Wilderness and Environmental Medicine, 16, 33 37 (2005)
BRIEF REPORT
Spectrum of Injuries from Glacial Sports Sebastian T. Schindera, MD; Juergen Triller, MD; Lynne S. Steinbach, MD; Heinz Zimmermann, MD; Juka Takala, MD; Suzanne E. Anderson, MD From the Departments of Radiology (Drs Schindera, Triller, and Anderson), Trauma and Emergency Medicine (Dr Zimmermann), and Intensive Care Medicine (Dr Takala), University Hospital of Bern, Inselspital, Bern, Switzerland; and the Department of Radiology, University of California, San Francisco, CA (Dr Steinbach).
Objective.—Glacial sports continue to be a popular form of wilderness activity, but no published studies have commented on this type of sport or focused on the injury patterns of glacial accidents. The objectives of this study were to investigate the types and frequency of injuries associated with a glacial-crevasse or ice-field fall. Methods.—The trauma registry data and radiology record system of a pediatric and adult level 1 trauma center were evaluated from January 1997 through August 2003. All admissions with injuries caused by a glacial-crevasse or ice-field fall were reviewed. Results.—During the 5½-year period we identified 12 patients, of whom 9 (75%) were male. The average age was 30.2 years with an age range of 9 to 57 years. Six patients fell into glacial crevasses, and the other 6 slid down an ice field of a glacier. Leading diagnoses were head injury (44.6%), thorax injury (20.1%), and lower extremity injury (18.4%). Serious injuries were observed in 66.6% of the patients with a Glasgow Coma Scale of 3 to 8. Conclusions.—A wide spectrum of injuries is associated with glacial accidents. They range from common extremity injuries with fracture or joint instability and peripheral frostbite to potentially life-threatening nonorthopedic trauma, which requires intensive clinical and radiological work-up. Injury prevention strategies should focus on wearing helmets to reduce head injuries and adequate clothing to forestall or prevent hypothermia, for these are the most severe and life-threatening injuries. Key words: glacial sports, crevasse fall, ice-field fall, injury rates, injury prevention
Introduction Ice climbing and ski mountaineering on active glaciers have become increasingly popular in the past decade in the Swiss Alps, with known inherent risks. Crevasses and crests are the greatest danger facing those who climb and ski on active glaciers. As gravity relentlessly pulls the glacier downhill, large cracks develop in areas where the ice is under tension. These crevasses can be hundreds of feet deep and tens of feet wide. Deep winter snow can cover up these crevasses usually by forming snow bridges, which may completely hide them. The inexpeA preliminary report was presented at the European Congress of Radiology in Vienna, Austria, March 5–9, 2004. Corresponding author: Sebastian T. Schindera, Department of Radiology, University Hospital of Bern, Inselspital, CH 3010 Bern, Switzerland (e-mail:
[email protected]).
rienced athlete may step through or ski over a sun-weakened snow bridge and fall into the cavernous depths. In the golden age of alpinism, most of the accidents in the Swiss Alps ended fatally. In the early 1960s the introduction of helicopters brought a new dimension into mountain rescue, allowing prompt retrieval at high altitudes even with adverse meteorological conditions. An important time-reducing factor for a mountain rescue alert nowadays is that many athletes carry a 2-way radio or mobile telephone with them on the glaciers. Therefore, more severely injured patients, even in sites with difficult access, can be rescued and referred quickly to a designated trauma center. We know of no reports regarding injury patterns of glacial accidents in the sports and wilderness medicine setting. Therefore, we evaluated the types and frequencies of injuries due to glacial accidents over a 5½-year
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Table 1. Demographics of glacial accidents Patient Characteristics
n (%)
Gender Female Male
3 (25) 9 (75)
Age group (y) ⬍10 10–20 21–30 31–40 41–50 51–60
1 1 5 3 1 1
Mechanism of injury Glacial-crevasse fall Ice-field fall
6 (50) 6 (50)
Glasgow Coma Scale score ⬍8 9–12 13–15 Hypothermia
8 1 3 8
(8.3) (8.3) (41.3) (25) (8.3) (8.3)
(66.6) (8.3) (25) (66.6)
period in an attempt to better delineate injury patterns and assist in prevention strategies. Materials and Methods Only patients who were involved in glacial-crevasse or ice-field falls were included. We defined a glacial-crevasse fall as a plunge into a glacial cleft (between 12 and 90 feet) and a glacial ice-field fall as sliding down the icy surface of the glacier for at least 75 feet. Other athletes with minor traumatic sports injuries that occurred secondary to skiing or snowboarding on a glacier were excluded. All patients were air transported to the emergency unit of a level 1 trauma center serving as a referral center of the Alpine heart of Switzerland. Data were obtained from the trauma registry of our department from January 1, 1997, through August 30, 2003, and additional information was obtained through the radiology record system. Twelve patients were identified from these records. For each patient, the following data were obtained from the trauma registry: age and sex, Glasgow Coma Scale score on admission,1 time of injury, means of rescue and transportation, mechanism of injury, and type of injury. We classified significant injuries into 6 body areas: head, spine, thorax, abdomen, upper extremity, and lower extremity. We recorded the location and type of trauma.
Figure 1. Seasonal distribution of glacial accidents.
Results The majority of patients (n ⫽ 11, 92%) arrived directly from the rescue site to our level 1 trauma center. Only 1 patient was initially evaluated in a smaller hospital and then referred to us. Because of the difficult sites of the accidents and also the severity of the injuries, all patients were rescued and transported by helicopter (Rega, Air Zermatt). The demographic data are presented in Table 1. The average age of the athletes was 30.2 years old (range 9 to 57 years). Five of the athletes (41.3%) were between 21 and 30 years and 3 (25%) were between 31 and 40 years. Nine of the patients (75%) were male. Eight of the patients (66.6%) had severe hypothermia from the cold exposure and immersion in ice. Six of 12 patients (50%) fell into a crevasse, with the deepest crevasse at 90 feet (range 12–90 feet). The other 6 patients (50%) slid down a glacial ice field, with the greatest distance at 600 feet (range 75–600 feet). Figure 1 shows that more injuries occurred in the summer months from June to September (75%, n ⫽ 9) than in the winter months of November to March. Three of the patients were ice climbing, 4 were mountaineering, and 1 was snowboarding when the glacial accident happened. The type of sport related to the accident of the other 4 patients was unknown. Of the 12 patients admitted for glacial-crevasse or icefield falls, 11 (91.6%) sustained multiple injuries. Eight patients (66.6%) had Glasgow Coma Scale scores of 8 or less (consistent with severe head injury), 1 patient (8.3%) had a Glasgow Coma Scale score of 9 to 12 (moderate severity), and the remaining 3 patients (25%) had Glasgow Coma Scale scores of 13 to 15 (minor head injury). No deaths occurred in the 12 hospitalized patients. Table 2 shows a complete distribution of the 65 diagnoses. The most common area of injury was the head
Glacial Sport Injuries
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Table 2. Injury patterns of glacial accidents during 1997 and 2003 Anatomic location Head
Spine
Thorax
Abdomen
Upper extremity
Lower extremity
Total
Type of injury Concussion Cerebral contusion Skull or facial fracture Subdural hematoma Epidural hematoma Subarachnoid hematoma Cerebral ischemia Cerebral edema Subtotal Fracture (C1, T3, T5) Subluxation (C6/C7) Brachial plexus paresis Subtotal Pulmonary contusion Rib fracture Pneumothorax Subtotal Contusion Paralytic ileus Subtotal Humerus fracture Radius fracture Frostbite of fingers Subtotal Pelvic fracture Femur fracture Tibia fracture Fibula fracture Cruciate ligament strain Frostbite of toes Subtotal
No. (%) of all injuries 5 5 8 2 3 1 2 3 29 3 1 1 5 5 4 4 13 2 1 3 1 1 1 3 1 1 4 3 1 2 12 65
(7.7) (7.7) (12.3) (3.1) (4.6) (1.5) (3.1) (4.6) (44.6) (4.6) (1.5) (1.5) (7.7) (7.7) (6.2) (6.2) (20.1) (3.1) (1.5) (4.6) (1.5) (1.5) (1.5) (4.5) (1.5) (1.5) (6.2) (4.6) (1.5) (3.1) (18.4) (100)
(44.6%) followed by thorax (20.1%) and lower extremity (18.4%). The leading forms of head injuries were skull or facial fractures (12.3%), concussions (7.7%), cerebral contusions (7.7%), and subdural and epidural hematomas (7.7%). To our knowledge, none of our patients was wearing a helmet. Three patients had spinal fractures (C1, T3, and T5) and 1 had a spinal dislocation (C6/C7). One patient sustained a severe right-sided brachial plexus paresis by hanging with both arms in a narrow crevasse (Figure 2). Of the 13 thoracic injuries, 5 were pulmonary contusions, 4 were rib fractures, and 4 were pneumothoracies. Abdominal injuries were less common, with 2 cases of liver contusion and 1 case of posttraumatic paralytic ileus.
Lower extremity injuries (18.4%) were more common than upper extremity injuries (4.5%). The majority of the 12 lower extremity injuries were fractures (75%), and the rest were ligamentous sprains and frostbite. Tibial fractures were the most common lower limb fracture (n ⫽ 4), followed by fibular (n ⫽ 3) and femur (n ⫽ 1) fractures. Only 1 patient sustained cruciate ligament injury of the knee. There was a single incident of a fracture to the humerus and radius. Frostbite injuries to the peripheral soft tissues of toes occurred in 2 patients and of a finger in 1 patient. Discussion Our study describes glacial sports injuries in patients who either fell into a glacial crevasse or slid down an ice field. Our study helps clarify the types and frequencies of injuries that can occur in this setting. Although these injuries are uncommon and may occur only in certain parts of the world, it is important to know the injury patterns for a thorough clinical and radiological evaluation in the emergency department as well as for injury prevention. Most injured glacial athletes were male (75%) and in their late 20s or early 30s, though the age range was broad (9 to 57 years). This illustrates the attraction and appeal of the glacier to different age groups. The demographics of our study population reflect the findings of earlier reports of skiing and snowboarding injuries.2–5 Although most snow-sports injuries are winter phenomena, most glacial-crevasse and ice-field falls (n ⫽ 9, 75%) occurred in the summer months, when the higher temperature and the sun weaken the snow bridges over the crevasses or glacial cracks. Summer is also the most popular season for glacier trips. The middle of the winter appears to be the safest period for traveling on a glacier because the snow cover is strong and the main parts of the crevasses are closed. Our findings show that head injury is the most frequent injury in glacial accidents related to glacial-crevasse or ice-field falls. Head injuries have been previously reported as the leading cause of severe snow-sport injury in skiers and snowboarders of all ages.6–8 Our review reports a much larger percentage of head and facial injuries (44.6% of total injuries) than reported in a previous study by Skokan et al6 (20% of total injuries). This may be due to the high speeds attained during the falls, the unforgiving nature of icy objects, the different mechanism of the accident, or the fact that falls on ice are usually longer than on snow and the injuries are therefore more likely to be severe. A study of ski injuries in Sweden reported that head injury among skiers wearing helmets was 50% lower
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Figure 2. A 57-year-old mountaineering female athlete fell into a 36-foot deep crevasse and was held fast by her arms. She wore summer clothing and suffered from severe hypothermia (20.4⬚C) and required extracorporal blood rewarming with a heartlung machine. She experienced a right-sided brachial plexus paresis. A, Coronal Short Tau Inversion Recovery (TR: 4800, TE: 30) image shows increased signal intensity within bone marrow C3–C6 (white arrow) consistent with trabecular bone bruise. B, Coronal Short Tau Inversion Recovery (TR: 4800, TE: 30) image shows extensive soft-tissue injury adjacent to the paravertebral musculature (arrowheads). C, Parasagital T1 image (TR: 792, TE: 15) with marked soft-tissue haematoma (between the thin arrows). The asymmetry of the brachial plexus was evident with right-sided marked swelling of the brachial plexus (between the thicker arrows). D, Parasagital T1 image (TR: 792, TE: 15) shows normal-appearing contralateral left brachial plexus (2 white arrows).
Glacial Sport Injuries than for skiers who did not wear helmets, which confirms the effectiveness of helmets in preventing head injuries.9 Helmets have also been shown to be protective against head injury in other sports, such as bicycling.10 Therefore, we strongly encourage the use of helmets by athletes when traveling on a glacier. In our study, lower extremity injuries were by far more common than upper extremity injuries. These differences are not unexpected because the athletes fall feet-first and reduce the speed and absorb the impact of the landing with their lower extremities. Fractures of the ankle involving the tibia and fibula were the most common lower extremity injuries. In our study group, only 1 patient had a cruciate ligament sprain, suggesting less torsional forces around the knee during such falls. Although fractures are the most common injuries resulting from glacial accidents, the treating physician must be alert to other, more severe, potentially lifethreatening injuries such as thoracic and abdominal injuries, which occurred in 20.1% and 4.6% of our patients, respectively. One of the neurologic injuries deserves further mention and occurred in our oldest patient (57 years). She fell 36 feet into a crevasse during glacial mountaineering and was stuck in the narrow crevasse with both arms over her head and her whole body weight hanging down for several hours. This extreme hyperextension of the brachial nerves caused a brachial plexus paresis with a partial rupture of the C7 and C8 nerve roots on the right side (Figure 2). The patient was in cardiac arrest with a body core temperature of 20.4⬚C at the time of the rescue, but she was successfully resuscitated. In total, 8 cases of hypothermia (66.6%) and 3 cases of frostbite of the fingers and toes occurred in our study. Patients were prone to cold-induced injury because of the combination of wearing summer sports clothing and the long rescue times caused by difficult terrain. These patients required close evaluation for cold-induced softtissue injury. A weakness of our study is its retrospective nature and small patient-group size. Fortunately, these glacial accidents are uncommon. We were also limited because all our information had to be obtained from radiology and trauma center databases, which, at times, may not have contained all relevant information of interest.
37 Glacial-crevasse or ice-field falls may result in severe, multisystem trauma. Although orthopaedic injuries predominate, injuries to the head, spine, thorax, and abdomen may be very significant and life threatening. Injury prevention strategies for travelers and athletes recreating on glaciers should focus on head injuries (eg, helmet use) and on cold-induced trauma (eg, use of appropriate protective clothing). Acknowledgment The authors thank the air rescue organizations, Rega and Air Zermat, for their support. References 1. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81–84. 2. Furrer M, Erhart S, Frutiger A, Bereiter H, Leutenegger A, Ruedi T. A retrospective analysis of 361 patients including mechanism of trauma, severity of injury, and mortality. J Trauma. 1995;39:737–741. 3. Federiuk CS, Zechnich AD, Vargyas GA. Telemark skiing injuries: a three-year study. Wilderness Environ Med. 1997;8:204–210. 4. Sacco DE, Sartorelli DH, Vane DW. Evaluation of alpine skiing and snowboarding injury in a northeastern state. J Trauma. 1998;44:654–659. 5. Federiuk CS, Schlueter JL, Adams AL. Skiing, snowboarding, and sledding injuries in a northwestern state. Wilderness Environ Med. 2002;13:245–249. 6. Skokan EG, Junkins EP, Kadish H. Serious winter sport injuries in children and adolescents requiring hospitalisation. Am J Emerg Med. 2003;21:95–99. 7. Diamond PT, Gale SD, Denkhaus HK. Head injuries in skiers: an analysis of injury severity and outcome. Brain Inj. 2001;15:429–434. 8. Levy AS, Hawkes AP, Hemminger LM, Knight S. An analysis of head injuries among skiers and snowboarders. J Trauma. 2002;53:695–704. 9. Sandegaard J, Eriksson B, Lundkvist S. Nationwide registration of ski injuries in Sweden. In: Mote CD, Johnson RJ, eds. Skiing Trauma and Safety. Philadelphia, PA: Eighth International Symposium, American Society for Testing and Materials; 1991:170–176. 10. Thompson DC, Rivara FP, Thompson RS. Effectiveness of bicycle helmets in preventing head injuries. A case-control study. JAMA. 1996;276:1968–1973.
