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Winter Sports-related Urologic Trauma
0022-5347/79/1211-0062$02. 00/0 THE JOURNAL OF UROWGY Copyright © 1979 by The Williams & Wilkins Co.
Vol. 121, January Printed in U.S.A.
WINTER SPORTS-RELATED UROLOGIC TRAUMA T. A. HILDRETH, A. S. CASS
AND
A. U. KHAN*
From the Department of Urology, St. Paul-Ramsey Hospital, St. Paul, Minnesota
ABSTRACT
There is no characteristic pattern of ski-related Ufiologic injuries except those associated with major blunt abdominal trauma. Isolated urologic injuries and injuries of the lower urinary tract are relatively uncommon. was followed by renal arteriography when the IVP showed non-function or renal parenchymal damage. Cystograms were obtained in the majority of the patients and retrograde urethrograms were obtained when indicated.
Outdoor winter sports often include high speed bodily propulsion (snowmobile travel, downhill skiing, sledding and ice sailing), as well as more sedate activities (ice skating, snowshoe travel, ice fishing, jogging and the old-fashioned snowball fights). New sports provide new thrills but they also involve a high risk of accidents. Statistics show that snowmobile travel is 4 times more dangerous than automobile travel and that it is safer for people less than 17 years old than for the adult population. 1 Skiing is becoming increasingly popular and it is estimated that there is a 15 per cent increase of actual skiers every year. 2 Estimates of the injury rate from skiing range from 3 to 10 per 1,000 skiers per day, 2 • 3 which amounts to between 150,000 and 225,000 skiing injuries annually. Although most of these injuries (>80 per cent) are orthopedic in nature, 4 urologic injuries are being recognized more often. Patients with winter sports-related injuries are seen frequently at hospitals near ski resorts and numerous publications testify to the experience available with ski-related orthopedic injuries. However, ski-related urologic injuries have not been reported frequently. We herein review our experience with winter sports-related urologic injuries during the last 8 years. Site oflnjury
Nature oflnjury
Urethra (1 case) Kidney (10 cases)
Contusion (1 case) Contusion (6 cases) Laceration (1 case) Rupture (3 cases)
Bladder (1 case) Kidney (6 cases)
Rupture (1 case) Contusion (6 cases)
Kidney (2 cases)
Contusion (1 case) Laceration (1 case)
Kidney (5 cases)
Contusion (4 cases) Laceration (1 case)
RESULTS
Injuries were tabulated on the basis of the nature of the sporting activity and on the severity of the injury (see table). Of the 11 patients who sustained ski-related urologic injuries 6 had significant intra-abdominal injury (laceration of the spleen in 4, laceration of the liver in 1 and mesenteric hematoma in 1), requiring laparotomy. In those patients in whom a description of a specific nature of trauma was recorded the most common cause of injury was loss of control and balance resulting in a fall on the ground. Most ski injuries (9 of 11) occurred late in the day. Two patients described injuries resulting from the ski pole being thrust into the flank while trying to maintain balance. Both of these patients underwent nephrectomy: 1 because of a previously diseased, hydronephrotic kidney and the other because of an extensive renal rupture without other significant abdominal trauma.
Associated Injuries Downhill skiing Ruptured spleen (3 cases) Mesenteric hematoma (1 case) Femur fracture (1 case) Liver laceration (1 case) Ruptured spleen (1 case) Snowmobiling Fractured pelvis (1 case)
Treatment Conservative Conservative (1 subsequent nephrectomy oflarge pre-existing hydronephrotic kidney) Repaired N ephrectomy Repaired Conservative
Hockey Conservative Repaired
Sledding Partial nephrectomy Ruptured spleen
(1
case)
CLINICAL MATERIAL
DISCUSSION
Between 1969 and 1977, 25 patients were seen in our emergency room with winter sports-associated urologic injuries. Of these 25 patients 11 were injured while they were downhill skiing, 5 while they were sledding, 7 while they were in snowmobiles and 2 while they were playing hockey. The 18 male and 7 female patients ranged in age from 8 to 28 years. Urologic injuries were suspected when trauma involved the flank, abdomen or pelvis and in the presence of gross or microscopic hematuria. Infusion excretory urography (IVP)
With the increasing popularity of winter sports, especially downhill skiing, sports-related injuries are becoming more common. While orthopedic injuries involving the long bones of the lower and upper extremities are by far the most common type of injury ,2 blunt abdominal trauma owing to collision with trees or tree stumps, ski poles or just from a fall on the ground may result in significant injury to the kidney. In 7 of 10 patients who sustained renal injury while skiing there was significant associated intra-abdominal injury requiring laparotomy. Only 4 of these 10 patients underwent immediate operation: repair of the laceration in 1 and nephrectomy for a ruptured (shattered) kidney in 3. In none of these patients was there any external evidence of flank trauma.
Accepted for publication April 21, 1978. * Requests for reprints: Department of Urology, St. Paul-Ramsey Hospital, St. Paul, Minnesota 55101.
62
63
WINTER SPORTS-RELATED UROLOGIC TRAUMA
Unlike ski-related orthopedic injuries that have a definite pattern related to the stress shears and change in forces on the long bones, there was no definite pattern of renal injury that could be considered characteristic of ski-related trauma. When signs and symptoms are out of proportion to the severity of the injury pre-existing renal pathology must be suspected and a complete investigation is indicated, as in 1 of our patients with a large hydronephrotic kidney. There was only 1 injury to the external genitalia by the ski and this injury was a urethral contusion. The majority of the ski injuries occurred late in the day, which is consistent with the contention that fatigue and poor lighting may contribute to ski accidents. Most patients with ski injuries seen at our hospital came from 1 particular ski area, which probably is an indication of the proximity of the hospital to this particular ski slope and the popularity of the slope rather than a reflection of the skiing conditions in this area. In our city snowmobile accidents were relatively uncommon and the severity of injuries sustained was mild. This sport is
more of a rural activity and, since our patient population is mainly urban, snowmobile injuries are probably being seen at outlying hospitals. Sledding and hockey also have been associated with urologic injuries, although infrequently. Jogging has been reported in the literature to have been responsible for a case of penile frostbite. 5 REFERENCES 1. Wall Street Journal, vol. 58, No. 20, p. 1, November 10, 1977.
2. Davis, M. W., Litman, T., Drill, F. E. and Mueller, J. K.: Ski injuries. J. Trauma, 17: 802, 1977. 3. Criqui, M. H.: The epidemiology of skiing injuries. Minn. Med., 60: 877, 1977. 4. Shealy, J. E., Geyer, L. H. and Hayden, R.: Epidemiology of ski injuries: effect of method of skill acquisition and release binding accident rates. Hum. Factors, 16: 459, 1974. 5. Hershkowitz, M.: Penile frostbite, an unforeseen hazard of jogging. (Letter to the Editor.) New Engl. J. Med., 296: 178, 1977.
Vol. 121, January Printed in U.S.A.
WINTER SPORTS-RELATED UROLOGIC TRAUMA T. A. HILDRETH, A. S. CASS
AND
A. U. KHAN*
From the Department of Urology, St. Paul-Ramsey Hospital, St. Paul, Minnesota
ABSTRACT
There is no characteristic pattern of ski-related Ufiologic injuries except those associated with major blunt abdominal trauma. Isolated urologic injuries and injuries of the lower urinary tract are relatively uncommon. was followed by renal arteriography when the IVP showed non-function or renal parenchymal damage. Cystograms were obtained in the majority of the patients and retrograde urethrograms were obtained when indicated.
Outdoor winter sports often include high speed bodily propulsion (snowmobile travel, downhill skiing, sledding and ice sailing), as well as more sedate activities (ice skating, snowshoe travel, ice fishing, jogging and the old-fashioned snowball fights). New sports provide new thrills but they also involve a high risk of accidents. Statistics show that snowmobile travel is 4 times more dangerous than automobile travel and that it is safer for people less than 17 years old than for the adult population. 1 Skiing is becoming increasingly popular and it is estimated that there is a 15 per cent increase of actual skiers every year. 2 Estimates of the injury rate from skiing range from 3 to 10 per 1,000 skiers per day, 2 • 3 which amounts to between 150,000 and 225,000 skiing injuries annually. Although most of these injuries (>80 per cent) are orthopedic in nature, 4 urologic injuries are being recognized more often. Patients with winter sports-related injuries are seen frequently at hospitals near ski resorts and numerous publications testify to the experience available with ski-related orthopedic injuries. However, ski-related urologic injuries have not been reported frequently. We herein review our experience with winter sports-related urologic injuries during the last 8 years. Site oflnjury
Nature oflnjury
Urethra (1 case) Kidney (10 cases)
Contusion (1 case) Contusion (6 cases) Laceration (1 case) Rupture (3 cases)
Bladder (1 case) Kidney (6 cases)
Rupture (1 case) Contusion (6 cases)
Kidney (2 cases)
Contusion (1 case) Laceration (1 case)
Kidney (5 cases)
Contusion (4 cases) Laceration (1 case)
RESULTS
Injuries were tabulated on the basis of the nature of the sporting activity and on the severity of the injury (see table). Of the 11 patients who sustained ski-related urologic injuries 6 had significant intra-abdominal injury (laceration of the spleen in 4, laceration of the liver in 1 and mesenteric hematoma in 1), requiring laparotomy. In those patients in whom a description of a specific nature of trauma was recorded the most common cause of injury was loss of control and balance resulting in a fall on the ground. Most ski injuries (9 of 11) occurred late in the day. Two patients described injuries resulting from the ski pole being thrust into the flank while trying to maintain balance. Both of these patients underwent nephrectomy: 1 because of a previously diseased, hydronephrotic kidney and the other because of an extensive renal rupture without other significant abdominal trauma.
Associated Injuries Downhill skiing Ruptured spleen (3 cases) Mesenteric hematoma (1 case) Femur fracture (1 case) Liver laceration (1 case) Ruptured spleen (1 case) Snowmobiling Fractured pelvis (1 case)
Treatment Conservative Conservative (1 subsequent nephrectomy oflarge pre-existing hydronephrotic kidney) Repaired N ephrectomy Repaired Conservative
Hockey Conservative Repaired
Sledding Partial nephrectomy Ruptured spleen
(1
case)
CLINICAL MATERIAL
DISCUSSION
Between 1969 and 1977, 25 patients were seen in our emergency room with winter sports-associated urologic injuries. Of these 25 patients 11 were injured while they were downhill skiing, 5 while they were sledding, 7 while they were in snowmobiles and 2 while they were playing hockey. The 18 male and 7 female patients ranged in age from 8 to 28 years. Urologic injuries were suspected when trauma involved the flank, abdomen or pelvis and in the presence of gross or microscopic hematuria. Infusion excretory urography (IVP)
With the increasing popularity of winter sports, especially downhill skiing, sports-related injuries are becoming more common. While orthopedic injuries involving the long bones of the lower and upper extremities are by far the most common type of injury ,2 blunt abdominal trauma owing to collision with trees or tree stumps, ski poles or just from a fall on the ground may result in significant injury to the kidney. In 7 of 10 patients who sustained renal injury while skiing there was significant associated intra-abdominal injury requiring laparotomy. Only 4 of these 10 patients underwent immediate operation: repair of the laceration in 1 and nephrectomy for a ruptured (shattered) kidney in 3. In none of these patients was there any external evidence of flank trauma.
Accepted for publication April 21, 1978. * Requests for reprints: Department of Urology, St. Paul-Ramsey Hospital, St. Paul, Minnesota 55101.
62
63
WINTER SPORTS-RELATED UROLOGIC TRAUMA
Unlike ski-related orthopedic injuries that have a definite pattern related to the stress shears and change in forces on the long bones, there was no definite pattern of renal injury that could be considered characteristic of ski-related trauma. When signs and symptoms are out of proportion to the severity of the injury pre-existing renal pathology must be suspected and a complete investigation is indicated, as in 1 of our patients with a large hydronephrotic kidney. There was only 1 injury to the external genitalia by the ski and this injury was a urethral contusion. The majority of the ski injuries occurred late in the day, which is consistent with the contention that fatigue and poor lighting may contribute to ski accidents. Most patients with ski injuries seen at our hospital came from 1 particular ski area, which probably is an indication of the proximity of the hospital to this particular ski slope and the popularity of the slope rather than a reflection of the skiing conditions in this area. In our city snowmobile accidents were relatively uncommon and the severity of injuries sustained was mild. This sport is
more of a rural activity and, since our patient population is mainly urban, snowmobile injuries are probably being seen at outlying hospitals. Sledding and hockey also have been associated with urologic injuries, although infrequently. Jogging has been reported in the literature to have been responsible for a case of penile frostbite. 5 REFERENCES 1. Wall Street Journal, vol. 58, No. 20, p. 1, November 10, 1977.
2. Davis, M. W., Litman, T., Drill, F. E. and Mueller, J. K.: Ski injuries. J. Trauma, 17: 802, 1977. 3. Criqui, M. H.: The epidemiology of skiing injuries. Minn. Med., 60: 877, 1977. 4. Shealy, J. E., Geyer, L. H. and Hayden, R.: Epidemiology of ski injuries: effect of method of skill acquisition and release binding accident rates. Hum. Factors, 16: 459, 1974. 5. Hershkowitz, M.: Penile frostbite, an unforeseen hazard of jogging. (Letter to the Editor.) New Engl. J. Med., 296: 178, 1977.