Snow and ice are unstable surfaces, and winter can be a treacherous time of year [B-roll of
people slipping on ice and car crashing on ice], but clearly Beijing is a dangerous place to
be….and I am not talking about communism. Today we’re going to take a look at some
of the most troublesome injuries from the 2022 Beijing Olympics.
For extreme athletes competing at the 2022 Beijing Olympics;
injury is part of the game. When everything is on the line, and athletes attempt to push
beyond their limits, the margin for error is quite slim. And in those pivotal moments,
when all eyes are on them– a small mistake, an over aggressive competitor,
or slightly miscalculated timing can result in a short cut to serious injury.
My sympathy extends to the olympians who have had their medal dreams dashed this year
(at least for the moment) by injury.
American Hockey player Brianna Decker suffered a horrific leg injury in her team’s
first game at the Olympics this year. While contesting a Finnish player for the puck,
Decker and her opponent became entangled and both players went down. She received medical attention
and diagnosis including a CT Scan and an MRI right there in the stadium. Brianna would not return due
to a nondescript “lower body injury,” but let's see what insight we can glean from the footage…
Decker’s legs, and the legs of her opponent are intertwined at the moment when both
athletes fall to the ice. Unfortunately, as they fall backward, Brianna’s left leg is trapped in
such a way that it is not free to rotate as she is falling. Since the leg is trapped below on the
ice by the inside edge of her skate, and above by her opponents body, any rotation that occurs while
she is falling will be isolated to the trapped segment between the knee and the foot. The knee
and ankle are both hinge joints whose primary plane of movement is the sagittal plane, or front
to back. Both of these joints accommodate small degrees rotation in the transverse plane as well.
But their tolerance for rotation is relatively low and once that tolerance is exceeded,
bad things happen, either at the joints themselves, or at the bones inbetween. Here, the
rotational force is transferred to the shin bone, or tibia itself. At a microscopic level, bones are
arranged in bundled columns called osteons. Osteons are very resistant to compression,
like the columns in Ancient Greek temples. However, they are absolutely trash when it
comes to rotation. Fix one end of a long bone in place and rotate the
other end of that bone in one direction or the other, and Houston, we have a problem.
Eventually, the rotational force applied to Decker’s leg becomes too great and the cortical
bone of the tibia fails causing a fracture. Although Brianna’s injury was not disclosed,
the mechanism of injury suggests that she suffered a spiral oblique tibia fracture,
near or slightly above the left ankle. The presence of
a fracture is corroborated by the lack of structural stability in the left lower leg
when she lifts her leg when being attended by the medical staff on the ice.
This fracture pattern is the typical pattern that is seen with long bones that have undergone
rotation. It is not possible to tell from the available footage exactly where the fracture is,
but it is likely to be below the level where Decker’s leg was trapped by her opponent’s legs.
Speaking of which, it is likely that there was a minor element of bending force applied to Decker’s
leg as well with her opponent’s leg serving as the fulcrum. We can assume that the injury was closed
since she was not rushed to surgery within 6 hours of her injury. If she were fortunate, her fracture
could be anatomically aligned, or reduced, in a closed manner and her leg could be immobilized in
a cast until her fracture healed. If unfortunate, as I suspect then her fracture would require open
reduction and plate or intramedullary rod fixation followed by cast immobilization until healed.
Either way, her Olympic dreams will have to wait for another four years.
Of the injury, Decker said that “a lot needs to set in.” Being sidelined less than 10 minutes
into your third olympic games is surely a lot to process… But Breanna has expressed gratitude for
her teammates and supporters who have reached out to offer support since the injury. Brianna
opted to stay in Beijing and support the team as they pursue a medal, instead of returning
to the USA to undergo surgery. Fortunately, most fractures can be fixed any time up to
14 days from the time of injury before the surgery starts to become more difficult.
Our next patient is the 22 year old Yannick Chabloz of Switzerland who suffered multiple
injuries to his left hand and arm during a crash in the men’s combined downhill.
Rounding a corner at over 50mp/h, Yannick spun out of control and his body was sent flying sideways
first into the protective fence and then scraping down the hill.
In the crash, Chabloz’ left arm was the first body part to make contact with the fence,
and was then squished under his body when he landed on the hill. As he slides limply down over
the ridges in the hill, his left arm looks to have acquired a new elbow; bouncing ominously along.
The medical team was quickly by his side, wrapping his arm and stabilising it with a splint.
Shortly after the injury, his team reported that he had suffered a
complex wrist fracture, hand and scapula fractures in the incident.
For GS skiers in competition, the fencing on the periphery of the course is both a blessing
and a curse. THe fencing is designed to catch out-of-control or unconscious skiers before they
fly at high speed into the trees that line the course on either side. With speeds on the course
approaching 130 km/h or nearly 81 mph, a collision with a tree at that speed is going to be extremely
dangerous. So one the one hand, should you veer off the course in one of the aforementioned
conditions, the fencing can save you from a catastrophic, and potentially lethal collision.
But skiers travelling down the course are kind of like a rock with pointy spines sticking
out of it. Pointy spines that have a knack for getting caught in the holes of the fencing. So
on the other hand, while the holes are unlikely to completely stop an errant skier outright,
they are quite likely to catch a ski tip or a pole tip while the skier passes at speed,
and send the skier into a tumble…slower, but more chaotic.
From the footage, it is difficult to say exactly where Chabloz injured his arm,
but we can see that after sliding on his right side upon missing the turn,
his left arm collides with the fence. Immediately after striking the fence,
Chabloz spins like a top along the fence for a distance of approximately 50-60 feet before
being spit out onto the slope. The wrist and hand injury could be from the impact of the collision,
correction collisions, with the fence as he spun into and along its length, or they could
be from the sudden direction change as the ski pole secured to his left wrist was caught in
the fencing and his attached hand and wrist were suddenly, and violently, yanked into a direction
that they were not intended to go. A direct impact from a collision would result in an impacted,
fracture where the bone was punched into the shaft in one direction or another. A violent direction
change would be more likely to result in a displaced fracture with either simple angulation,
if the force were tangential to the shaft of the bone, or an oblique spiral, if there were
any rotation at the level of the wrist involved. Fragmentation or comminution of the wrist fracture
would be expected since this was a high energy collision. And I would be very surprised if
the wrist fracture did not also involve the joint surface of the wrist as well, given its violence.
All of these injuries would likely require operative stabilization with plate and screw
fixation, possibly on both the front and back of the wrist, if there was extensive comminution.
The scapula is a well-protected bone that lays on the back of the chest wall. The shoulder blade,
as it is otherwise known, is covered front and back by muscles of the rotator cuff, upper back,
and shoulders. Although it is relatively flat and exposed, it is generally fairly difficult
to injure, and it speaks to the presence of very high energy trauma when it is fractured.
It is likely that this injury occurred while Chabloz bounced across the course on his back
at 130 km/h or when he initially struck the fencing. When present, a scapula fracture is a
clue to medical personnel to look for associated intra-thoracic injuries because of the degree of
force that is required to injure this bone. Once ruled out, surgeons would decide whether
fixation of this fracture was required. For undisplaced, or minimally displaced fractures,
the surrounding muscles act as a splint, and formal fixation of the scapula is not required.
However, if the fragments were greatly displaced, or if the fracture line
extended from the scapular plate itself up into the glenoid, or cup of the shoulder,
then plate fixation of the scapula could become necessary. RElatively speaking,
the scapula if isolated, when compared to the wrist and hand injuries, would be of lesser
importance as it’s healing would be more forgiving and less likely to be complicated. The wrist,
conversely, is likely to require an extended period to heal and rehabilitate back to a state
that would allow elite level competition. Next, meet George McQuinn who was knocked
unconscious in a Men’s Freestyle Moguls event at the World Cup leading up to the Olympics.
McQuinn was unable to qualify for the Olympics– but this crash is scary enough that it’s earned
him an honorary mention in this video. Though it’s not really something to celebrate…
McQuinn was vocal on social media after the incident,
thanking his Sweet Protection helmet for saving him from long lasting damage (from count em’
two viscous bumps to the head), and even posting the footage from the crash.
Here he is facedown and completely limp sliding with the bumps of the mountain. In a moment like
this, when an athlete is completely unconscious from a blow to the head, there is a significant
chance of a concussion. Falling backward and striking your head on the ground is generally
not a good thing, but being whipped backward at speed and then landing directly onto the
back of your head on a hardened ski jump, is definitely a problem, no cap. With a concussion,
the brain is temporarily damaged by a blow to the skull. Because the brain actually floats
on liquid in the skull, any time you get hit in the head, you get two blows for the price of one.
The coup injury occurs when the brain on the side of the impact hits the inside of the skull.
The contre coup injury occurs when the brain bounces off the skull and then crashes into the
other side of the skull creating another injury there. Two hits for the price of one. Medical
Explanation. He was also at risk of: But it might also cause a cervical spine injury as a result of
the forward flexion of the neck, and possibly even a posterior skull fracture. Of course, with the
severity of the impact shown here, the neck would be forced into forward flexion upon impact of the
head with the floor. This might result of a burst fracture of the cervical spine, where one or more
vertebrae blow out their back wall into the spinal canal and spinal cord, or a facet dislocation,
where one vertebrae jumps its connection with an adjoining vertebrae. Neither of these injuries is
desirable and both result in serious instability of the cervical spine. There is also the potential
for a skull fracture at the back of the skull with injury to the posterior aspect of the brain,
including the cerebellum. And any time that you injure the skull, you have to worry about the
possibility of bleeding under the skull, either outside, or inside the lining of the brain.
This includes epidural, subdural, and subarachnoid bleeds, any of which can kill you either quickly,
or over time. Not to mention the potential abrasions and lacerations on his face
as a result of sliding down the hill like he did using his face as the parking brake.
The medical staff was by McQuinns side in moments. They stabilised him and placed him on a backboard,
treating him with the utmost caution. Luckily, he quickly regained consciousness and it became
clear that he would soon recover from a handful of minor injuries.
Our final patient is USA competitor Nina O’Brien
whose horrific crash in her second run of the giant slalom made front page news.
Following her injury, the USA Ski and Snowboard team issued a tweet on Nina’s behalf that included
an injury report. Nina suffered a compound fracture of her left tibia and fibula.
She was transported to the hospital in Yanqing where an initial stabilisation
procedure was successfully performed by local doctors.
When we slow the footage of Nina’s injury, we can see that her left foot hits a divot in the
snow which throws her slightly off balance and causes her to catch her right ski on the final
gate of the course. What follows is a flurry of skis and limbs travelling at a speed of
approximately 50mp/h, wherein the exact mechanism of injury is tricky to identify. But watch
closely as Nina is launched into the air, flying parallel to the ground for a brief
moment before her left leg makes impact with the snowy hill and her ski is ripped from her leg.
With the snow obscuring the exact mechanism of injury, it is hard to say exactly what happened.
However, from O’brien’s body position at the moment she collapses to the ground
we know that there is a rotational element involved with the injury mechanism,
since the inside of her right knee is touching the ground while he body is leaning to the
right. This signals that a significant amount of internal rotation has occurred at the hip, or
an equally large amount of external rotation has occurred at the femur or the tibia. Given the
injury pattern that was demonstrated, we now know that it was the tibia that was involved. But with
the injury being open in nature, it is likely that rotation would not be the only deforming
force that occurred at the time of injury. With a rotational force, a spiral oblique fracture
pattern would occur leaving a long spike of bone that was encapsulated by muscle tissue. However,
were you to bend the leg at the level of the fracture, such as when O’Brien collapsed and
fell to the ground, the sharp spike of the spiral fracture would have a short quick path
through the taut skin to the outside environment. And for the record,
that isn’t good. An open fracture would be more severe than would be a comparable closed fracture,
because of the added risk of infection. Open fractures like these, would also be more likely to
be delayed in healing. Consequently, open injuries such as this require urgent surgical attention so
that the wound and the exposed bone can be washed out and closed to reduce the associated risk of
infection. Oftentimes, these injuries are quite severe in terms of the wounds that have occurred
and the fracture patterns observed. They can often require a staged approach of treatment whose
pace is determined by the condition of the soft tissues around the fracture,
which can be quite traumatized. The initial goal is to stabilize the major fracture fragments
so that no further damage to the fragments or to the soft tissue around the wound, occurs.
O’Brien commented that after her initial stabilization at the local hospital
she planned to return to the US to undergo whatever additional surgeries would be required.
These might include additional washout procedures,
further soft tissue debridements as the injury to the soft tissues evolved,
and stabilization of any associated fibula fractures. Given the complexity of these injuries
recovery is typically prolonged with full healing taking anywhere from 6-12 months, or even more.
Pictured here at the Yanqing hospital, O'Brien was very grateful for both the
on-site medical staff and nurses and physicians at the hospital. And at
24 years old there is hope she will return for yet another Olympics.
Every time an athlete steps into a high level competitive environment,
they run the risk of injury– but in many winter sports, there are several added layers of danger;
extra equipment, slippery surfaces, and high speeds
add to the risk these athletes are taking. And my hat goes off to them. I wish all of
these athletes a speedy recovery! Let me know what you’d like me to cover next.
Thanks for your continued support.
As always, that’s been a word from dr Chris, not your everyday ortho.