Snowboarding Injuries

Am Fam Physician. 1999 Jan 1;59(1):131-136.

  See related patient information handout on snowboarding, written by the authors of this article.

Snowboarding is a popular winter sport that involves riding a single board down a ski slope or on a half-pipe snow ramp. Compared with injuries resulting from traditional alpine skiing, snowboarding injuries occur more frequently in the upper extremities and ankles and less frequently in the knees. Different types of snowboard equipment, rider stance and snowboarding activity tend to result in different types of injury. Snowboarder's ankle, a fracture of the lateral talus, must be considered in a snowboarder with a “severe ankle sprain” that has not responded to treatment. Risk of injury may be lowered by using protective equipment, such as a helmet and wrist guards.

Snowboarding is an increasingly popular winter sport in which participants ride an epoxyfiberglass board (resembling a large skateboard) down a ski slope or on a half-pipe ramp, a specialized snow structure used for performing tricks. Introduced in the United States in 1965 when Sherman Poppen bolted two skis together, snowboarding became popular with the introduction of commercial snowboards in the late 1970s. Today, with more than 3.4 million participants, snowboarding is the fastest growing winter sport in the United States. Snowboarders now make up 20 percent of the visitors to U.S. ski resorts. The National Sporting Goods Association estimates that since 1988, the number of snowboarders has increased 77 percent, whereas the number of skiers has fallen 25 percent. The popularity of snowboarding was further boosted after its introduction as an Olympic sport at the 1998 Winter Games in Nagano, Japan.

In the 1980s, most snowboarders were young males. Recent surveys have shown that females and older persons are increasingly more apt to take up this sport. For example, the male-to-female participant ratio dropped from 9 to 1 in 1989 to 3 to 1 in 1995.1,2

Snowboarding differs from downhill skiing in many respects. The most important difference is that 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 (Figure 1). Furthermore, snowboarders do not use ski poles, but use their hands and arms for balance, much like skateboarders or surfers.

FIGURE 1.

Snowboarder shown riding in regular-footed stance.

View Large


FIGURE 1.

Snowboarder shown riding in regular-footed stance.


FIGURE 1.

Snowboarder shown riding in regular-footed stance.

Equipment

SNOWBOARDS

Knowing the type of equipment used and the rider's position on the board is important in evaluating injuries. Traditional snowboards are symmetric, allowing the snowboarder to travel backward easily, that is, lead with the tail of the board (a move called a “fakie” by snowboarders). Asymmetric boards that enhance freestyle, slalom and giant slalom events are more recent introductions. Traditionally, snowboard riders use their left foot as the forward foot and face toward the right side of the board (known as the “frontside”). Occasionally, snowboarders ride in a reverse position, called “goofy-footed.”

BOOTS

Snowboarding boots come in three styles: soft, hard and hybrid. Traditionally, snowboarders use soft boots. The current soft snowboard boot is made of leather or synthetic material that allows moderate stability yet is balanced by moderate flexibility. The advantages of soft boots are increased maneuvering ability and comfort. “Sorrel-type” soft boots are worn by 75 to 90 percent of recreational snowboarders. Some beginners wear moon boots or hiking boots, both of which lack stability and may lead to a higher injury rate. These types of boots should not be used for snowboarding.

Hard boots provide greater ankle support and increased control, and are primarily worn by racers.

The increasingly popular hybrid boots are relative newcomers to the snowboarding scene. This classification includes boots that are constructed with a soft leather or synthetic outer shell and a stiff inner boot. Another design is constructed with a hard shell base and a soft upper component. This combination balances the increased comfort and maneuvering ability of soft boots with the increased stability of hard boots. Since each boot style places the body under different stresses, knowing the type of boot worn is important in determining the risk of injury.

BINDINGS AND SAFETY EQUIPMENT

Most snowboard bindings are non-releasable. Soft bindings are molded plastic shells with buckle systems that are used with soft boots and include a high back to give extended Achilles tendon support. The plate-type bindings consist of a steel and plastic base plate with heel and toe clips and are typically used with hard boots. Safety equipment includes helmets, face guards, goggles, forearm guards and wrist guards. Unfortunately, safety equipment is rarely used by recreational snowboarders.

Injury Patterns

Although advanced snowboarders may try more dangerous maneuvers such as jumps and other aerial tricks, beginning snowboarders are the most frequently injured. Almost one quarter of snowboarding injuries occur during a person's first experience,1,3,4 and almost one half occur during the first season of snowboarding.28 A typical first snowboarding experience consists of a cycle of brief rides followed by falls; since falling is the leading cause of snowboarding injuries, the beginning snowboarder is at high risk for injury.3

Jumps are the second most common cause of injuries and may be associated with head, facial, spinal and abdominal injuries.4 Collisions are associated with 5 to 10 percent of injuries.3,4,8 Severe injuries that require referral to a tertiary trauma center are rare. The most common cause of severe injury is collision with a tree. Severe injuries usually involve the head (54 percent), abdomen (32 percent), bones (32 percent) and thorax (16 percent).9

Four to 8 percent of snowboarding injuries take place while the person is waiting in ski-lift lines or entering and exiting ski lifts.8,10 Snowboarders push themselves forward with a free foot while in the ski-lift line, leaving the other foot (usually that of the lead leg) locked on the board at a 45- to 90-degree angle, placing a large torque force on this leg and predisposing the person to knee injury if a fall occurs. Equipment failures rarely cause injuries (0.5 to 1.2 percent).8,10

Although early studies showed that approximately one half of snowboarding injuries were located in the lower extremities, this pattern has changed with the evolution of snowboard boots and bindings. Currently, fewer than one third of snowboarding injuries are to the lower extremities (Table 1).1,38,10,11 The lead leg, which is at greatest risk, accounts for almost three quarters of such injuries.1,5,8 Injury location is related to boot type. Hard boots place the snowboarder at risk for fractures of the tibia and fibula at the level of the boot top, called “boot-top” fractures.2,6

TABLE 1

Summary of Snowboard Injury Studies

Study Number of injuries Upper extremity injuries (%) Lower extremity injuries (%) Wrist injuries (%) Knee injuries (%) Ankle injuries (%)

Pino and Colville, 19891

110

29.1

52.7

7.3

11.8

26.4

Abu-Laban, 19915

132

25.9

49

16

16

28

Ganong, et al., 19923

415

44

43

23.9

18.1

16.9

Bladin, et al., 19936

276

30

57

23

23

NEISS, 199311

565

47

31.8

20.4

12

12.8

Warme, et al., 19957

47

17

21

Calle and Evans, 199510

487

38

34.1

19.9

15

12.5

Davidson and Laliotis, 19968

931

40

38

19

17

16

Chow, et al., 19964

355

58

16

20.3*

2.8

3.1


*—Only fractures were included.

Information from references 1, 38, 10 and 11.

TABLE 1   Summary of Snowboard Injury Studies

View Table

TABLE 1

Summary of Snowboard Injury Studies

Study Number of injuries Upper extremity injuries (%) Lower extremity injuries (%) Wrist injuries (%) Knee injuries (%) Ankle injuries (%)

Pino and Colville, 19891

110

29.1

52.7

7.3

11.8

26.4

Abu-Laban, 19915

132

25.9

49

16

16

28

Ganong, et al., 19923

415

44

43

23.9

18.1

16.9

Bladin, et al., 19936

276

30

57

23

23

NEISS, 199311

565

47

31.8

20.4

12

12.8

Warme, et al., 19957

47

17

21

Calle and Evans, 199510

487

38

34.1

19.9

15

12.5

Davidson and Laliotis, 19968

931

40

38

19

17

16

Chow, et al., 19964

355

58

16

20.3*

2.8

3.1


*—Only fractures were included.

Information from references 1, 38, 10 and 11.

Knee injuries, especially sprains, account for approximately 16 percent of all snowboarding injuries (Table 2).1,38,10,11 Hard boots give the snowboarder approximately twice the risk of a knee injury compared with soft boots.6

TABLE 2

Average Distribution of Snowboarding Injuries*

Location Percentage

Wrist

23.0

Ankle

16.7

Knee

16.3

Head

9.2

Shoulder

8.3

Trunk

7.8

Other

6.5

Elbow

4.4


*—Table percentage values do not equal 100 percent because of varying methods of measurement used in the studies from which the information was compiled.

Information from references 1, 38, 10 and 11.

TABLE 2   Average Distribution of Snowboarding Injuries*

View Table

TABLE 2

Average Distribution of Snowboarding Injuries*

Location Percentage

Wrist

23.0

Ankle

16.7

Knee

16.3

Head

9.2

Shoulder

8.3

Trunk

7.8

Other

6.5

Elbow

4.4


*—Table percentage values do not equal 100 percent because of varying methods of measurement used in the studies from which the information was compiled.

Information from references 1, 38, 10 and 11.

Ankle Injuries

On the other hand, soft boots give the snowboarder approximately twice the risk of ankle injury compared with hard boots.1,3,6 Ankle injuries account for almost 17 percent of snowboarding injuries. Almost 50 percent of the ankle injuries are fractures, which are usually easily diagnosed.3,4 However, “snowboarder's ankle,” a fracture of the lateral process of the talus, may be difficult to see on a standard ankle x-ray series12,13 (Figure 2). This fracture may comprise up to 15 percent of those ankle injuries in snowboarders that require medical evaluation. Physicians should maintain a high index of suspicion for snowboarder's ankle in a snowboarder with a “severe ankle sprain” that is persistently painful, has limitation of motion and fails to improve with appropriate management2  (Table 3). The mechanism of injury is a forcing of the ankle into dorsiflexion and inversion, which may occur during a landing from an aerial maneuver or a jump, especially when the landing has been over-rotated.

FIGURE 2.

Radiograph showing a fracture of the lateral process of the talus, commonly termed “snowboarder's ankle.”

View Large


FIGURE 2.

Radiograph showing a fracture of the lateral process of the talus, commonly termed “snowboarder's ankle.”


FIGURE 2.

Radiograph showing a fracture of the lateral process of the talus, commonly termed “snowboarder's ankle.”

TABLE 3

Types of Snowboarding Injuries

Degree of injury Location of injury
Head Shoulder Elbow Wrist and hand Trunk Knee Ankle

Common, less serious injuries

Soft tissue injuries*

Sprain

Soft tissue injuries*

Sprain

ACL sprain

Sprain

Fracture

MCL sprain

Fracture

Soft tissue injuries*

Less common, more serious injuries

Concussion Closed head injury

Dislocation Fracture

Dislocation Fracture

Dislocation Fracture

Clavicle fracture Internal injuries

Fracture

Fracture


ACL = anterior cruciate ligament; MCL = medial collateral ligament.

*—Includes abrasions, contusions and lacerations.

TABLE 3   Types of Snowboarding Injuries

View Table

TABLE 3

Types of Snowboarding Injuries

Degree of injury Location of injury
Head Shoulder Elbow Wrist and hand Trunk Knee Ankle

Common, less serious injuries

Soft tissue injuries*

Sprain

Soft tissue injuries*

Sprain

ACL sprain

Sprain

Fracture

MCL sprain

Fracture

Soft tissue injuries*

Less common, more serious injuries

Concussion Closed head injury

Dislocation Fracture

Dislocation Fracture

Dislocation Fracture

Clavicle fracture Internal injuries

Fracture

Fracture


ACL = anterior cruciate ligament; MCL = medial collateral ligament.

*—Includes abrasions, contusions and lacerations.

CLASSIFICATION OF ANKLE INJURIES

Snowboarder's ankle injuries are classified by degree of severity. A type 1 fracture is an articular process chip fracture of the talus with no extension into the talofibular joint. A type 2 fracture is a single large fragment extending from the talofibular joint to the subtalar joint. A type 3 fracture is a comminuted fracture of the entire lateral process. A lateral plain ankle x-ray with the ankle in 10 to 20 degrees of inversion may be better than standard ankle views for viewing the fracture.12,13 Other diagnostic tests, such as computed tomographic scanning or magnetic resonance imaging, may be useful in evaluating these injuries.

TREATMENT OF ANKLE INJURIES

Treatment for a nondisplaced or minimally-displaced fracture (less than 2 mm) is a short-leg, partial-weightbearing cast for six weeks. Patients with large displaced fractures and comminuted fractures should be referred to an orthopedic surgeon for possible open reduction and internal fixation, and/or excision of the fragments.

Upper Extremity Injuries

Upper extremity injuries make up an increasing proportion of the total number of snowboarding injuries, rising from approximately one quarter of all injuries in the early 1990s to almost one half of all injuries today. The lead upper arm appears to be slightly more vulnerable to injury.1,8  The wrist is the most common site of injury, accounting for almost one quarter of snowboarding injuries (Table 2) and for one half of all fractures.35,10 Other common fracture sites are the clavicle and the elbow.3,4 The shoulder is the most common site of dislocation, accounting for almost two thirds of dislocations, followed by the elbow, which accounts for almost one quarter of total dislocations.3,4

Compared with skiers, snowboarders have a much higher risk of wrist injuries (23 percent versus 4 percent) and ankle injuries (17 percent versus 5 percent) but a lower risk of knee injuries (16 percent versus 38 percent).1,38,10,11 Despite the lack of releasable bindings, snowboard-related knee injuries tend to be less severe than those experienced by downhill skiers. This lower risk may be related to features that are unique to snowboarding: (1) the shorter length of the board results in a smaller potential lever arm and lower forces during twisting injuries, and (2) a single board decreases the number of edges that can get caught, thereby decreasing the chance of a twisting crash or of the knees rotating in different directions.

Injury Prevention

Although most snowboarders do not wear protective equipment, some snowboarders wear wrist guards similar to those worn by inline skaters. These wrist guards have been shown to be very effective in preventing wrist injuries in in-line skaters.14 Although protective equipment decreases the overall incidence of injury by reducing the force of impact, it may actually place the areas proximate 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 “wrist-guard–top” fractures.15,16 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, six had a shoulder injury and four had radial shaft fractures.4 Novice snowboarders who refuse to wear wrist guards are advised to keep their hands in a “closed-fist” position while snowboarding. This hand position minimizes the temptation of snowboarders to check themselves with an open hand when falling, since falling on a hyperextended wrist increases the risk of injury. Falling backward was the mechanism of injury in almost three quarters of wrist injuries in one series.8 Since beginners are most likely to lose their balance and fall backward, they are most likely to benefit from wearing wrist guards. Some instructors have their beginning students use ski poles to decrease the frequency of falling.

Head Injuries

Another frequent impact area in beginning snowboarders is the back of the head. Fortunately, the force load on the head is usually relatively mild since most of the force is first absorbed by the buttocks, back and upper extremities, and impact usually results only in headache. Many instructors recommend that beginning snowboarders wear a helmet during their initial attempts at the sport to prevent or reduce the severity of head injuries.

The Authors

CRAIG C. YOUNG, M.D., is associate professor of orthopedic surgery and community and family medicine at the Medical College of Wisconsin, Milwaukee. He is also the medical director of sports medicine. Dr. Young received his medical degree from the University of California, San Diego, College of Medicine, and completed a residency in family medicine at the University of California, Los Angeles, College of Medicine. He also completed a fellowship in primary care sports medicine at the Cleveland Clinic Hospital. Dr. Young is a volunteer team physician for the U.S. snowboard team.

MARK W. NIEDFELDT, M.D., is assistant professor of community and family medicine and orthopedic surgery at the Medical College of Wisconsin. He received his medical degree from the Medical College of Wisconsin, where he also completed a residency in family medicine and a fellowship in primary care sports medicine. Dr. Niedfeldt is also a volunteer team physician for the U.S. snowboard team.

Address correspondence to Craig C. Young, M.D., MCW Sports Medicine Center, 9200 W. Wisconsin Ave., Box 26099, Milwaukee, WI 53226-3596. Reprints are not available from the authors.

The authors thank Chris McLaughlin for editorial assistance in the preparation of the manuscript.


Figure 2 provided by Michael Timins, M.D.

REFERENCES

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2. Bladin C, McCrory P. Snowboarding injuries. An overview. Sports Med. 1995;19:358–64.

3. Ganong RB, Heneveld EH, Beranek SR, Fry P. Snowboarding injuries: a report on 415 patients. Physician Sportsmed. 1992;20:114–21.

4. Chow TK, Corbett SW, Farstad DJ. Spectrum of injuries from snowboarding. J Trauma. 1996;41:321–5.

5. Abu-Laban RB. Snowboarding injuries: an analysis and comparison with alpine skiing injuries. Can Med Assoc J. 1991;145:1097–103.

6. Bladin C, Giddings P, Robinson M. Australian snowboard injury data base study. A four-year prospective study. Am J Sports Med. 1993;21:701–4.

7. Warme WJ, Feagin JA Jr, King P, Lambert KL, Cunningham RR. Ski injury statistics, 1982 to 1993, Jackson Hole Ski Resort. Am J Sports Med. 1995;23:597–600.

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9. Prall JA, Winston KR, Brennan R. Severe snowboarding injuries. Injury. 1995;26:539–42.

10. Callé SC, Evans JT. Snowboarding trauma. J Pediatr Surg. 1995;30:791–4.

11. U.S. Consumer Product Safety Commission. NEISS: National Electronic Injury Surveillance System. Washington, D.C.: U.S. Consumer Product Safety Commission, 1997.

12. Nicholas R, Hadley J, Paul C, James P. “Snowboarder's fracture”: fracture of the lateral process of the talus”. J Am Board Fam Pract. 1994;7:130–3.

13. McCrory P, Bladin C. Fractures of the lateral process of the talus: a clinical review. “Snowboarder's ankle. Clin J Sport Med. 1996;6:124–8.

14. Schieber RA, Branche-Dorsey CM, Ryan GW, Rutherford GW Jr, Stevens JA, O'Neil J. Risk factors for injuries from in-line skating and the effectiveness of safety gear. N Engl J Med. 1996;335:1630–5.

15. Cheng SL, Rajaratnam K, Raskin KB, Hu RW, Axel-rod TS. “Splint-top” fracture of the forearm: a description of an in-line skating injury associated with the use of protective wrist splints”. J Trauma. 1995;39:1194–7.

16. Hoflin F, van der Linden W. Boot top fractures. Orthop Clin North Am. 1976;7:205–13.


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