Skiing, especially snowboarding, is seeing a continuous increase in participation. With the rise in participation and competition levels in these winter sports, the number of injuries has also increased.Upper extremity injuries are more common in snowboarding, while lower extremity injuries are more prevalent in skiing.Head injuries, particularly concussions, are common in both sports. These activities must consider environmental conditions, such as high altitudes and UV radiation. The purpose of this article is to discuss the most common musculoskeletal injuries in skiing and snowboarding, as well as considerations for initial assessment and classification into appropriate levels of care. It is crucial for sports medicine physicians covering these sports to understand the initial assessment and treatment of these injuries. Given the potential for serious injuries in these sports, it is important to quickly identify injuries that require urgent evaluation and treatment. As participation and injury rates in these sports increase, it is also important to consider preventive strategies that can minimize the risk of injury.
1. Skiing is becoming increasingly popular
Skiing and snowboarding are two of the most popular winter sports, with over 9 million active participants in the 2017 to 2018 snow season (the current domestic skiing situation is very good). Snowboarding emerged much later, having been introduced in the 1970s and only recognized as an Olympic sport in 1998.
2. Epidemiology
There are some significant differences in the patterns and severity of injuries between skiers and snowboarders. Due to differences in epidemiological research methods, it is challenging to determine the exact injury rates in these sports. Most injury reports are based on self-reports, ski patrol data, or data from trauma centers. Generally, injury rates in these environments are reported to be between 1 and 5 injuries per 1000 athlete days. Snowboarders are more prone to acute injuries than skiers. Over the past decade, the injury rate in snowboarding has continued to rise, while the injury rate in skiing has stabilized. Males are more frequently injured in alpine skiing and snowboarding. The average age of injured skiers is also higher than that of injured snowboarders.
There is solid evidence that skiers sustain more lower extremity injuries, while snowboarders sustain more upper extremity injuries.
The most common skiing and snowboarding injuries categorized by age/competition level
When studies compare specific injury types between the two winter sports, snowboarders suffer more shoulder, neck, humeral, and torso injuries than alpine skiers. Snowboarders are at a higher risk of head trauma, particularly concussions. While lower extremity injuries, especially knee injuries, are less common among snowboarders, ankle injuries seem to be more common among snowboarders.
3. Clinically
In general, injured skiers and snowboarders will initially be managed on the slopes by ski patrols. After triage, depending on the specific situation, athletes may be seen in resort clinics, nearby clinics, or local emergency rooms. While most larger ski resorts have their own medical facilities, such as standard radiography or ultrasound, smaller mountains or remote ski areas may not offer these services. (Intracranial hemorrhage, blunt abdominal solid organ lacerations) and characterizing fractures, but smaller clinical environments may lack advanced medical equipment such as CT scans and MRIs. MRI is superior to CT in assessing soft tissue injuries (especially limbs). Therefore, it is crucial to transport injured athletes to a higher level of care for severe trauma cases. Ultrasound is an important tool that can help identify certain life-threatening conditions by performing assessments such as Focused Assessment with Sonography for Trauma (FAST) and Extended FAST (eFAST). Computed Tomography (CT) scans are used to assess internal soft tissue injuries.
Due to the severity of injuries in these sports, which can sometimes be life-threatening, it is essential that medical personnel treating skiers and snowboarders are adequately trained to manage a variety of medical conditions and are confident in providing care in emergencies. It is recommended that personnel working in ski mountain clinics or urgent care facilities receive training, including but not limited to Basic Life Support, Advanced Cardiac Life Support, and Advanced Trauma Life Support. Additionally, providers should be able to utilize ultrasound and certain forms of anesthesia (e.g., conscious sedation), as this may be necessary for fracture and joint reduction procedures. Medical personnel in small clinical environments without emergency resources should be familiar with protocols for the urgent transfer of critically ill patients to higher-level care facilities.
1. Initial Assessment, Resuscitation, and Emergency Management
For acute injured athletes in or near medical facilities on the slopes, the first step is to triage and use primary and secondary surveys to assess for life-threatening injuries. On the slopes, the risk of hypothermia and traffic delays should be prioritized. Pelvic and femoral fractures have a high risk of hemorrhagic shock. Intravenous access and adequate pain management (for rib and pelvic fractures) should be achieved as soon as possible for patients undergoing FAST and eFAST. Using appropriate imaging studies for focused examinations and assessments can help determine the urgency of the condition and the need for further care. All potential abdominal and thoracic injuries should be addressed. If possible, a brief history should be taken, and the mechanism of injury should be inquired about to understand the injury better.
For these athletes, removing sports-specific gear (especially boots) may be challenging. Medical providers with the highest level of experience in ski and snowboard equipment should be responsible for the removal of gear.
2. Stabilization, Immobilization, and Transport
Critically ill patients should be stabilized and transported to facilities with higher levels of care as soon as possible. Athletes with open fractures should be transported quickly (e.g., in most cases, muscle necrosis usually occurs after arterial blood flow is insufficient for more than 6 hours) for subsequent care and surgical intervention. Transport should not be delayed for additional assessments. If no life-threatening or limb-threatening injuries are found after initial evaluation, appropriate stabilization and follow-up care can be arranged. The appropriate mode of transport from the ski area to medical facilities and higher-level care depends on the athlete’s injury situation and severity. Attempts to reduce dislocated joints or displaced fractures should be made under appropriate analgesia or anesthesia. After reduction, the injured body part should be immobilized to reduce the incidence of complications. Most injuries that occur in these athletes are non-emergency (e.g., non-displaced clavicle fractures, acromioclavicular joint sprains, ACL tears), requiring initial stabilization, oral pain management, and follow-up within 2 to 5 days.
A 38-year-old female skier sustained an open distal tibial fracture.
4. Musculoskeletal Injuries
1. Upper Extremity Injuries
Snowboarders are more likely to suffer shoulder, elbow, forearm, and wrist injuries than skiers. Among snowboarders, the most common upper extremity fractures are distal radius fractures, followed by clavicle fractures and proximal humerus fractures. In skiers, clavicle fractures are the most common type of fracture, followed by distal radius fractures and proximal humerus fractures, all of which account for a small percentage of all skiing injuries. Glenohumeral joint dislocations are the most common joint dislocations among skiers and snowboarders. This is followed by acromioclavicular joint injuries and elbow dislocations.
Wrist fractures are the most common fractures among snowboarders and are also common among skiers. These usually occur at the distal radius and are often the result of falling onto an outstretched hand. This injury is common among young and inexperienced skiers. As with any fracture, the initial assessment of a distal radius fracture should include skin integrity and neurovascular status, and CT scans should be performed if possible. Many distal radius fractures can be treated with immobilization alone, but significant angulation, displacement, or open fractures require surgical treatment.
Ulnar Collateral Ligament (UCL) injuries (sometimes referred to as “skier’s thumb”) are more common in skiers than snowboarders. The mechanism of this injury is usually a sudden abduction force to the thumb after a fall when the skier still has their ski poles in hand, and surgical treatment is required for injuries involving significant tearing or associated displaced avulsion fractures. Non-surgical treatment may be appropriate for partial tears and cases with very low laxity. Treatment is guided by X-ray findings, the presence of avulsion fractures, and the degree of UCL laxity.
Clavicle fractures in snow sports are usually caused by jumps followed by impact with the snow surface. These most commonly involve the middle third of the clavicle. Acutely, there may be noticeable deformity, swelling, and bruising at the fracture site, and protection of the affected shoulder is indicated. The examination should include neurovascular assessment, signs of skin breakdown, skin tenting, and evaluation for associated upper extremity injuries, visceral injuries, or cervical spine injuries.
If the fracture is stable and there is no significant displacement or obvious tenting of the skin, non-surgical treatment can be offered.
AC joint injuries are more common among advanced snowboarders who fall onto their shoulder with their arms adducted. Patients typically present with AC joint tenderness and a positive cross-arm test, with or without obvious deformity. Most injuries can be treated non-surgically.
Glenohumeral joint dislocations are most commonly anterior dislocations and can severely present with loss of the lateral shoulder contour and fullness anteriorly, with the patient holding their arm in abduction. Management after reduction will be based on age, history of recurrent dislocations, or associated injuries. After assessing neurovascular status and performing CT scans (if indicated), dislocations should be reduced as soon as possible.
Proximal humeral fractures are most common in young novice skiers from high-impact forces. The most common types of proximal humeral fractures in this population are greater or lesser tuberosity avulsions. Patients typically present with pain, swelling, bruising, and inability to move the shoulder.
2. Lower Extremity Injuries
Lower extremity injuries occur more frequently in skiing than in snowboarding. This is largely due to differences in equipment, overall posture, and mechanisms of falls. Skiers often experience greater torsional forces, increasing the risk of knee ligament injuries. Due to the nature of their equipment, snowboarders do not experience as much lower extremity torque. While lower extremity fractures are not common in skiing, tibial plateau fractures and tibial shaft (“boot top”) fractures have been reported. Foot and ankle injuries are the most common lower extremity injuries among snowboarders.
Knee ligament injuries are the most common lower extremity injuries among skiers, typically caused by internal rotation and valgus loading. Experienced snowboarders attempting tricks and jumps have a higher incidence of knee ligament injuries compared to inexperienced snowboarders. ACL injuries often occur in conjunction with MCL and meniscal injuries. Most athletes and active individuals with ACL tears will undergo surgical reconstruction to maintain knee stability.
Ankle sprains are more common in snowboarding, possibly due to the use of softer boots compared to ski boots. Lateral process talus fractures (FLPT), also known as “snowboard fractures,” are a relatively unique occurrence in this sport. This injury typically presents as anterior lateral ankle pain, with the typical mechanism being dorsiflexion, hindfoot inversion, axial loading, and internal rotation. This injury may be misdiagnosed as an anterior talofibular ligament sprain. If left untreated, complications such as avascular necrosis, subtalar arthritis, and non-union may occur. CT may miss FLPT, so if there is a high suspicion of this injury.
Ankle X-ray (lateral view)
LPT Pressure Test . This maneuver induces pain because the fractured LPT is compressed against the calcaneus. The test is performed by applying passive dorsiflexion and eversion forces to the foot while pressing the foot toward the head and maintaining external rotation of the lower leg.
Metatarsal fractures are also common in snowboarding, usually caused by hard landings on flat surfaces. Most isolated metatarsal fractures can be treated non-surgically.
Skiers and snowboarders wearing hard boots may also sustain mid-shaft tibial and fibular (“boot top”) fractures. These injuries typically require urgent surgical fixation.
5. Non-musculoskeletal and Severe Injuries
While musculoskeletal injuries are the most common type of injury in snow sports, severe injuries are more likely to affect the head, face, spine, chest, and abdomen. More severe injuries, including spinal, thoracic, and renal injuries, are more likely to result from collisions rather than falls. In scenarios where snowfall is 5 cm or less, among severe injuries presenting to emergency departments in the US, 47% to 57% are head injuries, 29% are spinal injuries, 37% are thoracic injuries, and 35% are abdominal injuries.
1. Facial Injuries
Facial injuries are more common among skiers and snowboarders during recreational activities, typically resulting from falls or collisions. Typical facial injuries in skiing and snowboarding include facial fractures, dental injuries, and alveolar soft tissue injuries. Male skiers and snowboarders are more likely to sustain facial fractures. Snowboarders tend to suffer more maxillofacial injuries than skiers. For any suspected facial fractures, emergency management should include assessment of ABC (Airway, Breathing, Circulation), ensuring airway safety, and evaluating for associated cervical spine or head injuries. Any individual with suspected facial fractures or unstable dental injuries should be treated at an emergency facility. The physical examination should include assessment for missing teeth, facial asymmetry, or unequal pupils, which may indicate further potential trauma.
2. Head Injuries
Head injuries are a leading cause of death and serious injury in skiing and snowboarding, ranging from concussions to severe traumatic brain injuries. Concussions are the most common type of head injury in skiing and snowboarding. A comprehensive head trauma assessment may include standard sideline concussion assessment tools such as the Sport Concussion Assessment Tool, 5th Edition (SCAT5). If an individual suffers any head injury that results in symptoms, they should not be allowed to return to play on the same day. In stable and non-emergency head injuries, athletes can be monitored for worsening symptoms, but any skier or snowboarder suspected of having cervical spine injuries, worsening symptoms, altered mental status, or signs of intracranial bleeding should be immediately transferred to a tertiary care facility.
Early identification of any severe head injury is crucial, which will require transfer to a tertiary care center. In skiing and snowboarding, falls are the leading cause of traumatic brain injury. Collisions with obstacles (trees, rocks, lift poles) are the least common injury mechanism but are associated with more severe head injuries. The incidence of skull fractures is higher in skiers than in snowboarders. In snowboarding, severe head injuries, including subdural hematomas, may occur due to aerial maneuvers and landing failures, and are more common in park terrain.
3. Spinal Injuries
Spinal injuries account for 1% to 17% of all injuries in alpine sports. The lumbar spine is the most common site of spinal injuries for both skiers and snowboarders, and it is not uncommon for more than one spinal segment to be affected. Most severe spinal injuries occur in skiers, while spinal injuries in snowboarders tend to be more stable and lower-risk injuries. Isolated transverse process fractures, spinous process fractures, or thoracolumbar compression fractures are more common in skiers. This difference may be due to the different injury mechanisms in each sport. Injuries in skiing are more common due to high-speed collisions leading to rotational injuries, while injuries in snowboarding are more common due to jumps and falls.
Risk of cervical spine injuries is high while skiing and may result in permanent neurological consequences. The initial assessment of spinal injuries should include evaluation of motor and sensory function, as well as assessment for associated injuries (brain injuries, lung injuries, vascular injuries, or visceral injuries). If cervical spine injuries or unstable spinal injuries are suspected, the patient should be transferred to a tertiary care center.
4. Chest Injuries
Chest trauma is more common in skiing than in snowboarding. The most common skiing and snowboarding-related chest injuries in US emergency departments are rib fractures, lung injuries, pneumothorax, hemothorax, and clavicle fractures. Isolated rib fractures can be treated with supportive care and careful repositioning precautions. Given that the same mechanism may lead to potential lung injuries, chest wall injuries should be assessed on the same day, preferably at a facility with X-ray capabilities. Any lung injuries, such as pneumothorax or hemothorax, should be sent to the emergency department for further evaluation and management.
5. Abdominal and Pelvic Injuries
Abdominal injuries are more common in snowboarding than skiing. The most common abdominal injuries in these sports are injuries to the spleen, kidneys, pelvis, liver, and gastrointestinal tract. Intra-abdominal injuries are most commonly solid organ lacerations, while pelvic injuries are most commonly fractures.Specifically, splenic injuries are more likely to occur in snowboarders than in skiers, and male snowboarders are more likely to sustain splenic injuries than female snowboarders. While most severe injuries in skiers and snowboarders are caused by collisions, a prospective study on splenic injuries indicated that these injuries are more likely to occur due to falls or jumps among snowboarders. Ultrasound is a valuable tool for identifying these injuries in the pre-hospital setting.
6. Environmental Injuries (Altitude, UV Radiation, Cold Injuries)
Given that most recreational skiers and snowboarders travel from low-altitude areas to high-altitude resorts, altitude sickness is an important environmental consideration in these sports. Acute Mountain Sickness (AMS) is the most common form of acute altitude sickness, typically seen in individuals who are not acclimatized to altitudes above 2500 meters. Symptoms of AMS are non-specific and include headaches, gastrointestinal symptoms (loss of appetite, nausea, vomiting), fatigue, and dizziness. Other altitude-related illnesses include High Altitude Pulmonary Edema and High Altitude Cerebral Edema, which are rare. The primary treatment for all forms of altitude sickness is descent to a lower altitude. Preventive measures for altitude sickness primarily include ascending gradually to high altitudes and may include the use of acetazolamide and dexamethasone.
UV radiation levels at ski resorts can also be high, increasing by 2% to 3% for every 100 meters of altitude, and increasing by as much as 40% due to reflection from the snow. It is recommended that alpine athletes receive education on the need for UV protection and use sunscreen with an SPF of 30 or higher, especially on highly exposed areas such as the nose and lips.
Skiers and snowboarders face the risk of cold injuries related to environmental factors, including accidental hypothermia, which is defined as a core temperature unintentionally dropping to 35°C or below. Hypothermia is uncommon in resort skiing and snowboarding, but should be considered among backcountry skiers, especially as this condition is associated with trauma. Clinical evaluation in the pre-hospital setting should guide the severity of hypothermia based on two signs: shivering and any changes in mental status. Most patients diagnosed with hypothermia require treatment and monitoring in a hospital, but shivering, alert, and uninjured patients may be treated outside of the hospital. Treatment should include preventing further cooling, sheltering, rewarming to support shivering, and actively warming when possible.
Frostbite is a cold injury caused by localized cold exposure, primarily occurring on peripheral body parts, with the severity of progression varying with the severity of the injury. Frostbite may occur due to isolated body parts being exposed to the cold, and thus may be seen among recreational skiers and snowboarders in frontline and remote settings. The goal of frostbite prevention should be to maximize blood flow and minimize heat loss from soft tissues. On-site treatment for early frostbite should primarily include treating associated injuries, rapid rewarming in water or other environments at 37°C to 39°C, preventing refreezing or trauma, dressing injured tissues, and systemic hydration. Subsequently, individuals should be transported to emergency medical facilities for further treatment.
While avalanche safety is typically not an issue within ski and snowboard resort boundaries, it is an important consideration for backcountry skiers. Avalanche injuries can be fatal due to multiple injuries and asphyxiation.
7. Injury Prevention
Skiing and snowboarding expose athletes to various musculoskeletal injury risks, making it essential to understand the practicality of various preventive strategies. Beginners are at the highest risk of injury, so appropriate education, sport-specific guidance, and risk awareness training are crucial for novices. Education should include the use of protective equipment and proper lift techniques. It has been shown that wearing helmets can reduce the risk and severity of head injuries while skiing and snowboarding, without increasing the risk of cervical spine injuries. Multiple studies have shown that wearing wrist guards has protective effects, particularly for beginners. Other preventive techniques that may be beneficial include neuromuscular training and improving core strength.
8. Conclusion
Snowboarding and skiing present winter athletes with a variety of injury risks. Upper extremity injuries, particularly wrist injuries, are the most common injuries among skiers. Lower extremity injuries, especially knee ligament injuries, are the most common injuries among skiers. It is important for sports medicine physicians to recognize and treat the most common musculoskeletal, head, body, and environmental injuries in these athletes. Helmets, wrist guards, and appropriate pre-activity guidance have been shown to reduce injury rates in skiing and snowboarding. More research is needed on fall prevention strategies and the most effective types of protective equipment.
