Trauma on the slopes
As skiers in the southern hemisphere hang up their boots, in the northern hemisphere skis and boards are being waxed and snowsuits donned in preparation for the season ahead. Brett Henyon discusses points to consider when airlifting injured skiers from the slopes
First published in ITIJ 120, January 2011
As skiers in the southern hemisphere hang up their boots, in the northern hemisphere skis and boards are being waxed and snowsuits donned in preparation for the season ahead. Brett Henyon discusses points to consider when airlifting injured skiers from the slopes
Can you imagine what the inside of your helicopter would look like if you cut into a down-filled skiing jacket to expose and treat your patient in flight? How about the untoward harm created by a missed open fracture of an extremity that is now pulseless in the trauma bay? Ski sport injuries are unique in the aspect that there are often complicating factors with identification, extrication, and transport. The kinematics of trauma are very clear and the sport has inherent dangers. There are many ways to mitigate the risks of participating in these types of winter sports, but invariably injuries will occur. Often these injuries are minor and we can often predict the injury patterns. However, sometimes the injuries are severe and complex – but we can still predict the injury pattern. Knowing these injury patterns, understanding the things we can do to mitigate these injuries as an industry, and predicting transport considerations for the air medical industry all coalesce into what we can all do to make the ski industry safer.
Even though we, as air medical providers, typically see the most severe injuries, we need to be sure we look for the less severe injuries in certain patient populations. An overlooked or missed injury can create increased debilitation and lengthen rehabilitation. We typically see lower extremity injuries in skiers and upper extremity injuries in snowboarders. Many resorts are also adding tubing hills, bike parks, and other specialised ski boards – although statistical data on these patterns is limited, based on simple kinematics we can suspect isolated head and upper torso injuries.
ski sport injuries are unique in the aspect that there are often complicating factors with identification, extrication, and transport
Annual statistics of injury patterns remain consistent – even with rapidly evolving ski safety equipment such as improved binding release technology, helmet education campaigns, and overall safety education programmes. For alpine skiers and alpine snowboarders, sometimes these orthopaedic injuries can be so severe they are not overlooked. But sometimes, due to the complexity of additional life threatening injuries, they can be missed during the initial treatment phase.
Common injuries
For alpine skiers, sprains and strains of the lower limb still account for over half of the injuries related to falls. The most common lower extremity injury involves the knee with damage to the medial collateral ligament (20 to 25 per cent of all injuries) and is typically seen in beginners or lower intermediate skiers. A valgus load is applied to the knee joint as a result of the fall, skis crossing or the ‘snowplow’ stance widening. Anterior cruciate ligament injuries account for 10 to 15 per cent of all ski injuries as a result of the ‘phantom foot fall’, where the tail of the downhill ski and the stiff back of the ski boot act as a lever to apply a bending and twisting force across the knee of the downhill knee. With this injury pattern, the uphill arm is back, the skier is off balance to the rear, hips are below the knees, bodyweight is on the inside edge of the downhill ski tail, the uphill ski is unweighted, and the upper body is facing the downhill ski. Distal tibia and fibula fractures are common boot-top fracture patterns for skiers. Additionally, complex femur fractures can be associated with improper binding settings resulting in a twisting segmental femur fracture and supracondylar femur fractures, especially with older patients or those with some form of degenerative bone disease. Mid-shaft femur fractures are the most common femur injury seen in the ski industry, and packaging considerations are paramount to the air medical industry. If the traction splint extends too far, loading into the helicopter can become complicated or often impossible without releasing traction and adjusting the splint. Another not-so-common injury that can complicate helicopter loading is a posterior hip dislocation.
For snowboarders, over half of the injuries are related to the upper limb. The most common injury patterns of the upper extremity involve the wrist. The most common wrist injury is a Colles’ fracture as a result of falling onto wrists in extension, and the fragment is displaced dorsally. A Smith’s fracture is a reverse Colles’ fracture of the distal radius caused by falling onto flexed wrists but is less common. Clavicle fractures are also very common as a result of falling backwards with the arm outstretched. While none of these injuries is life-threatening and often of minimal concern during the initial treatment of the multi-system trauma patient, they should be addressed and splinted in some manner in order to prevent worsening the injury during transport.
Ground support
Different ski resorts have varying training or safety standards. Many in the US adhere to the National Ski Patrol Standard of Outdoor Emergency Care or an equivalent. Indeed, many areas require their ski patrol to have emergency medical technician basic, and some areas are staffed with personnel with paramedic level of care. While the size of the mountain is not a deciding factor regarding the level of care that can be provided, the local resources are often used to complement on-the-hill care. While most ski areas have either an on-site clinic for basic first aid, many resorts are developing mountain clinics that can be staffed by advanced scope providers, nurses, physician assistants, and doctors. For the on-the-hill injuries there will always be a two-stage process to the treatment of every patient: the initial on-the-hill exam and treatment, and the secondary assessment and treatment. Often in the air medical setting, the patients will go directly from the on-the-hill treatment and packaging directly to a waiting helicopter. Consideration for what the initial responders have exposed/assessed and consideration for wet, cold, hypothermic patients is a must. It is paramount to suspect certain injuries, anticipate certain transport challenges, and be ready to adapt.
Emergency medical services are unique, because this profession usually attracts a certain ‘type’ of person. We have all heard the term that we are a bunch of ‘Type A’ people. This is very true to a degree. Most of us are all pretty assertive, sometimes to a fault. We all tend to be fairly detail oriented, social and not have a whole lot of patience. Understanding our likeness throughout all venues of emergency services will help promote a team approach from the on-the-hill injury to the back of the helicopter, no matter how experienced or inexperienced the ‘team’ may be.
training with your local ski patrol or mountain rescue group will improve interactions and ultimately improve patient care
Ski patroller training varies by resort and, most importantly, it varies by region. For example, there are some ski areas that do not need to worry about avalanche mitigation and control, and there are some resorts where one of the primary daily activities is avalanche forecast and control work. This variation is the same for medical backgrounds and training provided. Many ski resorts throughout the US rely on a volunteer ski patrol component, and many of these patrollers have the basic training required to rapidly assess, identify, and treat many life threatening emergencies. Unfortunately, their exposure to critical patients with life threatening emergencies is sometimes very low in frequency, so excellent training programmes are a must. These patrollers are sometimes complemented in their treatment by either paid resort employee patrollers or local emergency medical providers.
For a ski patroller, assessing and identifying hazards, marking them appropriately, and educating the skiing and snowboarding public is an ongoing job function. For us as air-medical providers we need to understand that often the injuries happen in difficult to access locations, on terrain that is sometimes unstable, icy, or hazardous to access. It will sometimes cause more harm to expose a critical patient or provide all the ‘textbook’ treatments. Patient packaging may sometimes be done in very creative and innovative ways. Training with your local ski patrol or mountain rescue group will improve interactions and ultimately improve patient care.