A Case of an Insufficiency Fracture of the Medial Proximal Tibia Secondary to Osteomalacia Associated with Long-Term Saccharated Ferric Oxide Administration.

This article presents a case of insufficiency fracture of medial proximal tibia caused by long-term administration of saccharated ferric oxide (SFO) in a 77-year-old female. In this case, 2-year administration of SFO for iron deficit anemia induced hypophosphatemic osteomalacia and finally resulted in an insufficiency fracture of medial proximal tibia. Hypophosphatemia and pain due to the insufficiency fracture were recovered promptly by withdrawing SFO administration and rest. This case represented varus deformity of the knee associated with osteoarthritis, which may also cause the insufficiency fracture of medial proximal tibia in addition to osteomalacia due to long-term administration of SFO. Long-term SFO administration should be avoided because of a definitive risk of osteomalacia and fragile fracture.

Characteristics and Risk Factors of Spinal Fractures in Recreational Snowboarders Attending an Emergency Department in Japan.

OBJECTIVE: The purpose of this study was to elucidate the characteristics of spinal fractures during recreational snowboarding and to determine the risk factors for these fractures. DESIGN: Case series study. SETTING: The Oku-mino ski area during the 7-year period between the 2005 to 2006 and 2011 to 2012 skiing seasons. PARTICIPANTS: Eight thousand seven hundred twenty-three snowboarders with injures. INTERVENTIONS: Cases involved snowboarders with spinal fractures; controls were snowboarders without spinal fractures. MAIN OUTCOME MEASURES: The characteristics of spinal fractures were assessed using a standard form and patient records, including radiographs. Multivariate regression analysis was performed to investigate risk factors for spinal fractures, including age, type of slope, snow condition, accident cause, self-reported skill level, experience level, and the use of protective equipment. RESULTS: Of 8723 snowboarders with injuries, 431 snowboarders presented with spinal fractures (4.9%). The most common spinal fracture was isolated transverse process fracture in the lumbar spine (33.2%, n = 143), followed by compression type fracture in the lumbar spine (25.1%, n = 108). Age (20-39 years), terrain slopes (half-pipe/box/kicker/rail), and jump-landing failure were associated with a significantly high risk of spinal fracture. CONCLUSIONS: Among the recreational snowboarders, isolated transverse process fracture in the lumbar spine was the most frequent spinal fracture. Age (20-39 year old), terrain slopes, and jump-landing failure were found to be risk factors for spinal fracture. CLINICAL RELEVANCE: Identification of characteristics and risk factors for spinal fractures during snowboarding is useful information to create a preventive strategy for the fractures and make snowboarding a safer sport.

Comparison of tibial shaft ski fractures in children and adults.

OBJECTIVE: To examine whether child and adult skiers have different risk factors or mechanisms of injury for tibial shaft fractures. DESIGN: Descriptive epidemiological study. SETTING: Prospectively analyzed the epidemiologic factors, injury types, and injury mechanisms at Sumi Memorial Hospital. PATIENTS: This study analyzed information obtained from 276 patients with tibial fractures sustained during skiing between 2004 and 2012. MAIN OUTCOME MEASURES: We focused on 174 ski-related tibial shaft fractures with respect to the following factors: age, gender, laterality of fracture, skill level, mechanism of fracture (fall vs collision), scene of injury (steepness of slope), snow condition, and weather. Fracture pattern was graded according to Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification and mechanical direction [external (ER) or internal rotation (IR)]. RESULTS: Tibial shaft fractures were the most common in both children (89.3%) and adults (47.4%). There were no significant differences in gender, side of fracture, mechanism of fracture, snow condition, or weather between children and adults. Skill levels were significantly lower in children than in adults (P < 0.0001). Type A fractures were more dominant in children (73 cases, 72.3%) than in adults (39 cases, 53.4%). There was significantly more ER in children than in adults (P < 0.0001). Among children, female patients had significantly more IR than ER; in contrast, among adults, women were injured by ER. CONCLUSIONS: We found significant differences in some of these parameters, suggesting that child and adult skiers have different risk factors or mechanisms of injury for tibial shaft fractures.

Hip pads reduce the overall risk of injuries in recreational snowboarders.

OBJECTIVE: The purpose is to determine common injuries in recreational snowboarding as targets of preventive strategy and protective gear that reduces the overall risk of these injuries. METHODS: The subjects comprised 5561 injured recreational snowboarders. On the basis of patients' self-reporting form, 'the common snowboarding injuries' (cut-off point >2.0% in prevalence) were decided, and all injured snowboarders were categorised into two groups: common injuries and the other injuries (control). Several factors such as age, gender, self-reported skill level, experienced seasons, experienced days, previous snowboarding school attendance and the use of protective gears (helmet, elbow pads, wrist guards, backbone guard, hip pads and knee pads) were recorded. Multiple logistic regression analysis was conducted to investigate which type of protective gear reduced the overall risk of the common injuries. RESULTS: The common snowboarding injuries consisted of eight types, in which distal radial fracture was the most common (17.7%), followed by head injury (9.4%) and clavicle fracture (6.5%). In univariate regression analysis, skill level, experienced seasons, experienced days and the use of hip pads and knee pads were manifested potential risk factors on the common injuries. In subsequent multivariate regression analysis, the use of hip pads was related with a lower overall risk of these common injuries (OR, 0.84; 95% CI, 0.75 to 0.95), specifically that of distal radial fracture and glenohumeral dislocation. CONCLUSIONS: The use of hip pads is recommended for snowboarders as it reduces the overall risk of common snowboarding injuries.

Lower extremity injuries in snowboarding.

BACKGROUND: In snowboarding, the upper extremity is known as the most common injury site and little information is available for lower extremity injuries. Here, we aim to discuss lower extremity injuries during snowboarding. METHODS: We retrospectively analyzed the epidemiologic factors, injury types, and injury mechanisms for injured snowboarders (7,793 cases) between 2004-2005 and 2008-2009 seasons; information was gathered via questionnaires. Individuals were classified into a lower extremity injury group (961 cases) and a control group with other injuries (6,832 cases). RESULTS: The incidence of lower extremity injuries in snowboarding was 0.16 per 1,000 participant days, accounting for 12.3% of all snowboarding injuries. The mean age of the lower extremity injury group and injured control group was 26.1 years ± 5.9 years and 25.1 years ± 5.6 years, respectively. Approximately 90% of snowboarders in both the groups were equipped with soft-shelled boots. Skilled snowboarders tended to sustain lower extremity injuries (p<0.0001). In lower extremity injuries, the most common injury type was lacerations/contusions (22.4%), resulting from collision with other snow sports participants. The most common fracture site was the ankle. Overall, in lower extremity injuries, the leading side was the most commonly injured (53.8%). CONCLUSIONS: A typical lower extremity injury in snowboarding is lacerations/contusions caused by collision with other snow sport participants. Lower extremity injuries in snowboarding differ considerably from well-known upper extremity injuries in terms of injury types and mechanisms. The incidence of lower extremity injuries is high and deserves further attention.

Glenohumeral dislocations in snowboarding and skiing.

BACKGROUND: Glenohumeral dislocations occurring during snowboarding and skiing are severe and often leave after effects. However, little is known about their aetiology and injury pattern. The purpose of this study was to elucidate the feature of glenohumeral dislocations in these winter sports. METHODS: The injuries sustained by snowboarders and skiers, who were admitted to our hospital during five ski seasons from 2004 to 2009, were analysed using questionnaires and patients' records. A retrospective cohort study and a multivariate regression analysis were performed to reveal the epidemiology and injury pattern of glenohumeral dislocations. RESULTS: The overall rate of glenohumeral dislocation was 0.0583 per 1000 participant days (0.0676 per 1000 participant days in snowboarders and 0.0295 per 1000 participant days in skiers). Glenohumeral dislocations in snowboarding were significantly more common in higher age, male gender, injuries resulting more from falls, wet snow conditions, injuries of the leading-side joint and engaging the toe-side edge of the snowboard. Similarly, in skiers, glenohumeral dislocations were significantly more common in higher age, male gender, higher skill level, injuries resulting more from falls and injuries occurring on steep slopes. Nearly all (95.8%) of the glenohumeral dislocations were of the anterior type, and the prevalence of fracture-dislocations of the glenohumeral joint was higher in skiing (33.9%) than in snowboarding (12.4%). The variables strongly associated with glenohumeral dislocations in snowboarding and skiing were age, gender, snow condition and skiing speed. CONCLUSION: Snowboarding and skiing are sports with increased risk of glenohumeral dislocation compared with the general population, and the injury pattern differs between them. In snowboarding, injury patterns seem to be influenced by performance style.

Posterior cruciate ligament mediated avulsion fracture of the lateral tibial condyle: a case report.

Avulsion fractures of the posterior cruciate ligament (PCL) are uncommon. On the basis of the site of damage of the PCL, hyperflexion, pretibial trauma, and hyperextension are proposed as mechanisms of PCL injuries. On the other hand, avulsion fractures of the tibial condyle are also rare. We report a PCL-mediated avulsion fracture of the lateral tibial condyle along with the tibial insertion of the PCL by extension-distraction force on the knee that has not been previously described in any study. This rare case may imply that application of an extension-distraction force to the PCL cause the avulsion fracture.

Characteristics of upper extremity injuries sustained by falling during snowboarding: a study of 1918 cases.

BACKGROUND: Little epidemiological research on characteristics of upper extremity injuries resulting from snowboarding has been conducted, particularly in relation to snowboarding stance, falling direction, and the side of the body where the injury occurs. HYPOTHESIS: Snowboarding stance and the direction of the fall may influence the frequency of the side or the location of the upper extremity injury. STUDY DESIGN: Descriptive epidemiology study. METHODS: This study analyzed the information obtained from 1918 patients with fractures or dislocations of the upper extremity (excluding the fingers and scapula) sustained during snowboarding/sliding between 2000 and 2008. Diagnosis, injured part and side, stance (regular or goofy), and falling directions were prospectively analyzed. Associations among these parameters were also analyzed. RESULTS: As characterized by skill level, patients were beginners (57.9%), intermediates (38.0%), and experts (4.0%). Eighty-eight percent had not received instruction from licensed instructors. Diagnoses included wrist fractures (53.7%), upper arm fractures (16.8%), shoulder dislocations (11.5%), and elbow dislocations (9.8%). In sum, 1742 (90.8%) patients were in regular stance when they fell, whereas 176 (9.2%) were in goofy stance. There was a significant difference in the prevalence of the injured side between the 2 stances. When the injured sides were classified according to the sliding direction, wrist fractures (61.7%) occurred on the side opposite the sliding direction, whereas shoulder dislocations (65.6%), upper arm fractures (82.9%), and elbow dislocations (79.8%) occurred on the same side as the sliding direction. When the injured sides were classified according to the falling direction, wrist fractures (68.1%) and elbow dislocations (63.5%) occurred because of backward falls, and shoulder dislocations (68.9%) and upper arm fractures (60.7%) occurred because of forward falls. CONCLUSION: Two snowboarding stances as well as 2 falling directions had a significant influence on the frequency of the injured side in the upper extremity.

Pelvic fractures resulting from snowboarding.

BACKGROUND: Information regarding pelvic fractures sustained during snowboarding is scant. PURPOSE: To analyze the epidemiologic data, injury patterns, and types of pelvic fractures sustained during snowboarding. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We analyzed the epidemiologic factors, injury patterns, and types of pelvic fractures in 145 patients with snowboarding-related pelvic fractures who were admitted to our institution from the 1998-1999 to the 2006-2007 ski season. RESULTS: The incidence of snowboarding-related pelvic fractures was 0.102 per 10 000 ski lift tickets, which amounted to 2% of all snowboarding-related fractures (fifth most common type of fracture among all snowboarding-related fractures). Of the pelvic fractures, 85.5% were stable (type A according to the Tile classification) and 14.5% were unstable (types B and C according to the Tile classification). Isolated sacral fractures had the second-highest incidence (24.1%) after pubic bone and/or ischium fractures (46.9%). A distinct female prevalence was seen (52.4%). Jumps and isolated falls were the main mechanisms of injury (80%), and the incidence of collision was significantly higher in the unstable group than in the stable group (P = .037). In all, 57.9% patients classified their skill level as "intermediate," and only 9.7% of patients had received professional snowboarding lessons. A total of 30 subjects (20.8%) had other injuries along with pelvic fractures; the patients with multiple injuries were significantly more frequent in the unstable group than in the stable group (P = .035). CONCLUSION: Pelvic fractures resulting from snowboarding accidents included a higher proportion with isolated sacral fractures in the stable group and a lower prevalence of associated injuries in the unstable group compared with those resulting from other causes.

Skill level-specific differences in snowboarding-related injuries.

BACKGROUND: Snowboarding-related injuries have been associated with specific snowboarding skill levels, but differences in specific skill level have not been identified. HYPOTHESIS: Injury patterns are different among skill levels. STUDY DESIGN: Descriptive epidemiology study. METHODS: The subjects were 19 539 snowboarders from the Oku-Mino region in Gifu Prefecture, Japan, who were admitted to our hospital during the 12 snowboarding seasons from 1996 to 2008. They were asked to complete a questionnaire regarding age, gender, self-estimated skill level, injury location, injury type, mechanism of injury, and protective gear. Physicians documented diagnostic variables and injury severity score; these variables were compared among the self-estimated skill levels. RESULTS: Of the total 19 539 injured snowboarders, 1204 (6.2%) were novices, 6409 (32.8%) were beginners, 9260 (47.4%) were intermediates, 1918 (9.8%) were experts, and the skill level was not known in 748 (3.8%). Proportions of the trunk and multiple injuries increased with increases in skill level; however, the number of head/face injuries decreased with increase in skill level. Upper extremity injuries also decreased with increase in skill level, except in novices. Dislocations and multiple injuries increased with increase in skill level, while lacerations/contusions, fractures, and bruises decreased. The mean overall injury severity score was 3.28 + or - 0.02, and the value increased significantly with increase in skill level. The proportion of collision and isolated fall injuries significantly decreased with increase in skill level, but that of jump injuries significantly increased. The percentage of protective gear use increased with the increase in skill level. CONCLUSION: Prevalence of injury type, injury location, mechanism of injury, and percentage of protective gear use varied according to skill level, and the severity of the injury increased with increase in skill level. On the basis of our observations, we believe that snowboarding injury prevention strategies should be formulated according to skill level.

Symptomatic lumbar mobile segment with spinal canal stenosis in a fused spine associated with diffused idiopathic skeletal hyperostosis.

BACKGROUND CONTEXT: Chronic, continuous stress at the junction of a stable/unstable site of the spine in diffuse idiopathic skeletal hyperostosis (DISH) has been reported to cause a nonunion. Back pain resulting from the nonunion has been rarely reported and few operative treatments have been suggested. PURPOSE: To report and discuss the pathogenesis, treatment, and surgical outcome of a rare cause of back pain. STUDY DESIGN: Case report of back pain caused by a single lumbar segment is lacking bony union at the caudal end of a fused spine associated with diffuse idiopathic skeletal hyperostosis. METHODS: Back pain in a 66-year-old man who had suffered for 10 years worsened. The back pain and thigh pain became intolerable, and the left buttock and thigh became numb. Radiographs and computed tomography images showed continuous hyperostosis in the anterior aspect of the vertebral bodies from C2 to L2. At the caudal adjacent level of these fused segments, L2/3 level was mobile and had canal stenosis. Decompression and posterior lumbar interbody fusion (PLIF) were performed. RESULTS: The pain disappeared soon after the operation. The nonunited segment showed bony union at the 5-year follow-up. CONCLUSIONS: PLIF may be an option for surgically treating symptomatic nonunited lumbar segments at the caudal end of a fused spine with DISH in cases unresponsive to conservative treatment.

Traumatic spinal cord injuries from snowboarding.

BACKGROUND: Little information has yet been made available on the types and mechanisms of snowboard-related spinal cord injuries or their neurologic involvement. PURPOSE: To review the cause and types of spinal cord injuries seen in snowboarders. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The subjects were 18 patients (mean age, 24.0 years) referred to the authors' institution for neurologic deficits associated with spinal injuries between November 1, 1995, and April 9, 2005. The clinical features of these patients were reviewed with respect to epidemiologic factors, mechanism of injury, fracture pattern, and neurologic status. RESULTS: The 18 snowboarders with spinal cord injuries constituted a very homogeneous group. First, almost all patients (94.4%) were young men. Second, most of the patients were intermediate or expert boarders. Third, the most common cause of injury was a failure of intentional jumping (83.3%). Fourth, the most commonly affected site was the thoracolumbar junction (66.7%), and the most common type of fracture was an anterior dislocation fracture (66.7%). Finally, in the thoracolumbar group, most patients (83.3%) were classed as Frankel grade A or B. CONCLUSION: It is fundamentally important that snowboarders, especially young men, be made aware of the spinal injury risk associated with jumping.

Tibial osteochondroma causing foot pain mimicking tarsal tunnel syndrome: a case report.

Nerve entrapment syndromes of the lower extremity are relatively rare in patients with multiple hereditary osteochondromatosis. A case of tarsal tunnel like symptoms in a 52-year-old woman with a distal tibial osteochondroma is presented. This case emphasizes that the possibility of nerve compression needs to be considered in a patient with multiple hereditary osteochondromatosis and that tibial osteochondromas can be a cause of tarsal tunnel-like symptoms.

Wrist fractures from snowboarding: a prospective study for 3 seasons from 1998 to 2001.

OBJECTIVES: To elucidate the epidemiology and the mechanisms of snowboarding wrist injuries, especially distal radial fractures. DESIGN: A prospective survey of snowboarders with distal radial fractures. PARTICIPANTS: From November 21, 1998, to April 22, 2001, we analyzed and interviewed 5110 injured snowboarders, and a total of 740 snowboarders with distal radial fractures were studied. On the basis of the medical records and radiographs, the severity of distal radial fracture was analyzed according to the AO classification. RESULTS: Distal radial fractures occurred at a rate of 0.31 per 1000 snowboarder visits and were assessed in 740 snowboarders in this study. Most of the injured snowboarders were either of beginner (42.0%) or intermediate level (48.1%). The most common events leading to an injury in snowboarding were falling (59.6%) and jumping (36.1%). Comminuted and articular fractures classified as AO types A3, B, and C, which required surgical treatment, made up 63.2% of distal radial fractures in snowboarders. The most remarkable differences between the first-time or beginner group and the intermediate or expert group were that the former had a significantly higher proportions of extra-articular fractures classified as AO type A (P < 0.05), and the latter were significantly more likely to have compression or complex intra-articular fractures such as AO type C (P < 0.05). Furthermore, first-time or beginner snowboarders were more likely to be injured because of a simple fall than were the intermediates or experts (P < 0.05). Over 60% of distal radial fractures classified as AO type C in the intermediate or expert group resulted from jumping. Furthermore, the side opposite to the snowboarder's preferred direction of stance was more often affected. A high incidence of injury during opposite-side edging, which is used more frequently in snowboarding, was found in novice female snowboarders. CONCLUSIONS: This study suggested several patterns in the nature of wrist injuries sustained while snowboarding, and these facts should be taken into consideration in the diagnosis of wrist injuries in snowboarders.

An analysis of hip dislocations among snowboarders and skiers: a 10-year prospective study from 1992 to 2002.

BACKGROUND: We evaluated the types and mechanisms of hip dislocation sustained while snowboarding and skiing, a subject about which there have been few studies. METHODS: In a prospective cohort study between 1992 and 2002, we studied 30 snowboarders and 8 skiers with hip dislocations. RESULTS: The incidence of dislocation with or without fracture of the hip joint in snowboarders was five times higher than in skiers (0.45 per 100,000 visits for snowboarders vs. 0.09 for skiers). The most remarkable differences between skiing and snowboarding hip injuries were that in the former there was a significantly higher incidence of anterior hip dislocation (p < 0.05) and in the latter there was a significantly higher incidence of posterior hip dislocation (p < 0.05). Furthermore, the rate of type V hip dislocation (with fracture of the femoral head) was higher in snowboarders (9 of 30 cases [30.0%]) than in skiers (1 of 8 cases [12.5%]). CONCLUSION: Hip dislocations are much more common in snowboarders than in skiers. Furthermore, the causes and types of hip dislocation differ between snowboarding and skiing.

Upper extremity injuries in snowboarding and skiing: a comparative study.

OBJECTIVES: To determine the types and causes of upper extremity injuries sustained while snowboarding. DESIGN: A prospective survey of snowboarders with upper extremity injuries, especially fractures and dislocations. PARTICIPANTS: Between 1995 and 2000, we analyzed and interviewed 6,837 injured snowboarders and 2,175 injured skiers, and a total of 2,742 snowboarders and 361 skiers with fractures or dislocations of the upper extremities were studied. RESULTS: The ratio of upper extremity injuries to all injury types was significantly higher in snowboarders (40%, p < 0.001). Shoulder dislocations accounted for 5.5% of all injuries in skiers but 71% of all dislocations. In comparison, 6.5% of snowboarders' injuries were shoulder dislocations, representing 50% of all dislocations. It was noted that dislocation of the elbow joint was a more characteristic injury of snowboarders (30%) than of skiers (3%). The most frequently fractured site in skiers was the clavicle (32% of all fractures), and in snowboarders, it was the wrist (62% of all fractures). The most frequently affected side of the snowboarders' upper extremity was the left, with the exception of wrist fractures. With the exception of wrist fractures, the edge side that caused the accident was the opposite of the side that was injured. Most snowboarders did not have initial instruction from professional instructors (93%) and did not use protective equipment (87%). CONCLUSIONS: The results of this study indicate that the upper extremity injuries are much more common in snowboarders than skiers. In particular, upper extremity fractures in snowboarders are three times more common than in skiers. Furthermore, in snowboarding, wrist fractures have a different underlying cause compared with other upper extremity injuries.