Skiing accident abroad. What to do?

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You break down on a slope in Italy or Austria. Return to Poland or rely on the insurer and doctors who will be provided by the resort? – Haste is a bad advisor. While in the case of most fractures, “fast” X-ray examination may be enough to determine the type of injury and the method of surgical treatment, in the case of complicated fractures it is often necessary to perform, for example, computed tomography, MRI, and in the case of surgery, detailed discussion of all available options – says Dr. Jarosław Feluś, an orthopedist.

1. If we are able to get up on our own after a fall, we are often tempted to continue riding, even if the pain is excruciating. – Often, even serious damage to the joint begins to cause pain after several dozen minutes or even several hours, when the tissues swell and the joint exudates (hematoma). Continuing the ride, although it may seem at first that nothing serious happened, may lead to deepening of the damage – this type of behavior should be strongly discouraged – says Dr. Jarosław Feluś, an orthopedist from Krakow
2. There are injuries that really should not be delayed, where the results are decided by the hours. However, the thesis that postponing the operation by a few days or even weeks will worsen the prognosis in the majority of patients cannot be clearly defended, says Dr. Feluś. Often the procedure is performed only after the patient has completed rehabilitation to help regain full range of motion
3. While in the case of most fractures, “fast” X-ray examination may be enough to determine the type of injury and the method of surgical treatment, in the case of complicated fractures it is often necessary to perform, for example, computed tomography, MRI, and in the case of surgery, detailed discussion of all available options. And we will not do it quickly, abroad, the more that most of us, even if we know English well, are probably not the “medical” one

Holidays, winter, white madness. Full fun. We are on the slope, we fall, there is a crunch in the knee and the pain that the proverbial “stars in the eyes”. What to do?

Dr Jarosław Feluś, orthopedist: this is quite a typical situation. After the first ailments have subsided, we must somehow get down. There are several possibilities here. If it hurts badly – call the appropriate services for transport. Quite often, however, the ailments disappear, allowing you to go down on your own, or even continue driving. This, however, should be strongly advised against. Often, even serious damage to the joint begins to cause pain after several, several dozen minutes or even several hours, in the evening, when the tissues swell and the joint exudates (hematoma). So, continuing to drive after this type of injury, although it may initially seem that nothing serious happened, may lead to the deterioration of the damage – this type of behavior should be strongly discouraged. You should descend or carefully descend and finish this day’s adventure – wait until the next morning. If the discomfort increases, pain restricts the movement in the joint, and the knee becomes stiff and “tight inside” during movements, this usually indicates the seriousness of the injury (after all, blood spills into the joint from damaged structures – ligaments, menisci, or intra-articular fractures).

And what’s next? In Poland, there is usually no problem, we go home and make an appointment with a recommended orthopedist who treated, and often operated on, someone we know, or has good opinions on industry websites. But what if we are in Austria, Italy or France – the most common destinations for our ski trips?

JF: We are usually insured, and in most alpine ski resorts, there are trauma centers, where there is a possibility of obtaining professional first aid: initial diagnosis (medical examination, X-ray examination to exclude fractures), often punctures (joint puncture and evacuation of hematoma), immobilization of the injured knee (stabilizer, i.e. an orthosis or a plaster cast). It is worth taking advantage of this opportunity. It is also worth remembering about those activities that we can implement on our own in the early post-traumatic stage, namely protection of the damaged joint, relief of the limb, placing a cold compress on the knee (lowering the temperature constricts the blood vessels, reducing joint exudate, and reduces the swelling of periarticular tissues. ), a gentle pressure dressing, also covering the shin (prevention of clots in the veins of the calf), lifting the limb. Mnemonic – easy to remember, the English word PRICE (Protection, Rest, Ice, Compression, Elevation). All these activities in the early post-traumatic period will minimize the body’s response to the trauma as much as possible.

In many cases, we also receive offers to undergo immediate surgery. Is it worth it? After all, these are clinics in ski resorts, the doctors working there certainly have appropriate experience, we are insured, and we do not have to wait in the queue for a possible treatment for several or several months. So I guess it’s worth …

JF: This is a very difficult question that cannot be answered unequivocally. The above arguments are certainly important and worth considering. Nevertheless, as often in life – haste is a bad adviser.

Firstly, while in the case of most fractures, the X-ray examination, usually offered as the only “fast” diagnostics in such centers, may be sufficient to qualify and determine the type of surgical treatment, while in the case of complex, multi-fragmented fractures, especially those related to the surface In order to perform the optimal for the patient, extended diagnostics is often needed (e.g. computed tomography). On the other hand, in the case of suspected damage to the ligamentous apparatus, menisci and articular cartilage, the routine preoperative diagnostics, except in exceptional cases, is an examination using magnetic resonance imaging (i.e. MRI). In the past, arthroscopy of the knee (joint coloscopy) was treated as a quick diagnostic method.

And today?

JF: Such a procedure was unequivocally abandoned. Having operated for over a decade several dozen of this type of patients every year, I cannot imagine performing the procedure without making an accurate diagnosis, without discussing all available treatment options with the patient and without determining the optimal option for a specific patient. For example, the anterior cruciate ligament, the most frequently damaged structure in the knee, can be reconstructed in several ways, using various tissues as a graft. In selected cases, we can reattach our own detached ligament to the bone attachment site (without the need to reconstruct it from other structures). Finally, we can strengthen our own damaged ligament with synthetic material to support its healing. In some patients, the reconstructor itself (depending on the severity of instability, but also in relation to the expected level of activity after the injury) can be supported by reconstructing the second ligament (anterolateral) at the same time to protect the anterior cruciate ligament graft against excessive overload. This type of double reconstruction is a relatively new concept, but very promising in the context of clinical results and used more and more widely, especially among athletes.

You can get lost in this number of possibilities …

JF: In this particular example, you can see how many variables affect our final decision and that what may be good or sufficient for one patient will not be optimal for another. In addition, we confront our information with the expectations of the patient, who is more and more aware and educated, but also has specific plans for his future and the goals he wants to achieve by undergoing surgical treatment. Therefore, it is difficult for me to imagine establishing a tactic of conduct without the aforementioned detailed diagnostics and discussing with the patient in detail the benefits and effects of each of the available options. And let’s add to it similar considerations regarding the supply of meniscus injuries (they often accompany injuries of the cruciate ligament). In this matter, a dozen or so years ago the matter seemed simple – the damaged meniscus was partially or completely removed. Now, thanks to the advancement of knowledge, we know that the removal of the meniscus during the reconstruction of the cruciate ligament is a “kiss of death” for the knee, in which degenerative changes will develop within a short time. Therefore, at present, it is imperative to sew it together with the restoration of continuity, and thus – function. However, this changes the postoperative procedure, most often extending the period of recovery, which may also be in contradiction with the patient’s current plans. Similar considerations also apply to planning the method of repairing the accompanying damage to the articular cartilage or other ligaments.

Putting it right – plans are plans, but treatment can’t wait, right? So if there is an opportunity for a quick treatment….

JF: Again a provocative thesis. Of course, you can list such injuries, the treatment of which really should not be delayed, where the results are decided by hours. However, the thesis that postponing the operation by a few days, or even weeks, will worsen the prognosis of the effect of our actions in the majority of patients. Please note that the healing process may, and should, begin much earlier, and the surgery itself is its next stage. In the preoperative period, the patient works with a physiotherapist. This is a very important part of the therapeutic process. It allows you to mute the symptoms of inflammation accompanying the injury, regain full range of motion (as long as there are no morphological obstacles to this, such as a dislocated meniscus or ligament fragments blocking extension), rebuild the muscles around the joint and generally restore the proper functioning of the joint to some extent.

And as for the patient’s comfort?

JF: It also allows to educate the patient about the postoperative period, define goals and plan for further actions. Finally, it allows the patient (which may seem a truism, but believe me is very important) to establish contact with the therapist and break the barrier of embarrassment. The process of physical therapy is very intimate – you work physically, often sweating and groaning in pain in close proximity and physical contact with another person. It takes a part of oneself to be exposed and the rejection of natural, socially conditioned embarrassment and shame. In the practice of my team, patients who start working with a physiotherapist before surgery are happy to return to the same person during the procedure and the cooperation is usually exemplary. And in reconstructive surgery there is no success without the synchronous and complementary work of the entire team (surgeon – patient – physiotherapist).

And finally, the last, practical issue – the patient, usually a professionally active person, or during the education process, is surprised by a completely unplanned situation such as an injury. Usually, the entire schedule of tasks and events is prepared for the period after the holiday. And these few or several days of delay in the planned procedure allows you to overcome the mess resulting from the forced extended (sometimes by several weeks) absenteeism.

So making a decision in affect right after the injury may be a bad idea. Although it seemed that treatment abroad was a guarantee of the best care.

It is clear that the decision on immediate surgery in the Austrian or Italian “clinic on the slope” should be made with great care, after analyzing all the pros and cons.

Additionally, we should remember that in this type of centers, treatment and contact with the patient ends at the moment of discharge. The patient does not return to control, does not report his feelings and health problems. So it sometimes happens (I am far from saying that this is the rule, but I have seen such a situation with my own eyes many times, leading patients after their return to the country) that the methods used, or the implants used to repair damaged structures, are not, to say the least, , appropriately newest and highest quality. This fact should also be taken into account when making some treatment decisions.

So what would you recommend the doctor to a good friend of yours calling for advice to his cousin who had a knee sprained a few hours ago while skiing in Cortina d’Ampezzo? It’s swollen and it hurts when it starts moving.

JF: I’d recommend elevating the limb, wrapping the knee with a cold compress (cartridges for the refrigerator, towel-wrapped food stuffs), and oral anti-inflammatory / analgesic medications. The next morning, I would recommend going to the nearest trauma center for an orthopedic examination, joint puncture (evacuation of the hematoma), basic radiological diagnostics, immobilization of the limb in a stabilizer (in these centers, such stabilizers are often given to patients) or a cast (depending on the recommendations) medicines) and obtaining a prescription for anticoagulants. This would allow a relatively comfortable return to the country. After my return, I would recommend an urgent MRI examination and an orthopedic consultation with the result to determine further treatment.

Is this type of joint damage the end of adventures on the slopes in the future?

JF: Usually not, but it depends on many factors. Potentially and in theory, we are able to successfully repair or reconstruct most, or virtually all, damage resulting from a knee joint injury. The vast majority of patients are able to return to the level of pre-injury activity after the treatment and reconstruction of the repaired structures is completed. However, not all of them – in some functions of the pond it is not possible to restore it to such an extent that it would allow the return to the sport, which is risky for the knee, such as skiing. Others do not return to their previous level of activity for fear of being injured again and undergoing prolonged and arduous treatment again. Finally, it should be remembered that returning to skiing after reconstructive treatment is associated with an increased risk of recurrence and / or injury to the opposite side. Both of these situations can permanently prevent you from continuing to practice white madness.

So what to do to minimize the risk of injury? Is it even possible?

JF: Appropriate physical preparation for skiing not only increases the pleasure of skiing, but also increases our safety level. Many people, going on a winter vacation, do not realize the need to work on their condition, muscle strength and body balance. Such ignorance or neglecting the previous motor preparation may sometimes carry a risk of injuries to the locomotor system. This mainly applies to people who lead a sedentary lifestyle, avoiding physical activity throughout the year. In such a situation, it is recommended to prepare for skiing at least 6 weeks before the planned ski holiday, with the intensity adapted to your motor abilities and the level of physical activity.

Can we prepare ourselves or rather use a trainer?

It is worth going to a physiotherapist who will tell you what exercises to do and with what intensity to properly prepare for the ski season. It is especially important to strengthen the lower body, back muscles, gluteal muscles and the muscles of the lower limbs. We should not forget about proximal stabilization exercises, i.e. abdominal muscles exercises, which are the basis for maintaining the correct standing position and, above all, the basis for maintaining balance during dynamic activities. This will avoid many injuries on the slope. Systematic training at least 3 times a week for 30 minutes is the absolute minimum to minimize the risk of injury during winter madness. Motor preparation will allow us not only to enjoy the ride, but also ensure good control of the track and the possibility of descending without constant stops due to exhaustion.

Fortunately, more and more people realize and appreciate the importance of proper motor preparation for the season. Due to the growing interest and demand, the team of physiotherapists with whom it cooperates has prepared a special training program dedicated to skiers. We hope that it will contribute, at least to a small extent, to the reduction of trauma – we will see soon, we have an appointment with patients for post-season telephone contact,

Another element immediately before starting the ride is warming up the whole body – preparing muscles and joints for dynamic work. It is worth spending a few – several minutes to warm up. Thanks to this, we will avoid stiffness in the joints.

What about driving after a long break?

It is also worth remembering to adjust the difficulty of the route to our skills. Deficiencies in the motor preparation and incorrect skiing technique combined with a demanding ski slope constitute a straight path to injury. When going skiing, it is worth taking a break after 2-3 hours on the first day of skiing to avoid excessive muscle fatigue and muscle soreness. Gradually increasing the effort while skiing will allow us to make the most of our time and reduce the risk of injury.

And finally, remember – the last exit is only the last one on a given day, not the last one in your life. It doesn’t have to be epic and memorable. We are already tired, distracted, often with our thoughts in the car, hotel or home. Let us descend carefully and fight the temptation in advance to prove to ourselves and to the world that we are better than Pirmin Zurbriggen, Marc Girardelli and Lindsey Vonn together. Otherwise, it may indeed happen that we will remember him for a long time.