The Mountain Echo

Dr Alan Griffiths of the English Medical Centre provides a cautionary tale for snowboarders who don’t wear wrist guards…

The wrist is the most common injury site for snowboarders, representing 20% of all boarding injuries. By contrast, wrist injuries account for just 2% of all injuries in skiers. The reason for this is fairly obvious. When skiers lose their balance they can move one of their feet out to prevent a fall. On a snowboard, however, both feet are generally fxed in the bindings, so boarders fall onto their outstretched hands much more than skiers.

This is the exact mechanism required to break the wrist. The most usual scenario is for the end of the main forearm bone (radius) to be forced upwards. The severity of the break depends on the amount of force involved. In hairline fractures, the bone is broken but not out of place. These are treated with a plaster cast for 6 to 8 weeks. With more force, the bone is pushed out of alignment. These fractures need to be manipulated back into place, usually under an anaesthetic, before being placed in a cast. In even more serious injuries the fracture requires an operation to insert metalwork in order to fx it, especially if the other forearm bone (ulna) is also broken.

The second most frequent wrist fracture involves the scaphoid bone. This is located between the base of the thumb and the wrist joint. The scaphoid is commonly broken by a fall onto the palm of the hand. It is a particularly troublesome bone to break because it has a poor blood supply and may not heal properly even with immobilisation in a plaster cast. To make things worse, the fracture does not always show up on X-rays straight away. If there is a suspicion of a fractured scaphoid after examination it is best to start treatment with a plaster cast even if the X-rays look normal. After ten days, check X-rays are necessary to confrm the diagnosis.

It has now been proven that wrist guards prevent wrist fractures in snowboarders. Several studies have all come to the same conclusion and a review article stated that one fracture could be avoided for every 50 boarders who wear guards. Don’t take my word for it, check it out for yourselves: The effect of wrist guards on wrist and arm injuries among snowboarders: a systematic
review. Russell K, Hagel B, Francescutti LH. Clin J Sport Med. 2007 Mar;17(2):145-50.

Another way of looking at it is that wrist guards reduce your risk of a wrist fracture by 85%. People still come out with the argument that guards are not 100% effective, but no protective gear ever is. Another objection is that guards can increase the likelihood a fracture further up the arm. This has not been shown in the studies mentioned above, and even it does occur it is a small price to pay for the proven protection that guards provide. Despite all this evidence, only about 10% of boarders wear guards.

I once treated a beginner snowboarder who had managed to break both of her wrists at the same time. She soon found out
who her best friends were when she realised that with a plaster cast on each arm, she wouldn’t be able to wipe her own backside for 6 weeks! You have been warned.

Most of what we read is all about keeping our bodies healthy, but this week is slightly different. Our mental health is intrinsic to our well-being and can often lead to poor physical health, or in itself be damaging. The questions tackled in this article are: How do I spot that I or someone else has a problem? And what can be done about it?

The main illnesses that we see as doctors are depression, eating disorders and psychoses such as schizophrenia. I’m going to talk mainly about the first, as it affects around ten percent of the population at some point in our lives. Major depression, also known as unipolar depression, is one of the more commonly encountered psychiatric disorders. It affects twice as many women as men. A lot of taboo still surrounds mental illness, one of the reasons accounting for many people not coming forward. So what causes it? Still an issue of great debate, it is now agreed that the chemicals (for the geeks among us, the main one is called serotonin or 5HT) between nerves in the brain become depleted in certain individuals. This is the basis for pharmacological therapy, which helps serotonin stick around for longer, making nerves fire again so that people feel more themselves.

The Blues, or if you’re a seasonnaire, Cabin Fever, hits us all at some point in our lives. Usually it’s because we’ve exhausted ourselves, we’re working too hard and this can all be compounded by a life event
such as a job loss, break-up, or even just that you’ve ruined your latest skis, or had your gloves stolen on a night out… The point is that depression is slightly different. So what makes depression different?
The tell tale signs to look out for in yourself or others are the following: Persistently low mood; lack of sleep or the opposite, excessive sleeping; early morning wakening; low appetite; difficulty concentrating or memory problems; thoughts about harming yourself or committing suicide. One of the earliest symptoms, often striking before any of the above, is loss of enjoyment in the activities that you used to enjoy. Many people with depression report a loss of interest in sex as well as sport, socialising, their jobs and so on.

So why am I depressing you all with this article? Well, the worst case scenario is suicide. It continues to rank as the second leading cause of death in adolescents and represents 10-30% of deaths in those aged 20-35 years. Major depressive disorder plays a role in more than one half of all suicide attempts. Ok, so on to how to avoid a run in with yourself…

There is now good evidence that for mild to moderate depression, spending time with animals helps (this does not include your room mates), even goldfish have been shown to help. More practical advice that is often ignored is exercise. Whilst it gets you out and about, meeting people and generally boosts self esteem, it also naturally increases serotonin levels. So get out of bed and go skiing / riding. Next up is talking to others… it is the basis behind cognitive, behavioural and other therapies for depression and basically boils down to ‘a problem shared is a problem halved’. Don’t isolate yourself. Talking to a friend, family or a counsellor can help immensely. Anti-depressants are effective but much more so when combined with counselling.

Now, for the things to avoid, yes, it’s alcohol and drugs. Most are central nervous system depressants (i.e. depressing), those that are stimulants almost invariably leave you depressed for some time afterwards, and long-term problems are now well documented. Cannabis is also well established as triggering and worsening schizophrenia. There is also the indirect problem of cost, which itself will lower your mood. A bender doesn’t come cheap in Val.

Depression is more common than you think, just because you don’t hear people talking about it in the pub doesn’t mean it isn’t an issue. If you are feeling low and the above measures haven’t helped then please go to see a doctor to put you through the right channels and get a plan in place. Have a happy rest of season!

Dr Alan Griffiths of the English Medical Centre gives the low- down on knee injuries that commonly occur in skiers…

The knee is much more complicated than a simple hinge joint. In addition to two ligaments either side (the medial and lateral collateral ligaments), there are also two internal ligaments (the anterior and posterior cruciate ligaments) that act as central stabilisers. There are also two menisci made of cartilage, that act like shock absorbers to prevent the femur from impacting directly against the tibia.

The most common skiing injury involves the medial collateral ligament being overstretched during a fall. This accounts for about 15% of all skiing injuries. The ligament’s fibres tear, which causes swelling and pain around the inside of the knee. It is relatively rare for the ligament to snap completely. Fortunately the more minor tears heal up without the need for an operation. The menisci can also tear (usually the medial meniscus) to varying degrees. In minor tears the meniscus bleeds into the joint, causing pain and stiffness. In severe tears a fragment ofcartilage can prevent the joint from flexing or extending, locking the knee. Meniscal injuries usually settle down with time, but may require an arthroscopy if they do not fully resolve.

The anterior cruciate ligament (ACL) is often injured when skiers fall, especially if the ski binding does not release. The mechanism of injury involves flexing and twisting the knee. Patients sometimes experience a popping sensation, and may describe that the knee feels as if it is about to give way when they try to put weight on it. Minor ACL tears can heal without an operation. Complete ACL tears
can cause the knee to become unstable, and do not heal on their own. An operation is then usually required. Unfortunately, stitching the two ends of the torn ligament together is not successful. Instead a piece of the patient’s hamstring or patellar tendon is grafted between the femur and tibia in place of the snapped ligament. The operation is not usually performed until at least a couple of months after the injury, in order to allow the inflammation to settle down. The rehabilitation afterwards takes several months, so it is certainly not a minor injury.

The initial treatment of these knee injuries revolves around the Rest, Ice, Compression and Elevation (R.I.C.E.) principle to reduce swelling. Rest means restricting knee movements, usually with a knee brace. The type of brace required depends on the type and severity of injury. Crutches may also be needed to take the weight off the knee. Icing the knee in the acute phase can reduce the amount of swelling by resticting blood flow to damaged structures. Many people instinctively jump straight into a hot bath to soothe an injured knee, and then wonder why it swells up afterwards. Compression can be achieved with a simple crepe bandage, and elevating the knee is also effective at reducing swelling. If the knee does swell up you may require an X-ray to rule out an avulsion fracture. These occur when a ligament snaps off one of its attachments to a piece of bone, and may require specific treatment.

Because the knee is such a complicated joint, it is worth getting a professional opinion rather than a self-diagnosis. Obviously, the sooner you start the right treatment, the sooner it will get better.