Srinivasan Suresh, MD, MBA

Millions enjoy skiing, snowboarding, and sledding. These cold weather activities--while exhilarating--also cause many injuries, each with distinct clinical characteristics (

Here I discuss the injuries associated with skiing, snowboarding, snowmobiling, and sledding. The emphasis is on pediatric injury patterns and modes of treatment and prevention.

skiing is one of the world's most popular winter sports. However, it also carries a high risk of injury, the most common of which are:

 A sprain of the ulnar collateral ligament of the thumb in adolescents.

 A grade 3 sprain of the anterior cruciate ligament in adults.

The use of properly functioning modern equipment can decrease the rate of skiing injuries, especially in children.

Most investigators agree that younger skiers are at increased risk. Children have a higher rate of ski-related fractures of the lower extremities than adults, for example. Spiral fracture of the tibia is most common in children.

Improperly adjusted or poor-quality bindings and boots may account for the higher rate of injury. Children often use outdated hand-me-down equipment that does not fit or function properly. It is important to educate parents about providing modern equipment and to verify that the binding settings function appropriately for the child using the equipment.

In a 5-year retrospective study of patients younger than 19 years who were admitted to a pediatric trauma center after a skiing accident, 58% had been involved in collisions with stationary objects.

Between 20 and 30 deaths from downhill skiing accidents occur each year in this country. The cause of death is massive head or neck injury, and/or major thoracoabdominal injury. The main contributing factors are excessive speed and loss of control. Drugs and alcohol are rarely implicated. One study found that only 1 in 16 injured skiers was wearing a helmet.

 Parents must not overestimate their child's skill level. Advise them to discourage skiing near the edge of trails. Adult supervision of children and adolescents is advised.

 have gone so far as to recommend compulsory helmet use by all young recreational skiers. Theoretically, this is reasonable, but studies of helmet effectiveness have not been done. Design problems concerning sight and hearing still exist. Helmets tend to be costly and, because they must fit closely, must be purchased frequently for growing children. In a review of winter sports injuries, knee sprain was the most common injury (in 31%); this was followed by general bruising (10%) and laceration of the head and face (8%).

Cross-country skiing offers excellent cardiovascular conditioning without the jarring and pivoting of many aerobic sports. It is generally affordable and accessible to both recreational and competitive enthusiasts. It is also relatively safe, although not risk-free. The rate of associated injuries is difficult to establish because recreational skiers ski wherever snow is available and not necessarily at ski areas that provide immediate medical assistance.

 involves additional risks--avalanches and hypothermia among them. In general, the risk of injury decreases with increased experience and ability. However, injury patterns differ at different skill levels, and the average severity of injury may be higher among advanced skiers.

The lower extremity is at greatest risk and is affected in just over half of injuries. A sprain of the medial collateral ligament of the knee occurs after a valgus stress is applied to the knee, often when the skier catches a ski tip or edge while the leg is in a fixed position.

Theseare also common, particularly the acute inversion ankle sprain. Radiographs are needed to rule out ankle fracture in skiers who have bony tenderness directly over the lateral malleolus, the navicular, or the base of the fifth metatarsal; who have tenderness around the medial malleolus, the anterior ankle joint, and the syndesmosis; or who are simply unable to bear weight.

Acute, nonoperative treatment of ankle sprain involves rest, application of ice, compression, and elevation. Early range-of-motion exercises, such as tracing the alphabet with the great toe, and proprioceptive exercises done on a balance board or mini trampoline assist recovery. Sprains resulting from a significant rotatory force (eg, from a high-speed fall on downhill terrain) are often more severe, may take 6 weeks to improve, and may require more prolonged rehabilitation.

Acromioclavicular joint separation, common among cross-country skiers, can occur when the skier falls directly on the shoulder. Pain is present directly over the acromioclavicular joint, and deformity is seen in grade 2 and 3 sprains. Treatment is usually nonoperative and includes early range-of-motion exercises followed by shoulder-strengthening exercises. Shoulder dislocations, rotator cuff tears, and fractures of the clavicle have also been reported.

Thesemost often result from training errors or errors in technique. Treatment is individualized but, in general, therapy involves relative rest, stretching and strengthening exercises, and a gradual return to skiing.

 Cross-country skiers are often out on open terrain with little protection from the wind. Their speed can worsen the wind's effect. In fact, a skier moving 30 km/h (20 mph) in calm air at 210°C (14°F) is exposed to a windchill of 225°C (213°F). Such temperatures can result in frostnip or frostbite.

Attention to equipment is important for prevention of traumatic and overuse injuries. Boots, poles, and skis should be properly fitted to the skier and his or her skiing style to help minimize the potential for falls and overuse injuries. Properly waxed skis can prevent repeated backward slipping on icy, hard tracks, which can overstress muscle-tendon units.

Prevention strategies for overuse injuries focus on technique improvement, proper warm-up and cooldown exercises, and endurance and strengthening exercises for the muscle groups involved. Roller skiing as off-season training has increased in popularity and can be part of a good prevention strategy. Layered clothing, adequate hydration, and protective eyewear help prevent cold- and wind-related injuries.

Snowboarding is the fastest-growing winter sport in the United States. It involves riding a single epoxy-fiberglass board (resembling a large skateboard) down a ski slope or on a half-pipe snow ramp (a specialized snow structure used for performing tricks).

Snowboarding differs from downhill skiing in many respects. Snowboarders ride with both feet affixed by non-releasable bindings to a single board. Unlike downhill skiers, snowboarders stand perpendicular to the long axis of their boards. Furthermore, snowboarders do not use ski poles, but use their hands and arms for balance (much like skateboarders or surfers). Associated injuries frequently involve the upper extremities and ankles. The knees are less frequently involved than in traditional alpine skiing.

Wrist guards are very effective in preventing wrist injuries among in-line skaters and may also help prevent snowboarding injuries. Although protective equipment decreases the overall incidence of injury by reducing the force of impact, it may actually place the areas proximal to the device at increased risk by shifting the distribution of impact forces. For example, skiers and snowboarders who wear hard boots are at greater risk for "boot-top" fractures, and in-line skaters are at greater risk for "wristguard-top" fractures. This effect is illustrated in a survey that included 21 snowboarders who had been injured while wearing wrist guards: although none of these persons had a wrist injury, 6 had a shoulder injury and 4 had radial shaft fractures.

Lower leg fracture was more than 3 times as common among injured children as among teenaged and adult alpine skiers. Dislocation increased with age for both alpine skiers and snowboarders. Injury severity seems to increase with age: more adults than children need to be treated by a physician or in a hospital for their injuries.

These are among the most devastating injuries associated with all winter recreational sports. Tarazi and coworkers

 reported that the incidence of spinal injury among skiers was 0.01 per 1000 skier days and that among snowboarders it was 0.04 per 1000 snowboarder days.

 Jumping was the cause of injury in 20% of skiers and 77% of snowboarders. Neither age nor sex accounted for any significant portion of this difference. The rate of spinal injuries among snowboarders is 4-fold that of skiers.

With vehicles that reach speeds of 90 mph and that weigh more than 600 lb, it is not surprising that snowmobiling culminates in more than 200 deaths and nearly 14,000 accidents each year.

Incredibly, children younger than 17 years sustain 12% of all snowmobile injuries. Pyper and Black

 reported 70 snowmobile-related injuries in persons aged 2 to 17 years. These injuries had been caused by losing control of the sled, rollover, striking a fixed object, or striking a motor vehicle or another sled. Fifteen accidents involved more than 1 person, and 5 of the injured children were pedestrians. Three deaths in this series were related to head trauma.

The Consumer Product Safety Commission's database on children and snowmobiles contains information on 291 injuries and 75 deaths for 1990 through 1998.

 The commission reported that many states have no age or helmet regulations regarding snowmobile use.

The American Academy of Pediatrics reviewed available snowmobile injury data from 1997 through 1998.

 During that time, there were more than 10,000 emergency department visits related to snowmobiling accidents. Ten percent of those involved were younger than 15 years. Head trauma was the leading cause of death.

Because it is a family affair, sledding often involves very small children--those at highest risk for head injuries. Children younger than 6 years had 3 times as many head injuries as those older than 12 years.

 There are several contributing factors. Children younger than 12 years have proportionately large heads, higher centers of gravity, and lower levels of coordination and muscle strength.

Spurred by the steady rate of sledding injuries and the rising interest in many forms of winter sliding activities, the American Academy of Orthopaedic Surgeons has published guidelines for safe sledding.

 These recommendations are divided into essential and preferred components and focus on the environment of the activity, the instruments of sledding, and the operator (

In general, children are more likely to sustain upper extremity injuries than adolescents and adults. Children younger than 10 years incur more fractures and catastrophic injuries (head injuries) with individual recreational activities than they do during organized sports.

Key preventive measures are available online at 

http://www.kidsource.com/safety/winter.sport.safety.html.

For the patient with musculoskeletal injury, there are 4 phases of rehabilitation

 Limiting additional injury; controlling pain and swelling.

 Improving strength and flexibility of injured structures.

 Progressive improvement in strength, flexibility, proprioception, and endurance of the injured structures until near-normal function is achieved.

 Returning to the sport gradually through functional rehabilitation.


1. Deibert MC, Aronsson DD, Johnson RJ, et al. Skiing injuries in children, adolescents, and adults. 

 1998;80:25-32. 
2. Shorter NA, Jensen PE, Harmon BJ, Mooney DP. Skiing injuries in children and adolescents. 

 1996;40:997-1001. 
3. Morrow PL, McQuillen EN, Eaton LA Jr, Bernstein CJ. Downhill ski fatalities: the Vermont experience [published correction appears in 

 1988;28:95-100. 
4. Oh S, Schmid UD. Head injuries in childhood caused by skiing and their optimal prevention [in German]. 

 1983;38:66-72. 
5. Coolahan L, Jones JE, Fung SC, et al. 

 New South Wales Public Health Bulletin. 1994;5:88-90. 
6.Young CC, Niedfeldt MW. Snowboarding injuries. 

 1999;59:131-136, 141. 
7.Chow TK, Corbett SW, Farstad DJ. Spectrum of injuries from snowboarding. 

 1996;41: 321-325. 
8. Ekeland A, Rodven A. Injury types in Alpine skiing and snowboarding related to age groups. Abstract presented at: the 1st World Congress of Sports Injury Prevention. 

2005; 39:380. 
9. Tarazi F, Dvorak MF, Wing PC. Spinal injuries and snowboarders. 

 1999;27:177-180. 
10. Pray WS, Pray JJ. Sports injuries in children. 

 2004;10:16-24. 
11. Pierz JJ. Snowmobile injuries in North America. 

 2003;409:29-36. 
12. Pyper JA, Black GB. Orthopaedic injuries in children associated with the use of off-road vehicles. 

 1988;70:275-284. 
13. Rice MR, Alvanos L, Kenney B. Snowmobile injuries and deaths in children: a review of national injury data and state legislation. 

 2000;105 (3, pt 1):615-619. 
14. American Academy of Pediatrics. Committee on Injury and Poison Prevention. Snowmobiling hazards. 

2000;106:1142-1144. 
15.Finnegan MA, Tongue JR. The hidden dangers of winter sliding. 

 2003;409:73-77. 
16. American Academy of Orthopaedic Surgeons. 

[brochure]. AAOS; 1999. 
17. Purvis JM, Burke RG. Recreational injuries in children: incidence and prevention. 

2001;9:365-374. 
18. KidSource OnLine Inc. Winter sports injury prevention: safety on the slopes. Available at: http://www.kidsource.com/safety/winter.sport.safety.html. Accessed February 2, 2006. 
19. Hergenroeder AC. Prevention of sports injuries. 

Articles

Millions enjoy skiing, snowboarding, and sledding. These cold weather activities--while exhilarating--also cause many injuries, each with distinct clinical characteristics.

Winter Sports Injuries: Patterns of Injury--Preventive Measures

Fever is one of the most common symptoms for which children are brought to the emergency department. In most cases, fever is attributed to viral infections; in many cases, causes such as otitis media, pneumonia, and urinary tract infection are identified. Occasionally, however, one comes across an unusual case of fever accompanied by a sudden drop in blood pressure. A systematic approach to diagnosis and management is crucial in preventing morbidity and mortality.

A 12-year-old boy was brought by ambulance to the emergency department (ED) with fever and shaking of 3 days' duration. He was accompanied by his mother. The boy had spent the weekend at his father's home when he began to feel sick. Since returning to his mother's house, he has been lethargic and has had one episode of vomiting.

A year earlier, the patient had experienced a generalized seizure. A CT scan taken at that time showed an arachnoid cyst in the brain. The boy had been taking phenytoin, but his mother had discontinued the medication (without the physician's knowledge) a few weeks before the current ED visit because he had no new seizures and was "doing fine." He had also been taking methylphenidate for hyperactivity for the past year. 

In the ED, the boy's temperature was 40.2ºC (104.3ºF); he had not received any medication for fever at home. His heart rate was 146 beats per minute; respiratory rate, 22 breaths per minute; and blood pressure, 132/49 mm Hg. He was unable to sit up or stand. He appeared flushed, especially over his palms and soles; the erythema blanched with pressure. The sclera were icteric. There was a small, 0.5-cm nontender pustule on his left knee. The liver and spleen were not enlarged.

The boy was lethargic and responded to questions in monosyllables. Meningeal signs were absent. By the time the examination was complete, his blood pressure had dropped to 90/58 mm Hg. He received a bolus of normal saline, and ceftriaxone therapy was started after blood and urine samples were obtained for culture. A sample of the content of the pustule on his knee was also sent for culture. The boy was given dopamine to maintain his blood pressure and was admitted to the pediatric ICU (PICU).

In the PICU, the patient's white blood cell (WBC) count was 17,000/µg, with 15% bands, 71% neutrophils, 6% lymphocytes, and 8% monocytes. His hemoglobin was 13.2 g/dL; platelet count, 118,000/µg; reticulocyte count, 1.2%. Serum sodium level was 131 mEq/L; potassium, 4.3 mEq/L; chloride, 98 mEq/L; bicarbonate, 19 mEq/L; blood urea nitrogen, 1 mg/dL; and creatinine, 0.8 mg/dL. Urinalysis revealed the following: pH, 5.5; 2+ bilirubin; 1+ ketone; 2+ protein; 4 mg/dL urobilinogen; 10 to 20 WBCs; and 3+ bacteria. Serum bilirubin level was elevated at 5 mg/dL (direct fraction, 1.9 mg/dL). Levels of aspartate aminotransferase, alkaline aminotransferase, alkaline phosphatase, and creatine kinase were normal, as were prothrombin time and partial thromboplastin time. The d-dimer level in serum was mildly elevated at 3.61 mg/L. Urine was negative for myoglobin. Clindamycin was added to his antibiotic therapy.

Over the next 24 hours, the patient's blood pressure remained stable and the dopamine drip was tapered gradually. Blood and urine cultures at 24 hours showed no growth. The CT scan demonstrated a 3-cm right temporal arachnoid cyst without any acute changes. The culture from the pustule on the boy's knee grew coagulase-positive 

 also grew from the nasopharyngeal swab. 

Staphylococcal toxic shock syndrome (TSS)

The boy improved rapidly after 24 hours, and blood pressure support was withdrawn by 48 hours of admission. The erythema disappeared in 4 days, and he was sent home 5 days after admission on a 10-day course of oral clindamycin. The patient was doing well at home 10 days later and reported some generalized desquamation.

TSS is uncommon in children. Todd and colleagues

 initially described this entity in 1978 in 7 children between 8 and 17 years of age. TSS was later recognized to be more common in menstruating girls and women who used tampons. The incidence of menstrual-related TSS has declined since highly absorbent tampons were withdrawn from the market in the 1980s. Currently, nonmenstrual TSS accounts for most cases.

 The recognition and early management of TSS has reduced associated mortality.

TSS is caused by massive amounts of inflammatory cytokines produced as a result of stimulation of T lymphocytes by staphylococcal superantigen--the TSS toxin-1 (TSST-1). This toxin has a 3-dimensional structure that allows it to interact with relatively invariant regions of major histocompatibility complex class II molecules on the surface of antigen-presenting cells and with certain variable regions of the T-cell receptor chain. Unlike a typical antigen that may activate 1 in 10,000 T cells, superantigens may activate from 20% to 50% of T cells. The consequence of these interactions is the exaggerated release of bioactive cytokines, which are responsible for the clinical signs of illness associated with these toxins.

The diagnosis of TSS is mainly clinical. The CDC case definition requires the presence of 5 criteria (

 Nonmenstrual TSS may present differently from menstrual TSS in that the onset of symptoms may be delayed after the precipitating injury or event; also, there are more frequent CNS manifestations, less frequent musculoskeletal involvement, and more severe anemia.

 TSS is associated with a 2% to 5% mortality rate: early diagnosis is therefore crucial. A high index of suspicion--especially in patients who present with fever and shock without obvious cause--is particularly important. As in this patient's case, the offending staphylococcal lesion can be small and may be unnoticed by the patient.

The problems we encountered during diagnosis in our patient included the appearance of jaundice and hemoglobinuria, which swayed our diagnosis toward other hemolytic disorders. While hyperbiliru- binemia is a known finding in staphylococcal TSS, the cause in the absence of raised liver enzyme levels remains uncertain. This could be a result of hepatic underperfusion resulting from shock or a direct effect of staphylococcal toxin.

The immediate need for patients with TSS is aggressive fluid therapy and management of respiratory and/or cardiac failure. Initial empiric antibiotic therapy is with a combination of a b-lactamase-resistant antimicrobial agent and a protein synthesis-inhibiting agent, such as clindamycin. Inhibition of protein synthesis leads to diminished toxin synthesis. Antimicrobial therapy should be continued for a minimum of 10 days to ensure eradication of the organism, because recurrences are known to occur.

In addition, any abscesses should be drained. Consider intravenous immunoglobulin (IVIG) therapy if the area of infection cannot be drained; also consider this treatment for patients who respond poorly to standard treatment.

 Standard IVIG preparations contain neutralizing antibodies against the superantigens responsible for the clinical manifestations.

The mortality associated with TSS is high if proper treatment is not instituted immediately. Therefore, in addition to managing the patient's airway, breathing, and circulation, look carefully for any infected lesions that suggest TSS. As demonstrated in this case, early and appropriate management can result in a rapid recovery.


1. Todd J, Fishaut M, Kapral F, Welch T.Toxic-shock syndrome associated with phage-group-I staphylococci. 

 1978;2:1116-1118.
2. Gaventa S, Reingold A, Hightower AW, et al. Active surveillance for toxic shock syndrome in the United States, 1986. 

 1989;11(suppl 1): S28-S34.
3. Schlievert PM. Use of intravenous immunoglobulin in the treatment of staphylococcal and streptococcal toxic shock syndrome and related illnesses. 

 2001;108(4 suppl):S107-S110.
4. American Academy of Pediatrics. Toxic shock syndrome. In: Pickering LK, ed. 

2003 Report of the Committee on Infectious Diseases.

 26th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2003:624-630.
5. Kain KC, Schulzer M, Chow AW. Clinical spectrum of nonmenstrual toxic shock syndrome (TSS): comparison with menstrual TSS by multivariate discriminant analyses. 

 1993;16: 100-106.
6. Gourley GR, Chesney PJ, Davis JP, Odell GB. Acute cholestasis in patients with toxic-shock syndrome. 

 1981;81:928-931.
7. Andrews MM, Parent EM, Barry M, Parsonnet J. Recurrent nonmenstrual toxic shock syndrome: clinical manifestations, diagnosis, and treatment. 

Srinivasan Suresh, MD, MBA

Articles

Winter Sports Injuries: Patterns of Injury--Preventive Measures

Case In Point: Toxic Shock Syndrome