Sports Medicine Book

Downhill

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Downhill Skiing Related Knee Injury

Aka: Downhill Skiing Related Knee Injury, Knee Injury in Downhill Skiing
  1. See Also
    1. Downhill Skiing
    2. Nordic Skiing
  2. Epidemiology
    1. Knee Injuries account for one third of adult ski injuries
  3. Causes: Common ski injuries
    1. Medial Collateral Ligament Tear or MCL (25%)
      1. Valgus stress at knee while skier falls
        1. Beginner ski position: Internal rotation and valgus or wedge knee position
    2. Anterior Cruciate Ligament Tear or ACL (25%)
      1. Phantom Foot Injury (most common mechanism)
        1. Skier loses balance, Transferring weight posteriorly
        2. Knee flexed and internally rotated
      2. Valgus-External Rotation
        1. Skier falls forward and ski tip catches on inner edge
        2. Leg valgus and externally rotated
        3. Associated with MCL Injury
      3. Boot-Induced Anterior Drawer
        1. Skier lands after jump, Transferring weight posteriorly and ski tails striking first
    3. Meniscal tear
      1. Commonly accompanies ACL Tears and MCL tears
  4. Causes: Other associated injuries
    1. Segond Fracture
      1. Suggests concurrent ACL Tear, and is frequently associated with Medial Meniscus Tears
      2. Occurs with significant varus stress and tibial internal rotation
    2. Reverse Segond Fracture
      1. Suggests concurrent PCL Tear, MCL tear or Medial Meniscus Tear
      2. Typically occurs with valgus and external rotation stress
    3. Tibial Spine Avulsion (rare)
      1. Bone avulsion at ACL or PCL attachment
      2. Requires knee immobilization and surgical Consultation
    4. Tibial Plateau Fracture
      1. Initial CT may be required for diagnosis (outpatient MRI for associated Ligamentous Injury)
      2. Requires knee immobilization and surgical Consultation
  5. Causes: Uncommon ski injuries
    1. Lateral Collateral Ligament Tear (LCL Tear)
    2. Posterior Cruciate Ligament Tear (PCL Tear)
    3. Knee Dislocation
  6. Imaging
    1. AP and Lateral XRay
      1. Indicated in nearly all ski related knee injuries
      2. Consider additional views (e.g. Tunnel View, Sunrise View)
    2. CT Knee
      1. Indicated for suspected Tibial Plateau Fracture
    3. MRI Knee
      1. Outpatient follow-up if significant Ligamentous Injury or Meniscal Injury suspected
  7. Management
    1. Crutch use as needed
    2. Perform Exercises three times daily
      1. Knee range of motion Exercises
      2. Quadriceps and Hamstring strengthening Exercises (patient sitting or lying supine)
        1. Quad Sets
          1. Place towel roll beneath the knee and tighten anterior quad muscle several times
        2. Heel Slide
          1. Flex knee and slide heel toward buttock, then extend knee, sliding heel back to start
    3. Knee Immobilizer indications (avoid otherwise)
      1. Patellar Fracture or dislocation
      2. Patellar Tendon Rupture
      3. Knee Dislocation
      4. Displaced Tibial Plateau Fracture
      5. Tibial Spine Avulsion Fracture
  8. References
    1. Dolbec (2019) Crit Dec Emerg Med 33(1): 17-25

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