Cervical Fracture in a Nordic Skier
Timothy Floyd, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 13 - DECEMBER 1999
In Brief: Cervical injuries with subtle physical and radiographic signs can occur in any sport, even those that do not usually produce significant musculoskeletal trauma. In this case, a cross-country skier's symptoms—shoulder pain and thumb numbness—were initially thought to represent a shoulder injury. Reflex testing raised the possibility of a cervical spine injury. Radiographs were negative for fracture, but computed tomography revealed a fracture of the C-6 right articular pillar. The patient was placed in a rigid cervical orthosis. After 4 months the patient's symptoms resolved and the fracture healed.
Serious spinal injuries are uncommon in Alpine skiing and are rare in Nordic (cross-country) skiing (1-9). Spinal injuries in Nordic skiers are usually limited to either sacrococcygeal fractures or lumbosacral compression fractures from falling on the buttocks (1,2,8). Nordic jumpers can have more serious injuries, such as long bone fractures and concussions (9). A literature review indicates that this is the first report of a cervical facet fracture in a Nordic skier.
History. A 37-year-old man fell while participating in an 18-mile touring race. An experienced competitor, he was skate-skiing, a relatively new style of Nordic skiing in which the motion is similar to ice skating. He fell forward when his right ski tip plunged into a groomed and compressed portion of the track at the bottom of a small hill. He struck his forehead in soft snow, resulting in an abrasion of his forehead, but did not lose consciousness. He felt right shoulder pain but was able to ski another mile to a highway, where he caught a ride to the local hospital emergency department.
The patient's presenting complaints were right shoulder pain and numbness of the right thumb. When specifically questioned, he said his shoulder pain included the region from the lower portion of the neck to the deltoid insertion. He denied any radiating pain from the neck to the hand. He also denied any dizziness, disorientation, or confusion.
Physical examination. The physical examination was remarkable for 3/5 weakness in the patient's right elbow flexors and the wrist extensors, hypoesthesia in the right thumb and index finger, and an absent right brachioradialis reflex (biceps and triceps reflexes were brisk). He had no pain with movement of the neck. The right shoulder exam was normal.
Diagnostic imaging. In view of the neurologic signs, a cross-table lateral cervical radiograph (figure 1) was obtained. It demonstrated mild soft-tissue swelling anterior to C-5 (18 mm), suggesting a hematoma, and nonparallel overlap of the superior articular surface of the C-6 facets. Additionally, there was evidence of a mild rotational deformity when the posterior borders of the C-6 facets were compared with facets of more superior segments. Radiographs of the right shoulder were normal.
Diagnosis. A cervical computed tomography (CT) scan demonstrated a fracture of the C-6 right articular pillar with minimal neuroforaminal compromise (figure 2).
Treatment. The patient was placed in a rigid cervical orthosis (24 hours a day for 6 weeks) and observed closely. The orthosis allowed a safe range of motion without risking distraction of the fracture, which was held by ligamentous attachments. Lifting and skiing were restricted for 6 weeks.
Follow-up. Over the next 4 months the patient's neurologic deficit and associated hematoma completely resolved. Follow-up CT scans demonstrated fracture healing and remodeling of the fracture fragment in the neuroforamen. The patient was allowed to return to unrestricted athletic activity at 3 months.
Falls on soft snow while cross-country skiing may not be benign, even in young, healthy people, and when injuries occur, the nature of the injury may not be obvious. Despite cervical fracture and neurologic compromise, this patient was able to ski another mile to the nearest road.
Because the clinical presentation in the emergency department was not that of a typical cervical fracture, the patient was initially evaluated for a shoulder injury. Generalized proximal weakness was felt to be consistent with a soft-tissue shoulder injury, and hypoesthesia of the thumb is not uncommon in winter athletes, since cold conditions can cause temporary sensory deficits. However, thumb hypoesthesia and weakness of the brachioradialis and wrist extensors are also classic symptoms of a neurologic deficit involving the C-6 root. A cross-table lateral cervical x-ray yielded subtle findings. A change in the overlap of facet joints, as seen in the lateral radiograph, implies a significant bony or ligamentous injury that warrants further investigation.
As noted earlier, I believe this is the first reported case of cervical fracture in a Nordic skier. This case emphasizes the need for a high index of suspicion for cervical injuries, even when the patient's symptoms do not suggest a spinal injury and the mechanism of injury seems trivial.
Other cervical conditions may coexist in this population. Competitive Nordic skiers may develop enthesitis near the tip of the vertebra prominens where ligamentous attachments become inflamed from overuse. Axial cervical pain should not be attributed to degenerative disc disease without a vigilant search for acute injury.
As Nordic skiing grows in popularity, it is likely that more patients with subtle cervical injuries will present for evaluation.
Dr Floyd is an orthopedic surgeon at Sawtooth Orthopaedic Clinic in Sun Valley, Idaho. He is a fellow of the American Academy of Orthopaedic Surgeons, a member of the North American Spine Society, and a clinical instructor at the Johns Hopkins University School of Medicine and the University of Washington School of Medicine. Address correspondence to Timothy Floyd, MD, Box 1332, Sun Valley, ID 83353; e-mail to [email protected].