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- Dr Mike Langran |
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WRIST INJURIES
AMONGST SNOWBOARDERS 
Introduction
Wrist fractures
and snowboarding - the statistics
Increased
risk of wrist injury amongst beginner snowboarders
Learning to fall properly
New!
Is there any
evidence that wrist guards reduce the chances of breaking your wrist?
I heard that
wrist guards merely transfer the force further up the arm and lead to injury somewhere else..
What
about wrist fractures under the guards?
The need for
a standard for wrist guards
Some
recommendations for wrist guards
Updated!
Advice sheet
for managing a soft tissue injury of the wrist (or any other body part!)
References
Many studies have now demonstrated that snowboarding has a distinctly different pattern of injuries to alpine skiing - both in terms of the areas of the body that get injured and the types of injury sustained. Compared to skiers, snowboarders are far more likely to sustain an injury to the upper limb and less likely to injure the lower limb. The incidence of fractures (broken bones) is twice as high amongst snowboarders compared to skiers - (approximately 25% of all injuries in boarders are fractures compared to 12.5% in skiers). The reasons for these differences can be explained by the design of the equipment and the way it is used. When travelling on piste, snowboarders ride with both feet fixed firmly to the snowboard in non release bindings. The upper body is used to help generate turning forces on the board. In the event of a loss of balance and a subsequent fall, the instinctive reaction of a snowboarder is to outstretch a hand in order to try and break their fall. This mechanism is known as a 'FOOSH' amongst emergency department staff (standing for Fall Onto an Out Stretched Hand). As a result, the wrist is the single commonest site of injury amongst snowboarders - an area that is rarely injured whilst alpine skiing. It is important though - sustain a broken wrist and you won't be snowboarding for at least 6-8 weeks, if not longer. With more severe breaks, I'm not joking when I say you may never be able to snowboard again....
The severity of the break is determined by several factors - the speed and force of the impact and the exact position of your arm when you fall being three examples. Severe wrist fractures include those where:-
The bones have been pushed out of position (a 'displaced' fracture)
The bones have been pushed through the skin (an 'open' or 'compound' fracture)
The break goes through the line of the wrist joint (a so called 'intra-articular' fracture)
The wrist has been broken into many different fragments (known as a 'comminuted' fracture).
Unfortunately, these can occur in combination as well making the injury all the worse. Get all four of these together in the same injury and you're in deep poop - you can hang your snowboard boots up for a very long time..... Not only this, a severe injury like this may also affect your ability to work, write and function in general. You don't realise how many day to day tasks you need your wrist for until you injure it. So although overall they occur relatively infrequently, and the majority of snowboarders never injure their wrists, you should take the potential for these injuries seriously, especially if you are a beginner - the group at highest risk of all.
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Displacement of the bone fragments is the commonest problem, because of the (often considerable) forces involved. Displaced fractures are easy to recognise because of the so-called 'dinner fork' deformity that results (see pictures above). These injuries require manipulation under anaesthetic (MUA - basically what this entails is that under general or local anaesthesia the bones are pushed and pressed until they go back into the correct position) and/or the insertion of orthopaedic metalwork (this needs a general anaesthetic!) to realign the damaged joint. As I have already mentioned, in the longer term they can lead to the premature development of osteoarthritis with chronic pain and disability.
Wrist fractures and snowboarding - the statistics
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The latest data
from our own Scottish Snow Sports Safety Study and other studies from across the
globe indicate that 25% of all
snowboard injuries affect the
wrist joint - far and away the commonest area to be injured (the shoulder being
the next most common site of injury - 12% of all injuries). 70% of all wrist
injuries were fractures (broken bones). The latest statistics (based on 38500
snowboarding injuries from 1998-2004 treated by the French Medicins de Montagne
group) show that a wrist fracture occurs once every 1135 days snowboarding. For
teenagers, the risk is much higher as a wrist fracture in this group occurs once
every 500 days. So even though its the most common injury
you can still see that the absolute risk is very low. Beginner snowboarders are
also at higher risk, especially those trying snowboarding for the very first time. 43% of the wrist injury group were
boarding for the very first time compared to only 12% of the uninjured control population.
Similarly, experienced boarders were less likely to injure their wrist - by a
factor of 2.5.
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Increased risk of wrist injury amongst beginner snowboarders
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So why are beginner snowboarders at greater risk of wrist injury? And who cares some might argue! My rationale is that one of the first things a novice snowboarder must learn is the ability to maintain a stable stance – not easy, with both feet fixed in non-release bindings to a relatively narrow board. It would be logical to assume that beginner snowboarders are the least likely to have mastered this basic skill. Consequently, they are also more likely to lose balance and fall. When balance is lost, snowboarders (unlike skiers) cannot ‘step out’ a leg in order to recover the lost balance, as both feet are firmly attached to the board. The instinctive protective reaction in the event of the subsequent snowboard fall is to outstretch a hand to break the landing, thus placing the upper limb at risk of injury. I believe that this combination of inherent instability and a tendency to fall onto an outstretched hand, places beginner snowboarders at a higher risk of injury. Injuries to beginners (especially those on their very first day) are important because for snow sports to survive we have to encourage new people to take them up and an injury early on is unlikely to inspire someone to come back. In conclusion, I am firmly of the opinion that wrist guards should be part of the standard kit for a beginner snowboard and am working to try and convince others of this! Given the choice, wrist guards are of far more use (and cheaper!) than a helmet. |
Learning to fall properly
One of the simplest way to try and reduce the risks of injury to the upper limb
in general and the wrist joint in particular is to learn to fall properly. More
and more snowboard instructors are teaching boarders techniques to try and
reduce the risks of upper limb injury. Whilst no study has ever proven (or
indeed can ever prove) that doing this will reduce the risk of injury it does
make sense and is unlikely to do any photographs demonstrating these manoeuvres were kindly
supplied by journalist Daniel Elkan, with the assistance of Mike, instructor
with the SMT Snowboard School in Mayrhofen.
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Falling forwards |
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Falling backwards |
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Is there any evidence that wrist guards reduce the chances of breaking your wrist?
Snowboarding is not the only sport with a high rate of wrist injuries. Roller (in-line) skating is one such sport with a previously reported wrist injury rate of between 25 - 43%. Wrist guards are now worn by up to 33% of all skaters, with 54% of skaters wearing some form of protection (wrist, knee or elbow). It would seem that the wrist injury rate has now decreased amongst in line skaters. So, could wrist guards be the answer for snowboarders? The answer has come from three levels of evidence - laboratory based, epidemiological and randomised case/control studies.
The laboratory-based scientific studies that have been performed in this area are a bit bizarre – basically taking both arms off dead people, fitting one of them with a guard and leaving the other without and then seeing how much force it takes to break each wrist by simulating a fall. Four studies have now shown that, in the wrist with the guard on, one way or another more energy is needed to cause a fracture and that the fractures that do eventually occur are of a reduced severity. So now you know what really happens when you leave your body to medical science…Although these studies provide some important information, it was still argued that these laboratory conditions are unlikely to be exact replicas of the situation on-piste when a snowboarder falls.
The next bit of evidence came from epidemiological studies. The biggest of these was the Colorado Snowboard Injury Survey. Collating information from over 7000 snowboard injuries, this study demonstrated that snowboarders wearing wrist guards were half as likely to injure their wrists as snowboarders not wearing guards. A more convincing piece of evidence still but not quite enough for some. What was really needed was a study where a group of snowboarders were taken and half (taken completely at random) were given guards and half were not. In addition, there must be no major differences between the two groups in terms of age, sex, ability etc. For guards to be truly effective, the number of wrist injuries would have to be significantly lower in the group wearing guards. This is called a randomised controlled trial and provides very strong evidence - one way or the other.
Well, we now have
the benefit of three such trials and they all fortunately reached the
same conclusion - that wearing wrist guards reduces the risks of
sustaining an injury to the wrist. RØnning et al in
Norway took 5029 snowboarders and gave wrist guards to one half of the group.
They demonstrated a significant reduction in wrist injuries in the group wearing
guards. Machold et al did the same in Austria, this time with a group of 721
boarders. There were no wrist injuries in the group wearing guards but 9 serious
wrist injuries in the group not wearing guards. Finally, O'Neill compared two
groups of first-time snowboarders - 551 wearing guards that he had given them
and 1800 who did not wear guards (acting as the control group). Once again, no
wrist injuries were seen in the group wearing guards compared to 40 such
injuries in the group without guards on.
Finally, the most recent paper on the topic is perhaps the most important of
all. Russell, Hagel and colleagues published an overview of all the studies on
wrist guards in snowboarding - what's known in the business as a systematic
review. They conclude "Regardless of study design our analysis shows
consistently that wrist guards significantly reduce the risk of wrist injuries".
They also demonstrate that beginner snowboarders are the group who get the
maximum benefit from wearing wrist guards.
So there you have it. There really is no escaping the significance
of all these trials and studies which really do provide conclusive proof that
wearing guards protects against wrist injuries amongst snowboarders.
So if they work, why don't boarders wear guards?!
Good question! In most countries, less than 10% of all boarders wear guards. There are many reasons for this - uncool, too expensive, etc etc. Snowboarding has always enjoyed a cool image and wearing guards would seem to go against this. Having said that, nothing is more uncool than not being able to snowboard - which is the case if you break your wrist. Virtually without exception, every snowboarder I have treated in the last two years with a wrist fracture has said something along the lines of "...I'll definitely be getting some guards now...." (as they wince in agony until I get the morphine flowing...). What a pisser they had to endure pain and time away from the snow to learn the lesson. I did some research at my ski area asking just under 250 snowboarders who didn't wear guards the reasons why. The answers given (people could answer yes to more than one) are given below.
| Reason for not wearing | Wrist guards |
| (%) | |
| No need | 32.8 |
| Can't get hold of | 16.2 |
| Too expensive | 10.8 |
| Don't like the look | 2.5 |
| Uncomfortable to wear | 27.0 |
| Won't protect against injury | 8.3 |
| Not aware of their existence | 22.1 |
To comment on a couple of these points, guards are now more widely available - see below for some recommendations and details. The final thorny issue which is not so easy is the "no need" argument. I accept that the absolute risk of an injury is very low. But, for the sake of £40 or so, do you really want to take the risk of injuring your wrist and being unable to snowboard, perhaps for a very long time....?
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O.M.G!!! - This is an old chestnut with very little actual basis in fact but it still rears its ugly head far too frequently! In 1995 (quite a few years ago now), Cheng et al reported four cases where skaters (not snowboarders) wearing wrist guards sustained open forearm fractures immediately proximal to the wrist guard. They hypothesised that the guard could transfer the energy of impact from the hand to the mid-forearm level. Their report did not describe the splints each individual was using or if they were fitted properly. Whilst it may sound a cautionary note, very few other case reports have been forthcoming out of the many thousands of skating injuries occurring every year. You also have to remember that inline skating and snowboarding are different sports. Skaters usually fall onto concrete surfaces (consequently with a more abrupt stop involved). I am only aware of two individual cases where snowboarders wearing guards have sustained upper arm fractures, possibly as a result of wearing a guard. This must be compared to the thousands of potential wrist injuries that guards have prevented or reduced in severity. Subsequent biomechanical studies do not support Cheng’s theory and, in fact, demonstrate that one of the protective effects of guards is to dissipate impact energy safely throughout the device without increasing the forces at any one spot. I am very keen to hear from any other boarders who have broken their arms - at the upper level of the guard (i.e. not at the wrist itself) - whilst wearing wrist guards. The more details you can give about the accident, guard type, size etc the better. Please email me. I will get back in touch with you and this information will be used to collate a database so that this issue can continue to be looked at. So far, after four years of asking, only two snowboarders have come forward with such injuries. In neither case could you definitely pin the blame specifically on the wrist guard, it might have happened anyway. Even so, two injuries is not alot compared to the estimated 75,000 wrists that get broken every season as a result of snowboarding. The July 15th 2005 issue of the American Journal of Epidemiology published a piece of research by Hagel and colleagues from Canada. They studied 19 ski areas to determine the protective effect of wrist guards on injury. They found that overall wearing wrist guards reduced the risk of a hand, wrist or forearm injury by 85%. This was a statistically significant finding (i.e. it didn't just happen by chance). They also found a non-significant finding of a possible increased risk of injury to the shoulder or upper arm as a consequence of wearing wrist guards. This result may have occurred by chance. Even if it didn't, it is still the case that a wrist fracture is a more severe injury than an injury to the shoulder or upper arm. At the time of this update, you can read the article text free for yourself by clicking here. Even more recently than this, another paper that I have already mentioned (by Russell, Hagel and colleagues), after looking at all the studies on wrist guards in snowboarding (a so-called systematic review) has concluded that there is no proof of an increase in other arm or shoulder injuries amongst those boarders who wear wrist guards. So I really think we can lay this one to rest once and for all..... until the next time someone emails me or writes it on a snowboard forum! |
OK, so what about wrist fractures under the guards?
Of course, no wrist protection system could ever claim to prevent all wrist injuries from occurring - sometimes the forces are simply too great. In addition, some guards currently on the market have been seen to lead to unusual fractures directly under the guard itself. This has been most recently reported by the Medicins de Montagne group of doctors in the French Alps. At the last ISSS meeting in 2005, they reported on a series of cases where boarders wearing very short and rigid guards (designed originally for in-line skaters) had sustained wrist fractures directly under the guard. The take home message is that not every guard is as good as you might hope it will be in every situation, although I would say that I personally think wearing one of these guards is better than wearing no guard at all.
Thanks to Dr Marc Binet from Avoriaz for the illustrative photos and x-rays below.
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| Examples of nasty fractures of the radius and ulna wrist bones occurring directly underneath a short, rigid wrist guard. | ||
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Since posting these pictures, I have received a lot of emails from boarders who use these guards asking if they are still ok to use. My reply is that personally I would prefer a different system such as Flexmeter or Biomex (see below) but that short guards like those shown above are still likely to be better than no guards. It's your money and choice to decide to buy a different pair of guards. |
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The need for a standard for wrist guards
The real problem at the moment is the lack of a recognised standard for wrist guards - like there is for most other bits of protective equipment such as helmets. Standards ensure that the products can withstand certain forces under testing and give added reassurance that the product (in this case a wrist guard) may actually do what it claims it will! At the moment, its very hard for us all to know which particular wrist guard is actually more likely to protect against injury. This is something that the ISSS recognises as an urgent problem and we have set up a specific working group of experts to look into this. A recent study from the French Alps has provided some evidence to support what l have been suggesting for a couple of years now - namely, that to provide maximum protection a snowboard wrist guard should:
Have a degree of flexibility in the guard material - rigid inserts may be more likely to cause the sort of fracture shown in the pictures above
Should be situated along the back of the wrist, not on the palm side and
The guard should extend some distance up the forearm and not be of the short stubby type used by inline skaters.
At the bottom of this page, I make some suggestions for guards currently on the market. My personal preferences would be the Flexmeter or the Biomex system although I realise they are not easy to get hold of in some countries - I have added some new contact details for the Flexmeter which should help this problem.
In summary then, I think you can see that I (and my colleagues around the world) are very pro wrist guards! But we have our reasons - not the least of which is that we hate seeing so many young snowboarders with such painful injuries. I particularly hate seeing beginners injured because for snow sports to survive we have to encourage new people to take them up and an injury early on is unlikely to inspire someone to come back. I personally think that guards should be a routine part of a beginner snowboard hire package. I am also working to make information available at each ski area to make snowboarders aware of wrist guards and what they can do. It will take time, but it has happened before when other equipment advances proved beneficial. Once people realise that they can reduce the risk of injury, hopefully we will continue to see more guards being worn on the slopes and less “dinner fork” wrists in our patrol and casualty rooms. Time will tell…
Some recommendations for wrist guards
Flexmeter
Developed by ISSS member Dr Marc Binet from Avoriaz in France, the Flexmeter has a wide range of products including stand alone guards and integrated glove/guard systems. It is based on the premise that most wrist fractures result from hyperextension (the wrist getting forced backwards). The Flexmeter specifically prevents this happening using flexible Dupont materials. The very latest data for them is based on a 3 year case-control study at 3 ski areas in France where two groups of beginners were studied - one group wearing Flexmeters and the others wearing no guards. 2% of the group with guards on sustained a wrist injury compared to 11% in the group with no guards (this is a statistically significant result). Importantly, in the group wearing Flexmeters, there were no injuries seen above the guard on the arm. Flexmeter studies continue to be performed and hopefully will lead to more information in due course.
To find out more, visit the
Flexmeter website.
In the UK, you can buy Flexmeters online from
Alpsgear. Current prices are £29.99 for
the
single wrist guards,
£36.99 for the
double system and £53.99 - £63.98 for the
Flexmeter gloves
(depending on size).
To buy Flexmeters in other countries, follow these links:
USA -
www.flexmeters.com
France -
http://www.skimeter.com/fr/flex/fr_flexmeter.php
Germany - www.flexmeter.de
Netherlands - www.flexmeter.nl (for the
English version, click here)
Biomex
The Biomex Protection system has been developed in St Moritz by another respected ISSS member, Dr Georg Ahlbaumer - himself a keen snowboarder. Its design has been integrated into the Level range of gloves with such products as the Half Pipe GTX Biomex gloves and the Fly GTX gloves. You can visit the Biomex Protection website here.
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Advice sheet for managing a soft tissue injury of the wrist
Click here for our latest advice sheet on managing soft tissue injuries correctly
References
1. Schieber RA et al. In-line skating injuries. Epidemiology and recommendations
for prevention. Sports Med. 1995 June; 19(6): 427-32
2. Schieber RA et al. Risk factors for injuries from in-line skating and the
effectiveness of safety gear. NEJM. 1996 Nov 28; 335(22): 1630-5
3. Warda L et al. An observational study of protective equipment use among
in-line skaters. Inj Prev 1998 4(3): 198-202
4. Lewis LM et al Do wrist guards protect against fractures? Ann Emerg. Med 1997
29(6):766-769
5. Greenwald RM et al. Dynamic impact response of human cadaveric forearms using
a wrist brace. Am J Sports Med 1998 26(6):825-30
6. Staebler MP et al. The effect of wrist guards on bone strain in the distal
forearm. Am J Sports Med 1999 27(4): 500-506
7. Cheng SL et al. “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(6): 1194-1197
8. Idzikowski JR, Janes PC, Abbott PJ. Upper extremity snowboarding injuries. Ten-year results from the Colorado Snowboard Injury Survey. Am J Sports Med. 28(6): 825-832, 2001
9. Rønning R, Rønning I, Gerner T et al. The efficacy of wrist in preventing snowboarding injuries. Am J Sports Med. 29(5): 581-585, 2001
10. Machold W, Kwasny O, Eisenhardt P et al. Reduction of severe wrist injuries in snowboarding by an optimized wrist protection device: A prospective randomized trial. J Trauma. 52(3): 517-520, 2001
11. Sasaki K, Takagi M, Ida H et al. Severity of upper limb injuries in snowboarding. Arch Orthop Trauma Surg 1999; 119: 292-295
12. O'Neill DF. Wrist injuries in guarded versus unguarded first time snowboarders. Clin Orthop. 2003; 1(409): 91-95
13. Hagel BE et al. The effect of wrist guard use on upper-extremity injuries in snowboarders. Am J Epidemiology. 2005; 162(2): 149-156
14. Russell, K et al. The effect of wrist guards on wrist and arm injuries amongst snowboarders: A systematic review. Clin J Sports Med. 2007; 17:145-150
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© Copyright Dr Mike Langran 1999-2008 All international
rights reserved. No part of this web page may be reproduced in any form, or
by any electronic, mechanical or other means, without permission in writing
from Dr Langran. |
At present the
evidence is that at the most around 10% of all snowboarders world wide currently
wear wrist guards - in Scotland the figure is less than this, but I'm working on
it. Watch the video clip on the right for an example of a typical snowboard scenario
resulting in a wrist fracture .....turn up the sound for the full effect!
