Skier Knee Injuries – Part 3: If you are injured.

Despite our best prevention efforts discussed in Part 1 and Part 2 of this series, sometimes injury is unavailable. We know if a skier is injured, more than 40% of the time it is a knee that is involved. You injure your knee on the slopes – now what?

Situation and Safety. 

Regain your composure and consider your surroundings. It you are in steep hard pack terrain, it may be best to stay where you are rather than risk an uncontrolled slide. Conversely, if you are in a blind landing area below a roller or park feature, you may need to move quickly (crawl even) out of the danger zone before someone comes along to injure you even more.  

If it is your ski partner that is injured, placing their ski tails in the snow to form an “X” uphill can warn others there is a hazard ahead. 

Skis or Patrol Toboggan? 

Obviously, if you are in significant pain, bleeding, have other injuries, you will be riding the toboggan. If you injury is less severe, you will likely hope to keep your pride intact and ski out on your own. Trying to ski on an injured knee risks making a bad situation worse, and is generally not recommended. If you are determined to press on, here are some considerations. 

Gathering any “yard sale” of gear and then standing up, do you feel any spikes of pain or weird shifting inside the knee? These could suggest movement of fracture fragments or ligament rupture, neither are things you want to ski with. Once on your feet, shift your weight onto the injured side. If the knee gives way or has increasing pain, get some help. If the knee is still feeling ok, flex and extend it a few times. Next, turn and lean to each side to simulate some functional challenges. Only if all this goes very well is it reasonable to even consider trying to ski. Lastly, before you try to flex it once again and feel for swelling. Significant fluid in the knee will inhibit the quad muscles from firing and could increase risk of additional injury.

First Aid.

Wrap the knee comfortably snug with a 6” elastic bandage (ACE is one brand of this type). If the wrap is uncomfortable or the leg is turning colors below the wrap, loosen it. Elevate the leg, ideally above the heart, to reduce swelling. Apply a cold pack for 20 minutes each hour. Avoid aspirin, ibuprofen, and naproxen initially; they could increase bleeding into the tissues/joint. Alcohol can also increase bleeding and swelling, so try to avoid the temptation to drown your sorrow. Acetaminophen is a reasonable choice if you have some pain. 

If weight bearing is at all painful, stay off the knee until you have been evaluated by a medical professional. Have a friend help you get around until you can get some crutches. 

Is emergent evaluation needed?

It is a good idea to get significant injuries evaluated as soon as possible. This could involve dangerous driving on snowy roads or great expense, so trying to risk stratify your situation may be helpful.

Excellent Canadian research has shown that an age >55, a specifically tender kneecap or fibula head, inability to flex the knee fully or limp around are associated with a likelihood of a fracture seen on xray. This research didn’t involve children under 18. Since children can have open growth plates and incomplete bone strength, be more conservative with your decision making as you would with folks that meet the criteria described by the Canadians.

Severe pain, numbness, tingling, a pale or cold foot, dislocation of the knee (even briefly), a kneecap that remains out of place, other worrisome injuries are all compelling reasons to get to a hospital as soon as possible. A break in the skin associated with a possible fracture could mean the fracture is open – this injury is treated with emergency surgery. The place to be is the ER not you favorite apres spot. If you are feeling things moving around inside your leg while using crutches, better immobilization is likely needed to keep things from getting worse. 

Anyone who is intoxicated it not to be trusted. Experience tell us that someone who is intoxicated with alcohol or other substances can have severe injuries and not be aware of it. Use extreme caution with someone who is intoxicated and possibly injured. 

Speciality Evaluation.

Regardless if you are seen on the day of your injury, it is critically important to have a specialist in sports medicine or orthopedic surgery evaluate your knee in the days to week after your injury. Why is this?

Many patients with knee injuries are placed in a rigid knee immobilizer after been seen in an ER or other acute care setting. While sometimes helpful for protection immediately after the injury, this type of brace will lead to stiffness, weakness and delayed recovery if left on for more than a few days. A specialist will prescribe the optimal immobilization to protect the injury while minimizing stiffness and muscle weakness. An appropriate home exercise program is also useful, even while waiting for scans, surgical consultation or a formal Physical Therapy evaluation. 

A specialist will provide an accurate diagnosis or guide you to the scans or other tests needed to get one. Multiple research studies have shown that even in classic cases, diagnosis of major knee ligament injury could be delayed by weeks, months or even years! Extended delay to appropriate management of these injuries has been shown to cause further damage within the knee. 

Most importantly a specialist can help you map out the path to your optimal recovery. 

Thanks for taking the time to read these posts. I hope you have a safe season, but if you have an injury, please keep durangosportsmedicine.com in mind! 

References 

British Journal of Sports Medicine Dec 2000, 34 (6) 467; Injuries of the sporting knee.

Ann R Coll Surg Engl. 2013 Apr;95(3):188-91. Can the Ottawa and Pittsburgh rules reduce requests for radiography in patients referred to acute knee clinics?

Knee Surg Sports Traumatol Arthrosc. 2015 Apr;23(4):1201-5. Prevalence and consequences of delayed diagnosis of anterior cruciate ligament ruptures.

Injury. 2013 Dec;44(12):1862-5. Anterior cruciate ligament rupture: Delay to diagnosis.

Environ Health. 2016 Nov 8;15(1):104. Adverse weather conditions and fatal motor vehicle crashes in the United States, 1994-2012

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