinct to each specific sport, with predominantly lower extremity injuries in skiing and predominantly upper extremity injuries in snowboarding.
A recent focus on injury prevention has led to the development of helmets and wrist guards that have been proven to be effective in preventing injury. However, these technologic advancements have not yet been universally adopted by mainstream athletes.
The popularity of skiing and snowboarding continues to grow throughout the world, with 200 million participants worldwide and 12 million in the United States alone (11,13).
Snowboarders tend to be younger and have a reputation for greater risk taking.
Although modern equipment has led to a reduction in injury volume, the severity of injuries has increased because new equipment allows for greater speeds and sharper turns.
Current data suggest injury rates of about 1-6 per 1,000 skier days, with improved injury rates attributed to hard-shelled ski boots, release bindings, and better grooming of slopes (4).
Catastrophic injuries still occur, however, with an average of 20-30 deaths yearly in the United States alone, or 0.5 deaths per 1 million skier days (9).
The different biomechanics and equipment of skiing and snowboarding result in their vastly different injury patterns.
Snowboarders have both feet strapped to the board, resulting in less torsion injury to the knees. Also, the large surface area of the board and comparative difficulty making sharp turns result in lower velocity falls that allow the athlete to extend his arms and brace for impact. Subsequently, snowboarders have a significantly increased risk of injury to the hand, wrist, and arm.
Skiers, on the other hand, are capable of sharp, quick turns and high-velocity collisions. Fall on outstretched hand (FOOSH) injury is relatively uncommon, leading to a greater percentage of lower extremity injuries. In addition, a skier who has lost control can find his skis advancing in diverging directions, which causes a rotational torque and leads to a high incidence of knee injuries.
Snowboarders most often injure their backs while falling backward after a missed jump, causing axial loading and an increased incidence of compression fractures in the thoracolumbar spine. Conversely, skiers tend to fall forward after losing control or colliding with something and have a greater incidence of burst fractures (13).
Finally, lacerations, which are rarely found in snowboarders, have been noted to account for 8% of all injuries in skiers, where release bindings expose athletes to the sharpened ski edge (1).
As discussed, upper extremity injuries are uncommon in skiing, representing only an estimated 20%-35% of alpine ski injuries (14).
Shoulder injuries occur at a rate of 0.2-0.5 per 1,000 skier days and represent 4%-11% of alpine ski injuries, with the most common injury types being glenohumeral joint subluxations, rotator cuff strains, acromioclavicular joint separations, and clavicle fractures (16).
Although less common than in snowboarders, wrist and hand injuries do occur in skiing, typically as a consequence of a FOOSH injury. The most common fracture in the forearm is the distal radius or Colles fracture, named after the Irish surgeon who first described it in 1814. The diagnosis
is usually made based on plain radiographs, and immobilization is all that is needed if the fracture is not displaced. However, if the joint space is compromised, the neurovascular supply is injured, or the fracture is displaced, surgical intervention is often required.
The thumb is the most frequently injured digit of the hand in skiing, and the injury almost universally results from the traction caused when an isolated thumb is pulled away from the rest of the hand in a skier using poles, resulting in extension and forced abduction at the metacarpophalangeal (MCP) joint. The aptly named skier’s thumb is a sprain injury to the ulnar collateral ligament (UCL) of the first MCP joint. It is characterized by pain and tenderness to palpation over the ulnar aspect of the thumb and is diagnosed when laxity is noted on clinical exam. Conservative management with thumb spica casting followed by splinting is recommended when less than 30 degrees of valgus laxity are noted. A complete disruption of the UCL with retraction of the ligament to the adductor aponeurosis is known as a Stener lesion and is characterized by a palpable mass. In this case, or if a bony avulsion is present, surgical management is preferred. The UCL can also be injured through chronic stress rather than an acute, violent force and, in this case, is commonly referred to as “gamekeeper’s thumb.” Although UCL injury is undoubtedly the most common and most recognized injury pattern, dislocations, subluxations, and Bennett fractures of the base of the first metacarpal are also quite common in skiers (16).