The Mountain Echo

Both skiers and snowboarders are quite susceptible to shoulder injuries. They account for about 17% of skiing injuries and about 33% of injuries in snowboarders. The shoulder is made up of the collar bone (clavicle), the shoulder blade (scapula), and the arm bone (humerus). Everything is held in place by various ligaments and muscle groups. Dr Alan Griffiths of the English Medical Centre outlines the various patterns of injury…

A direct fall onto the shoulder may cause the collar bone to fracture. These clavicular fractures usually occur in the shaft of the bone. If the shape of the bone is not too deformed the treatment involves immobilisation in a brace. However, sometimes the fracture is displaced or angulated, when an operation to insert a metal plate may be required. Fractures towards the outer end of the clavicle are more serious and may not heal up properly without an operation.

The joint where the collar bone joins the shoulder blade is called the acromio-clavicular (AC) joint. There are four ligaments holding the joint in place, and the clavicle can become separated from the scapula depending on how badly the ligaments are damaged. In minor sprains, the ligaments are damaged but not stretched. With more force the ligaments can stretch slightly. These types of sprain are treated with a simple sling to support the weight of the arm. In severe sprains the ligaments can snap completely. This requires a special AC brace to push the collar bone back down or even an operation to fix it back in place.

The ball and socket joint of the shoulder is called the gleno-humeral joint. The ball-shaped part of the humerus is called the humeral head. The socket of the scapula is quite shallow, which allows a good range of movement, but makes it prone to dislocations. The humerus is held in place by ligaments and a group of muscles known as the rotator cuff. Rotator cuff sprains occur when the muscle fibres are stretched beyond breaking point. Sometimes a piece of bone can be ripped away from the head of the humerus where the muscle attach. This is known as an avulsion fracture. Treatment of rotator cuff sprains and minor avulsion fractures involves immobilising the shoulder with a sling or shoulder brace for a couple of weeks. Displaced avulsion fractures require an operation to fix them back into place.

If there is a direct blow to the shoulder or if the arm is wrenched suddenly, the head of the humerus dislocates out of the socket. Usually the humeral head comes to lie in front of and below the joint, but rarely it can dislocate backwards. Treatment involves manipulating the humeral head back into the socket using various techniques. The technique that you may have seen in the film ‘Lethal Weapon’ is not to be recommended ! An injection of painkiller and/or muscle relaxant is often required. X-rays are almost always necessary before and after the dislocation has been treated to make sure there is not an associated avulsion fracture.

Finally the neck of the humerus can break, at the point where the shaft of the bone joins the humeral head. Despite quite severe angulation these fractures usually heal up nicely with a simple sling for about three weeks. An operation is only required in really bad cases.

Spring is here and everyone wants to get a tan and do it cheaply. When you live in Val, the easiest way to do this is go up the hill “just for two hours” with no sun cream on and leather up that face!

Believe it or not, the sun is strong enough to burn, even in March. The Ozone layer is not what it used to be and for some reason, people are still not using sun cream. The Medical Centre has already seen several cases of sunburn and April’s about to bring a whole load more….

So how do we tan? We have cells in our skins called melanocytes, which secrete melanin when exposed to ultraviolet radiation. Melanin protects the skin from exposure and is brown in colour. The darker your skin, the more melanin you have. However, even if you are dark or black skinned, you are still at risk (albeit a reduced risk) of cancer. Every time you burn, you are damaging your skin at the genetic level i.e. you are damaging your DNA. Usually the body’s immune system comes round mopping up these damaged cells. When this mechanism fails, cells multiply out of control – this is cancer. The skin cancer you hear about commonly is melanoma.The incidence of melanoma has more than tripled in the white population during the last 20 years, and melanoma is currently the sixth most common cancer (4% of cancers). However, it’s responsible for more than 74% of skin cancer deaths. Yes, it is nasty.

What are the signs of cancer?
If you have a mole that has been present for years but suddenly changes then look out for the following warning signs: Changes in size and colour, border irregularity, asymmetry, itching and bleeding. Any new mole that appears and fits the above criteria should also be checked out.What are the risk factors? Skin that is fair, with fair hair and blue eyes. Melanoma is also associated with the number of moles present. Ultimately though, degree of intensity and length of exposure to sunlight is the most important risk factor. Sun beds are particularly risky.

Generally speaking there are two types of sun worshipper: The type that sits in the middle of the half pipe for maximum reflection, with factor 4 oil on and a pair of Speedos; and the type who works on the goggle tan putting some time in on the balcony. You know who you are! At the end of the season you will have a tan, even if you use factor 40. Take your time over it, use a high factor and avoid looking five years older and acquiring considerable damage along the way.

Ski resorts are expensive, but if you head to Casino, you can pick up some sun cream for a little less than at the pharmacy. If you have visitors, ask them to bring out some sun cream, preferably at least factor 30. Waterproof stuff is ideal as you’ll sweat when skiing.

Remember to reapply regularly and note that cream only starts working thirty minutes after you apply it. Classically, people forget to apply cream to the neck and ears which become exposed at lunchtime. Acquaint yourself with the “bad mole” criteria, and see your doctor if you are worried, but prevention is definitely better than cure!

Signs of a suspected melanoma are: 1/it increased in size; 2/ its borders are irregular; 3/ it became asymmetrical; 4/ colour has changed; 5/ it became itchy and began to bleed.

Dr Alan Griffiths from the English Medical Centre gives some rules of thumb…

You might think that injuries to the thumb are not that significant. However, the thumb allows you to grip with your hand and grasp objects with a pincer movement. Unless you’ve injured your thumb you’ve probably never given it a second thought. If you have injured your thumb you’ll know how disabling it can be.

Injuries to the thumb make up about 10% of all skiing injuries, compared to about 3% of snowboarding injuries. This difference is due to the fact that skiers use poles, which increase the liklihood of levering the thumb during a fall. Sometimes it is the pole strap which causes the damage. Opinions differ on how you should hold your poles. Some people advocate using the straps so that you don’t lose your oles,
but consider how important this is compared to increasing your risk of what could be a serious thumb injury.

Before I get on to specific injuries, a quick anatomy lesson. The thumb is made up of two bones, the distal phalanx and proximal phalanx. At the base of the thumb the proximal phalanx meets the first metacarpal bone at the metacarpo-phalangeal joint (MCPJ). Any of these bones can be fractured either from a direct impact or from a twisting mechanism. The treatment usually requires immobilisation in a cast, but occasionally an operation is required to insert metalwork, especially if the fracture is unstable. The joints between the bones can also dislocate, but this is uncommon and is usually easy to correct.

The bones are all held in place by collateral ligaments on either side. If a ligament is stretched or even snapped it generally heals up without any complications. However, the ligament at the MCPJ on the side nearest the index finger is the one most commonly injured. It is called the ulnar collateral ligament (UCL), and it is unusual because unlike the other thumb ligaments it doesn’t always heal up nicely if it ruptures. The reason for this is that the ends of the ligament fold back and cannot heal naturally. An urgent operation is then required to fix the UCL before it becomes beyond repair. Failure to repair a ruptured UCL can lead to arthritis in the joint, causing permanent pain and stiffness in a very important joint. Injuries to the UCL are known as ‘skier’s thumb’.

In some cases, the ligament is stronger than the bone it is attached to. As the thumb gets wrenched, the ligament pulls off a small fragment of bone, usually the base of the proximal phalanx. This is known as an ‘avulsion fracture’. If the fragment is displaced it will require an operation to insert a metal pin to put it back, even though the fragment is tiny. This is important because if there is a jagged edge to the joint, it will never work properly again and thumb movements will be permanently restricted.

So what should you do if you get skier’s thumb. First of all try not to move it. If you stretch an already damaged ligament you could convert a simple sprain (that would have healed up with a thumb splint) into a complete rupture that requires an operation. Similarly, you could convert an undisplaced avulsion fracture (that would heal up in a cast) to a displaced fracture that requires surgery.

The next thing you should do is get an X-ray. Patients often state that there cannot be a fracture because they can still move the thumb. This is so not true. An X-ray to exclude a fracture is the first thing the doctor will do if there is pain around the UCL. If there is no fracture the doctor will then assess how loose the ligament is. This is a specialised technique and is not something you should try yourself. If the ligament appears to have snapped completely you will be referred to an orthopaedic surgeon. If there is any doubt an ultrasound scan or MRI may be necessary.

People often do not realise the importance of thumb injuries, and it is not uncommon for them to leave it until the next day before seeing the doctor. They are then amazed when they require an X-ray and an emergency referral to hospital for what they thought was an insignificant injury. Don’t fall into the same trap!

This X-ray shows an avulsion fracture caused by the UCL at the base of the proximal phalanx of the thumb. Although the fragment is tiny and only slightly out of place, this fracture required pinning.