Axial Injuries
Spine trauma is among the most devastating injuries in winter sports, comprising 1% to 17% of all injuries in skiers and snowboarders.[13,14] As freestyle skiing, which involves extreme jumping and aerial maneuvers, has become popular, spine injuries in skiers have increased.
Most spine injuries occur as a result of intentional jumps rather than collisions.[15,16] A fall backward is the proposed mechanism of injury (which typically stresses the thoracolumbar junction), causing an axial load or a flexion-distraction moment. This mechanism of injury is important to consider during the initial assessment. Proper jumping and landing techniques should be taught and emphasized when the participant is young.
Spine injuries associated with skiing and snowboarding predominately affect the thoracic and lumbar spine.[14,15,17] In a retrospective review conducted over a period of 5 years in Aspen, Colorado, Gertzbein et al[14] reported on a cohort of 119 patients with a total of 146 thoracic or lumbar fractures. The AO Comprehensive Classification was used to categorize 114 fractures, and the remaining 32 fractures (22%) were isolated spinous or transverse process fractures. Of 114 fractures, 94.7% were categorized as compression injuries based the AO classification system; 71% of these were simple compression fractures, and the remaining 23% were classified as burst fractures. Distraction and rotational injuries were much less common, comprising 4.4% and 0.9% of injuries, respectively.
The development of back pain in young elite skiers should be investigated. Rachbauer et al[17] radiographically evaluated elite skiers aged <17 years and compared the findings with those of recreational skiers of the same age. The average age at sport initiation was 6 years. Approximately 50% of the elite skiers had end plate lesions (with an anterior location being most common), compared with <20% in the recreational skiers. Persistently bending forward has been shown to increase intradiscal pressure greatly, subsequently causing fracture of the end plate and even disk herniation, which can be represented as Schmorl nodes that are sometimes identified on imaging. Greene et al[18] coined the term atypical Scheuermann disease to describe the vertebral changes and development of mechanical back pain. The surgeon must consider such a diagnosis when evaluating competitive youth skiers and should take into account the high loads applied to the spine versus the actual loading capacity of an immature spine.
Ogawa et al[19] performed a comprehensive review of 145 patients with snowboarding injuries over an 8-year period, focusing specifically on pelvic fractures. The incidence of pelvic fractures was 2%. Jumping was the main mechanism of injury observed; however, collisions—predominately with trees and ski towers—substantially correlated with unstable injury patterns. Using the Tile classification, those authors determined that, in patients with snowboarding-related pelvic injuries, the most common pelvic injury pattern was a type A (stable) fracture (85.5%), with isolated pubic or ischial fracture being most common, followed by isolated sacral fractures. Type B and C (unstable) fractures were less common than type A fractures, at 14.5%. Associated injuries were present in 20% of fractures, with a substantially higher prevalence of associated injuries found in the unstable fracture group compared with the stable fracture group. The authors of the study noted that, although sacral fractures are rare and typically are associated with pelvic ring fractures, isolated sacral fractures associated with snowboarding occur more often.[19] Therefore, the surgeon must maintain a high level of suspicion for isolated sacral fractures in patients who present with buttock pain related to snowboarding injuries.
J Am Acad Orthop Surg. 2018;26(1):e1-e10. © 2018 American Academy of Orthopaedic Surgeons
