The Mountain Echo

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.

This week I wanted to talk about chest injuries and the problems associated with them. How do you know if you have really done yourself a serious injury? Let’s face it, they all hurt a lot, so what can be done to prevent these injuries?

What exactly are we talking about? When you fall on to your chest, or your back, your ribs stop you from damaging your internal organs i.e. your heart, lungs and to a certain extent, your liver and spleen. The classic injury is a fall on to the snow, ‘winding’ the victim and leaving significant pain on movement and inspiration thereafter. This can often happen if you land on an arm that is tucked into the chest (usually in snowboarders), which can lead to a good going rib fracture. If you’re really unlucky, to add insult to injury, your board or skis may come up behind you and collide with your head: The classic Scorpion.

Back to chest injuries, the spectrum of damage is limitless. We see these injuries most days. The majority have suffered a tear in the muscles between the ribs. These are called the intercostal muscles and help you to breathe in. Unfortunately you can’t take a rest from breathing so this hurts a lot, especially as they have a rich nerve supply. Next up is the broken rib. This is a diagnosis made on examination and not on x-ray as most people believe. The majority of rib fractures do not cause problems and are difficult to see on x-ray film, so they are not routinely done. The treatment is good painkillers, rib strapping which takes the pressure away from the injury and instructions to take deep breaths regularly. Yes, this hurts a lot but it also keeps the miniature passageways open, discouraging bacteria from growing, because if you start coughing, that injury will really hurt.

“Have I popped my lung?” is a common question we get asked. The answer is usually no. So what is a popped lung? Excuse the analogy, but imagine that your fist is a lung, now put your fist into a half blown up balloon. It is now surrounded by two layers, right? These are called the pleura. If the outer layer is speared by, for example, a fractured and displaced rib, then suddenly air can enter the space between the layers and cause your lung (the fist, if you are still following) to shrink down. This is called a pneumothorax or collapsed lung. Usually, it’s not a problem, if you are young and fit, then it will re-inflate spontaneously over days or weeks, but a large one will cause you to feel breathless, contribute to pain and may need intervention in hospital (about four percent). Smokers are at greater risk of this injury.

The liver (right) and spleen (left) are also protected by ribs. However these ribs are called floating ribs as they are only fixed at the front but not the back. A blow to the left or right hand side, typically because of an overlying arm or by landing on a rail can damage these organs. They are delicate and have a very rich blood supply. They are each surrounded by a capsule which stems the bleeding in an accident, but once this bursts, the result can be fatal. If you notice a pain in the upper left or right of the abdomen (lower chest) then think about going to see the doctor. A racing pulse is another indication.

How do you prevent this from happening? Well, short of becoming a better skier/snowboarder, avoid carrying objects such as phones/keys/wallets in pockets around the ribcage. Avalanche transceivers are often a problem due to the strapping system, try to have these in the middle of the abdomen away from organs. In short, the difference between a muscle or rib problem compared to a collapsed lung is often a feeling of shortness of breath, so get yourself looked at.

Abdominal pain or racing pulse as described above should also be investigated. If you are worried about an injury, always go and see your doctor.

Dr Alan Griffiths from the English Medical Centre outlines what can go wrong when you hurt your ankle, and explodes a couple of myths at the same time…

Ankle injuries are more common in snowboarders (16% of all boarding injuries) than in skiers (6% of all skiing injuries). This is because boarding boots allow more movement than ski boots. However, it is not true that you cannot seriously hurt your ankle in a ski boot, as the picture shows.The ankle joint is made up of the lower part of the leg bones (tibia and fibula) and the talus bone underneath. The bony prominence at the end of the fibula (the thin bone down the outside of the leg) is called the lateral malleolus. The other knobbly bit on the inside of the ankle is called the medial malleolus, and is a part of the main leg bone (tibia).

Ankle sprains are common. They occur when the foot stretches the ligaments that hold the bones together. The ligament fibres become torn, which causes pain and swelling. In severe cases it can take several weeks for the ligaments to heal. Rest, Ice, Compression and Elevation of the foot are the mainstays of treatment (R.I.C.E.). The healing process can be speeded up by immobilising the joint with strapping or a splint.

When more force is involved, the bones that the ligaments are attached to can snap. Usually it is the end of the fibula that breaks. Treatment depends on the severity of the fracture. In simple breaks all that may be required is a plaster cast. But if there is any displacement of the bone fragment, an operation to insert metalwork becomes necessary. Similarly, if more than one bone is broken an operation is a near certainty.

It is much les common for the talus to fracture, but it is still possible. Minor talar fractures are generally treated with immobilisation in a plaster cast. However, because this bone takes all of the body weight, surgery is sometimes required to stabilise the fragments with metal screws. A part of the talus called the lateral process can snap yet not show up on ordinary X-rays. This fracture is almost never encountered apart from in snowboarders. Pain over the outside of the ankle that is not responding to treatment should prompt your doctor to consider a CT scan to exclude this specific “snowboarder’s fracture”.

Finally, the Achilles tendon should not be forgotten. This tendon attaches the calf muscle to the heel. It is usually injured in a forwards fall. If a few fibres of the tendon are strained it is not too serious, and heals up quickly with the RICE treatment. But if the entire ligament snaps it will take a good three months to recover in a plaster cast. Sometimes it requires an operation to stitch it back together, but this doesn’t really shorten the recovery time. If you hurt your ankle, do not fall into the trap of thinking that “if I can walk on it, there can’t be a break”. This is not the case, but what is true is that if you do walk on a broken ankle you are more likely to displace the bone fragment and increase your chance of needing surgery (see picture).

Mythbuster: this fractured lateral malleolus occured in a ski boot, and after walking around on it for two days the patient did not think it needed an X-ray. It actually required an operation to insert a metal plate.