Even More Learning - Winter Wipeout and Pain in the Neck

Want to know more about skiing and snowboarding injuries or cervical spine injuries in athletes written by some of our own?  Here are some teasers!

Winter Wipeout: Skiing and Snowboarding Injuries

• Katherine W.D.
• Dolbec, MD

Pearls:

• Avoid the use of a knee immobilizer, unless it is truly indicated.
• Initiate physical therapy exercises in the emergency department for knee injuries that do not require immobilization. Advise patients to begin aggressive range- of-motion and strength-preserving exercises immediately upon discharge.
• Ensure prompt hand surgery follow-up care for any patient with an injury of any grade to the UCL of the thumb. Surgery may be the only way to avoid long-term pain and functional compromise.
• Maintain a high index of suspicion for an LTPF [lateral talus process fracture] in any snowboarder with an appropriate mechanism of injury. Additional imaging may be warranted, even if the initial x-rays are negative.

Pitfalls:

• Placing a knee immobilizer on every patient with traumatic knee pain. This approach can impede rehabilitation, accelerate muscle atrophy, and diminish range of motion. If required for stability and comfort, other assistive devices and methods of bracing should be considered.
• Failing to recognize a possible UCL injury of the thumb. Unrepaired complete ruptures lead to long-term pain and functional impairment. It is safe to apply firm but gentle valgus stress to the first MCP joint when evaluating such cases.
• Failing to recognize mechanisms and examination findings consistent with an LTPF. These fractures are missed on as many as 50% of plain films; when possible, a CT scan should be obtained.

Pain in the Neck: Cervical Spine Injuries in Athletes

• Herman Kalsi, MD;
• Elizabeth Kaufman, MD, CAQ-SM;
• Kori Hudson, MD, FACEP, CAQ-SM

Pearls:

• For an apneic patient with a suspected c-spine injury, follow the Advanced Trauma Life Support guidelines by maintaining in-line spinal immobilization, securing the airway, and then moving on to the rest of the primary survey.
• To determine which patients need c-spine imaging, use the Nexus criteria or Canadian C-Spine Rule to guide the decision.
• Remember that stabilization and imaging of the spine should not take precedence over life-saving diagnostic and therapeutic procedures.
• Stingers and transient quadriplegia are often diagnoses of exclusion. It may be necessary to obtain imaging studies or a consultation with a spine expert to rule out more serious conditions.

Pitfalls:

• Ignoring high-risk patients who do not fit clinical decision rules. Patients with severe osteoporosis, advanced arthritis, cancer, or degenerative bone disease have a significant risk of c-spine injury and may warrant imaging, even without the application of a clinical decision tool.
• Administering methylprednisolone for the treatment of an acute spinal cord injury, which is no longer recommended.
• Failing to maintain a high index of suspicion for vascular and soft-tissue injuries associated with c-spine injuries, especially when neurological symptoms do not match head CT findings. Left undetected, these injuries can lead to potentially fatal outcomes.