Over the next years, I completed a Sports Medicine fellowship, Waves of Health began and affiliated itself with the Wilderness Medical Society and the idea for a book developed. The Strength and Conditioning Journal article put me in touch with other strength and conditioning specialists (CSCS credentials) such as Paul Hinniker, CSCS who developed the Taylor Knox Surf Exercises. There had been surf training books from experts like "Surf Flex" by Paul Frediani and "Fit to Surf" by Rocky Snyder. Scott Adams, CSCS of Surf Stronger developed excellent DVD's with top female pros and Hunter Joslin revolutionized balance training with the IndoBoard. Still, there was one thing I felt that the surfing community needed: self-care advice from the medical community. There wasn't a "Surfing Sports Medicine" book yet and, due to the kind of feral trips that surfers get themselves into, Wilderness Medicine was important to cover as well. After getting in touch with Andrew Nathanson, MD and Mark Renneker, MD of the Surfers' Medical Association, we agreed on publishing a comprehensive Surf Survival Guide. In 2009, I moved to Hawaii to consult with the Hawaiian Lifeguards, ASP Hawaii, the Vans Triple Crown of Surfing and community surfing events and really put the book material to the test. We have hosted a Wilderness Medical Society - Waves of Health Pipeline Masters Medical Conference for Surfing Doctors since 2009 during the waiting period for the Pipeline Masters. ASP Hawaii physician Leland Dao, DO and ASP Orthopaedic Surgeon, Warren Kramer, MD contribute to our conference and we have initiated postural correction studies with Tim Brown, DC of ASP and Intelliskin. Now, with Surf Survival: The Surfer's Health Handbook available at Quiksilver, Roxy, Amazon, Barnes & Noble, WalMart and even the closing Borders, we relentlessly continue our work to this day, inspired by the Waves of Health nonprofit. We have been present at every US ASP WCT event this year and have been featured twice in Transworld Surf, (once in the experts panel and once with a glowing review of Surf Survival) this year as well as Freesurf, Wilderness Medicine, the Honolulu Star Advertiser and Internal Medicine News.

Training: 

The following are pro surfing's elite trainers in addition to what we contribute on Surfline H&F. 

Click on their names to view their programs: Kevyn Dean, Matt Griggs, Johnny Gannon, Leif Robinson

Effective surf-specific training regimens not only focus on improving aerobic cardiovascular capacity and upper body strength and endurance, but also include an emphasis improving core strength, flexibility and balance, which are essential for high performance surfing.  A proper dynamic warm-up before surfing and a good post-surf stretch can go a long way towards preventing chronic neck, back, and shoulder overuse injuries, which are common among surfers. Remember to keep the core fundamentals of surfing in mind when you are training. When exercising on level ground becomes to easy or mundane, use unstable surfaces such as the IndoBoard, TRX or Swiss Balls to increase the "proprioceptive balance" component of your workout. That is the premise of most surf specific core workout routines such as Taylor Knox's Surf Exercises.You don't have to be a yogi, bodybuilder, 'CT professional or rubber grommet to get fit for surfing. Incorparate the mechanics of surfing into your fitness routine. Visualize duck-diving and pop-ups when doing push-up type exercises and imagine bottom-turns, snaps, airs and cutbacks when performing squatting and trunk twisting maneuvers. It is ultimately up to you to generate surf-specificity into your training.

Increase muscle and joint viscoelasticity with bands, QiGong, Yoga, Tibetan Rites or bodyweight exercises to break a sweat.   

Swiss balls and foam rollers are post-session regeneration tools for postural training and self-massage of muscle knots

Postural exercise is a lifestyle. Remember to keep the shoulders back and pelvis tilted forward during daily activity. Avoid the “big gut, no butt” posture by not only performing the detailed core exercises but also checking yourself in the mirror or aligning your back against a wall periodically. Use Indo Board sessions alone daily and in conjunction with other exercises as illustrated in the following page, at your own risk, to enhance variety and balance training with your routine.

Acute Injury and Medical Considerations from Head to Toe

Surfers and Concussions:

Imagine going over the falls, hitting your head on your board and then enduring a three wave hold-down. Unimaginable forces are causing major rotatory accelerations of the head now known to be the predominant factor in causing concussions. Surfers acknowledge some risk of head injury when surveyed (Wilderness Environ Med. 2006 17(2):73-4) but headgear is rarely used. Surfers get their bell rung often and it often gets minimized compared to the threat of drowning. Surfacing from the water seeing stars or forgetting the time and date may be a familiar occurrence, but it is one that heralds concussion. Concussions ruin balance and proprioception (joint position sense, knowedge of body motion in space and time: kinesthesia) which, in turn, increases the risk for further concussion and injury- including the lethal phenomenon of a concussion superimposed on a previous concussion: second impact syndrome. Orientation to time and date is the least sensitive measure in detecting concussion and may give false negative impressions (Am Fam Physician 2006; 74:1357-62). If a surfer is displaying altered mentation, they need help out of the water and formal evaluation. 

Water photographers and surfers have increasingly begun wearing helmets at Pipeline and other breaks where the stakes are high, and with good reason. Just before the last Pipeline Masters, a photographer sustained a skull fracture when a surfer's board ran over his head. This resulted in a clinically significant depressed skull fracture. Depressed skull fractures can often be felt with palpation of the skull beneath a scalp laceration. This examination should be done cautiously to avoid driving a depressed bone fragment deeper into the cranial tissue. The clinical examination for a depressed skull fracture may be misleading. The mobility of the scalp can result in nonalignment of the fracture with an overlying scalp laceration. As a result, the skull underlying the laceration may be normal, with the depressed area several centimeters away. Scalp swelling may also interfere with physical examination findings and hide any palpable bone defects. The signs and symptoms of a depressed skull fracture depend on the depth of depression of the free bone piece. Approximately 25% of patients sustaining a depressed skull fracture report loss of consciousness.

Sprains and Strains

It is important to define sprains and strains as well as factors that influence their healing. Many athletes will begin taking ibuprofen or other medicines to deal with sprain and strain type pain. This may end up being counterproductive as some medicines such as ibuprofen (Motrin, Advil) and celecoxib (Celebrex) may increase scar tissue formation. Other medicines, such as piroxicam and meloxicam may be beneficial in early treatment of sprains and strains. Corticosteroids have shown modest benefit in aiding muscle healing but require a doctor’s prescription.

Strains in Surfing

The shoulder, neck, back and hip tend to be predominantly vulnerable to strains in surfing. Strains are partial to complete muscle tears and are graded on a scale of 1-3. Grade 1 strains are associated with microscopic tears within the muscle fibers. There is no loss of strength and the muscle itself should heal within 10-21 days with minimal intervention. Grade 2 strains have reduced strength as the muscle fibers have been partially torn. These injuries require physical therapy and may take up to four weeks to heal. Grade 3 strains are a complete muscle rupture and often require expert care and radiographic evaluation. Swelling is common with Grade 2-3 strains.

Overuse type strains are generally Grade 1 and have an often distinct pain pattern. During surfing the pain is absent until one to two hours after surfing or training. Some rest from surfing will be necessary as chronic exacerbation can lead to scar tissue deposition and further rupture. Acute muscle and tendon injuries are associated with a continuous type pain.

Isometric exercises are important for the rehabilitation of muscle strains and should be done first followed by isokinetic exercises. Isometric exercises involve contracting the muscle without changing its length whereas isokinetic exercise occurs through the full range of motion. See individual exercise prescriptions for examples of isometric and isokinetic exercises for specific injuries. Isometric exercise enhances neuromuscular strength while isokinetic exercise builds the muscle itself along with its strength. Gentle controlled stretching should accompany rehabilitation to prevent shortening by scar tissue. Avoid active stretching in the first five days of any injury to prevent muscle spasms unless certain of heat-associated cramps as the cause.

 

Sprains in Surfing

A sprain is an injury to a ligament and can occur anywhere ligaments exist in the body (which is everywhere). Ligaments are tough fibrous tissues that hold bones together across a joint. Sprains can cause pain or instability at these points. Trained sports medicine physicians may stress these injuries to test the integrity of the ligament. However, only trained specialists should do this because of risks involved with displacing an underlying fracture in the area, such as a thumb sprain with a proximal phalanx fracture. Sprains are graded on a scale of 1-3, with 3 being the most severe.

Grade 1 sprains do not cause instability. They are associated with microscopic tears within the ligament. While there is pain and swelling, these injuries usually heal with time, rest, ice, compression wraps and elevation of the injury. Grade 2 sprains are partial ligament ruptures and may cause laxity and some instability within the joint, may require aggressive physical therapy and sometimes bracing along with prolonged rest, icing, compression and elevation. Grade 3 sprains are complete ruptures of the ligament and may be less painful than Grade 2 sprains with greater swelling. Magnetic resonance imaging (MRI) may be used to assess need for surgical stabilization or determination to brace the joint while the ligament heals. Most overuse sprains are Grade 1 but may progress to Grade 2 by surfers overly defiant to pain. Common overuse sprains include surfer’s elbow and multidirectional shoulder instability.

 

 

 

Musculoskeletal Acute Surfing Injury Considerations from the Neck Down:

Cranio-cervical injuries are rare but of particular concern because of the long-term consequences. 30 years ago, a study on Hawaii’s South Shore found cranio-cervical injuries to be the most common form of surf injury (Allen, R et al (1977): Surfing Injuries at Waikiki). Axial loading occurs at shallow breaks. When the crown of the head directly impacts rock, reef or even hard sand like a pile-driver, the “diving accident” or C1 burst (Jefferson) fracture occurs. Stabilize the C-spine with a four person log-roll maneuver, board and collar in the most efficient way possible (surfboard, leash and towel improvisation is inferior to the standard of care but may be the best available method) and transport by EMS or best method available, monitoring ABC’s to ED. If XR is negative then acquire CT neck for occult C1 fracture if continued pain. Atlantoaxial joint has 50% rotational ROM for the neck. Nodding occurs at the atlanto-occipital joint. Always test ligamentous instability with flexion and extension in full ACTIVE (not passive) Range Of Motion in any neck injury except if drunk or with altered mental status in which case, always transport to a hospital, get an X-ray and CT of the neck. Hyperflexion injury of the neck can fracture a piece of the spinous process at C6 or C7 (the "clay-shoveler's fracture) which will have neurologic symptoms. Bilateral dermatomal (skin area) patterns may give a preliminary indication of damaged structures in neck injury and brachial plexopathy (stingers): 

There are seven cervical vertebrae, C1-C7, each with a dermatomal referral pattern. There are eight cervical nerve roots, C1-C8 exiting above and below the respective vertebrae. Any dermatomal referral pattern warrants C-spine immobilization. Generally, if a surfer is tender at

The mandibular (jaw) angle, think of C1 injury (Jefferson fracture), Hyoid bone (finger breadth above Adam’s apple) think of C3 injury, Adam's apple (thyroid cartilage) think of C4 injury, lateral upper arm think of C5 injury, lateral forearm think of C6 injury, medial forearm think of C8 injury, and medial upper arm think of T1 injury.

Muscle weakness may also be a good indicator of the level of injury. If weak at (muscle correlated to nerve root): Trapezius C4, Deltoid C5, Biceps C6, Brachioradialis and wrist extensors C6, Triceps C7, and Finger extension C7-8 (Adapted from ACSM Sports Medicine Review, LWW, 1999). Immobilize the C-spine if these symptoms are present.

Remember that a herniated disc above the vertebrae, like a fracture, can cause weakness below innervator except in the cervical spine where the nerve root exits above. Unilateral dermatomal pain is not indicative of cord injury, but possibly nerve root injury. Surfers with histories of asyptomatic spinal stenosis and unilateral stinger (nerve root pain) can surf without restriction. Surfers with history of spear spine (loss of normal lordosis on lateral xray) unrelated to trapezial spasm (clear with spine specialist), radiographic Atlanto-Dens interval greater than 4.5mm (more common in Down syndrome), bilateral stingers (shooting pain from neck/shoulder to both hands), spinal contusion (burning hands syndrome) or multiple transient quadriparesis (temporary paralysis) should not surf or play contact sports as the risk of devastating spinal injury is high. That having been said, there are many groups that supervise surfing for victims of spinal cord injury such as the Life Rolls on Foundation that have done wonders for disabled athletes. Disabled athletes with spinal cord injuries have special considerations as sensory deficits to pain create potential for reduced perception of exertion. These athletes need periodic checks for hypothermia, skin lesions and infections.

 Rib fractures are associated with pulmonary contusions in 20-40% of cases. The injury is characterized by capillary disruption that results in the presence of intra-alveolar and interstitial hemorrhage, edema, protein, and fluid obstruction of the small airways with leukocyte infiltration- read simply as coughing up blood. Serial chest radiographs obtained beginning right after the injury show a fluffy infiltrate that may progress in extent and opacity over 24-48 hours. This is why hospitalization is necessary. Fractures of the fifth to ninth ribs can be single or multiple. Multiple fractures can present as flail chest, which is present when paradoxical respiratory movement occurs in a segment of the chest wall. This type of fracture requires at least 2 segmental fractures in each of 3 adjacent ribs, the costal cartilages, or the sternum. Pulmonary contusions are often a part of a major chest injury that includes 1 or more fractures of the thoracic cage, a pneumothorax, and a hemothorax. The contusions may occur due to the transmission of force through the chest wall with minimal fractures of the ribs or sternum; this mechanism is especially seen in the young. In middle-aged or elderly patients, pulmonary contusions are usually accompanied by multiple rib fractures. Transport by EMS promptly.

Rib fractures have a surfers’ corollary such that the sport has its own eponymous fracture. Surfer's rib is an isolated first-rib fracture and occurs in surfers who perform the lay-back maneuver. Fractures of the first rib have also been associated with thoracic outlet syndrome (J Trauma. Jan 2007;62(1):231-3). Thoracic outlet syndrome may manifest as a chronic dull or burning pain and weakness in the arm. Thoracic outlet syndrome is painful arm condition that may also result from scalene hypertrophy, occult lung cancer (smokers), surfer’s rib, anomalous cervical ribs or exertional related subclavian artery compression (subclavian steal syndrome). It may be confused with brachial neuritis or nerve entrapment syndromes that also cause shoulder and arm pain.Brachial Neuritis, also known as Parsonnage-Turner Syndrome, is a common inflammation of a group of nerves that supply the arm, forearm, and hand (brachial plexus).  It is characterized by severe neck pain in the area above the collarbone (supraclavicular) that may radiate down the arm and into the hand.  There also may be weakness and numbness (hyperesthesia) of the fingers and hands.

 

Scapula fractures are relatively uncommon, but professional surfer Damien Hobgood did recently suffer one in Tahiti, 2008. They do have a high association with concomitant injuries. Research shows that 80-95% of scapula fractures have associated injuries. The associated injuries may be multiple and/or life-threatening. As a result, diagnosis and treatment of scapular injuries may be delayed or suboptimal. Long-term functional impairment may occur. As more focus is placed on the proper management of scapular injuries, functional outcomes should improve. Associated injury patterns commonly involve the ipsilateral upper extremity and thorax. Frequencies of associated injuries are as follows: Rib fractures - 25-45%, Pulmonary injury (eg, hemopneumothorax, pulmonary contusion) - 15-55%, Humeral fractures - 12% (5-10% sustain a brachial plexus injury), Skull fractures - 25%, Central neurologic deficits 5%, Major vascular injury - 11%, Splenic injury requiring splenectomy - 8%

 

Scapula fractures account for 1% of all fractures, 3% of shoulder girdle injuries, and 5% of all shoulder fractures. Approximately 50% of scapula fractures involve the body and spine. Fractures of the glenoid neck constitute about 25% of all scapula fractures, whereas fractures of the glenoid cavity (glenoid rim and fossa) make up approximately 10% of scapula fractures. The acromial and coracoid processes account for 8% and 7%, respectively. Typically, scapula fractures result from high-energy trauma. Direct forces are most common, but indirect mechanisms also can be responsible. An example of an indirect force is a fall on an outstretched arm that causes the humeral head to impact on the glenoid cavity.                              

Suprascapular nerve entrapment should be suspected and included in the differential diagnosis of ill-defined shoulder pain. Ferretti et al (J-Bone-Joint-Surg-Am. 1987 Feb; 69(2): 260-3) examined ninety-six top-level volleyball players from eight teams that competed during the 1985 European Championships when twelve players were found to have asymptomatic isolated paralysis of the infraspinatus of the dominant side. Three players were studied with electromyography and Cybex-II isokinetic dynamometry. The results revealed denervation of the infraspinatus and approximately a 22 per cent loss of strength of the affected arm during external rotation. These findings were attributed to repeated stress due to stretching of the nerve during cocking of the arm and follow-through when the athlete was serving. It is plausible that repeated strenuous paddling could lead to this phenomenon in surfers.

Far more common injuries for surfers include acromiclavicular separation and clavicular fracture. Landing on the point of the shoulder causes trauma to the acromio-clavicular joint—or, in adolescents fracture to the clavicle or the shoulder being forced into anterior subluxation. If a serious clavicular fracture is not repaired with the right procedure, the athlete risks losing optimal shoulder and arm function on one side — compromising the entire upper body and overall performance.

The biology of the clavicle is different from all of the other long bones and enables it to heal more rapidly and reliably. We assist in this healing of less severe fractures by putting the athlete in a sling for the first five to seven days. They can then begin moving their shoulder - working towards trying to lift it over their head and improve range of motion. The disturbing clicking sounds, some very pronounced, generally persist for about a month. They are normal and will not affect the exercises or recovery. At four weeks or when the clicking, or popping, sounds subside; they can begin lifting lightweight objects -- such as an unopened soda can -- to build strength. Heavier weight can be added as comfort allows. Younger patients are back at their sport by six weeks, while older patients require more time -- usually three months. It is important to understand that the clinical healing will generally occur in advance of the x-ray healing and surgery is not always necessary. The x-ray will eventually match clinical results, though a bump will always remain - surgery or not. Surgical treatment exchanges a bump for a scar, provided no complications occur. When there is a severe displacement of the fracture - threatening to poke through the skin, or multiple fractures in the extremity, nerve injury, multiple rib fractures or a fracture close to the end of the clavicle – surgical intervention may be necessary. 

Acromioclavicular (AC) joint separation has six types in order of decreasing frequency: Type I - A slight displacement of the joint. The acromioclavicular ligament may be stretched or partially torn. This is the most common type of injury to the AC joint. Type II - A partial dislocation of the joint in which there may be some displacement that may not be obvious during a physical examination. The acromioclavicular ligament is completely torn, while the coracoclavicular ligaments remain intact. Type III - A complete separation of the joint. The acromioclavicular ligament, the coracoclavicular ligaments, and the capsule surrounding the joint are torn. Usually, the displacement is obvious on clinical exam. Without any ligament support, the shoulder falls under the weight of the arm and the clavicle is pushed up, causing a bump on the shoulder. Type IV- This is a type III injury with avulsion of the coracoclavicular ligament from the clavicle, with the distal clavicle displaced posteriorly into or through the trapezius. Type V is type III but with exaggeration of the vertical displacement of the clavicle from the scapula-coracoclavicular interspace 100-300% greater than the normal side, with the clavicle in a subcutaneous position. Type VI is a rare injury. This is type III with inferior dislocation of the lateral end of the clavicle below the coracoid.

Returning to surf is possible after rest and rehabilitation according to the grade of separation: Type I- RICE (Rest, Ice, Compression, Elevation) x 7 days, Types II- III-  RICEx14 days, Types IV-VI  may need surgical repair

Surfers may tape the AC joint down to prevent further painful symptoms. 

(Adapted from Handbook of Sports Injuries, 2004)

Most shoulder injuries are chronic in nature. These and acute injuries can be prevented by a proper strength and functional conditioning program developed by myself and other experts in the field of surfing sportsmedicine:

Shoulder dislocations should be reduced ASAP by skilled persons with X-rays taken at the hospital  to rule out additional fracture. Range of motion is limited from 0-10 degrees due to pain. In young contact sports athletes and surfers, the risk of re-dislocation without stablization surgery is 90-95% . The inferior glenohumeral ligament complex is the primary stabilizer of the shoulder against anterior dislocation, the most common dislocation in sports where the humeral head finds itself displaced under the coracoid process. Forceful anterior dislocations may leave a superoposterior impression fracture on the humeral head (a Hill-Sachs lesion, visible on xray) or an anteroinferior glenoid rim fracture (Bankart lesion) that may engage and prevent proper functioning and reduction of the arm. Abduction, external rotation and slight extension of the arm (“raise your hand in class”) is the vulnerable position when falling from height on a wave into the water. Reduction may be attempted by laying the surfer prone on the board in the water and applying downward traction on the affected arm (Stimson method). Surfers may attempt to reduce their own shoulder by grasping one knee with flexed hip in a bear hug fashion and extending the hip to give traction in hopes of reduction (Aronen method). The Kocher method of laying the patient supine and providing traction in 90 degrees of forward elevation, external rotation adduction and then internal rotation has been associated with proximal arm fractures and should be avoided. Emergency department evaluation is always a must after suspected dislocation for imaging to rule out further injury such as fracture.

Rehabilitation should begin with passive range of motion exercises after reduction. Injury to the axillary nerve can occur close to the inferior capsule of the glenohumeral joint, where it is susceptible to direct trauma secondary to glenohumeral dislocation ranges between 1-7% in uncomplicated anterior dislocations. The axillary nerve palsy causing dysfunction of the deltoid muscle is a catastrophic event to the shoulder girdle. Forward elevation can be limited to 33 degrees (range of 0 to 75 degrees). With this degree of loss of motion, attempts at elevation and abduction will result in superior subluxation of the humeral head with possible rotator cuff impingement and arthropathy. Once a shoulder has dislocated in a young athlete involved in contact sports, the chances of dislocating again are about 95% with stabilization surgery.

The most common shoulder injury is supraspinatus (rotator cuff) tendonitis classically known as shoulder impingement. This is also the muscle most commonly torn as an acute paddling injury in older surfers. In patients over 40 years of age, rotator cuff tear occurs with an incidence of 15%. In patients over 50, there is a 63% incidence (JBJS 1988; 70A:1308-1311). Surgery is indicated only if abductor dysfunction is evident. Otherwise progressive range of motion physical therapy is indicated. The impingement scenario causing the tendonitis may be twofold. External (Neer) impingement occurs when the supraspinatus tendon is abraded by a hooked or calcific acromion superiorly. Internal impingement is common among throwers, and possibly paddlers, where excessive pressure may occur between the supraspinatus tendon against the posterior superior labrum and cause a labral tear (SLAP II) itself. The peel back mechanism from biceps tendon over cocking during throwing (or paddling) may cause humeral head impingement from labral tearing (SLAP III) but does not involve the rotator cuff.

To compensate for the shallow socket, the shoulder joint has a cuff of cartilage called a labrum that forms a cup for the end of the arm bone (humerus) to move within. The labrum circles the shallow shoulder socket (the glenoid) to make the socket deeper. This cuff of cartilage makes the shoulder joint much more stable, and allows for a very wide range of movements (in fact, the range of movements your shoulder can make far exceeds any other joint in the body).

The labrum is made of a thick tissue that is susceptible to injury with trauma to the shoulder joint. When a patient sustains a shoulder injury, it is possible that the patient has a labral tear. The labrum also becomes more brittle with age, and can fray and tear as part of the aging process. The most likely labral tears are superior labrum running anterior-posterior (SLAP) near the long head of the biceps anchor. Symptoms of a labral tear depend on where the tear is located, but may include an aching sensation in the shoulder joint, catching of the shoulder with movement and pain with specific activities such as surfing. In addition, some types of labral tears, specifically with a Bankart lesion, can increase the potential for shoulder dislocations. The “Buford complex” is another antero-superior glenoid labrum variant, characterized by an absent antero-superior labrum and a cord-like middle gleno-humeral ligament (MGHL) that originates at the superior labrum, at the base of the biceps tendon and crosses the subscapularis tendon at 45º to insert on the humerus. Since a normal MGHL is the primary static restraint to anterior translation when the arm is abducted 90 degrees and externally rotated 90 degrees, inferior static restraining capabilities of a Buford complex (anatomic variant) will probably cause anterior instability. 

Wrist and Hand

Mallet finger is an extensor tendon avulsion injury occurs by an axial force against an extended finger. It requires immediate imaging and extension splinting for 6 weeks. Mallet finger can occur from a fall onto a surfboard or ocean floor. Neglected Mallet fingers may acquire a cosmetically and functionally undesirable swan-neck deformity. "Jersey finger" is a flexor tendon avulsion injury common to the ring finger when objects are ripped forcefully from a firm grip, such as a surfboard or rescued surfer in heavy wave action. It is a surgical emergency clinically diagnosed by inability to flex the finger joints. 

Finger and metacarpal dislocations and fractures may occur and need reduction into anatomical alignment and imaging to rule out further injury. All fingers should point toward the scaphoid at the thumb side of the wrist. Malrotation requires surgery.

Scapholunate dissociations (diagnosed first by DISI >70 degrees on lateral hand xray and confirmed by MRI), Lunotriquetral instability (diagnosed first by VISI <30 degrees and confirmed by MRI), Lunate fractures (may predispose to Kienbock’s avascular necrosis), TFCC tears (will display ulnar sided wrist pain and need MRI for accurate diagnosis), Radial styloid fractures, DRUJ separations, Colle’s and Smith’s fractures may all occur from fall onto the ocean floor or surfboard with outstretched hands. Scaphoid fracture is diagnosed by pain in the anatomic snuffbox on the thumb side of the wrist. All require transport for urgent evaluation with prompt immobilization and possibly surgery.

Lumbar Spine

A National Collegiate Athletics Association study showed that female athletes had higher rates of low back pain (LBP) than males (NCAA Injury Surveillance System 1997-1998). Risk factors for LBP in athletes differ from the general population in that strength, flexibility and functional deficits supercede lack of fitness or obesity which are the predominant factors for LBP in the general population (Spine 1998;23:828-833).

A condition called spondylolysis is common in back hyper-extenders, such as novice surfers, football players and gymnasts. It is a stress fracture of the pars intercularis, the thinnest sections of bone in the vertebral body. Progressive activity-related low back pain (LBP) with normal X-rays of the lumbar spine is treated with rest from surfing and a bone scan with SPECT images of the lumbar spine for occult stress fracture. Clinically, standing on one leg and hyperextending the back will reproduce the pain. This condition may be. As spondylolysis progresses, a bilateral stress fracture of the pars may occur in the lumbar spine, causing a slippage of the vertebral column known as spondylolisthesis. Treatment is still conservative unless the slippage angle becomes significant.

Hyperextension injury may chronically manifest as hyperlordosis. No-look paddles and neutralizing the spine consciously may help mitigate the pain. Spinal neutralization involves rounding out the back and strengthening the erector spinae muscles with quadriped and superman exercises. Hyperextension for novice surfers may have even more ominous manifestations. Nontraumatic acute myelopathy associated with surfing is a novel entity, with only 18 cases reported in the literature since 1998. It is proposed to be the result of an ischemic event in the distal thoracic and conus medullaris regions of the spinal cord, affecting inexperienced surfers and possibly related to spine hyperextension. (J Spinal Cord Med. 2007; 30(3): 288–293) Increased awareness of this rare condition may facilitate early recognition and treatment, which should contribute to improved neurological outcomes. (Spine. 2004;29(16):E353–E356). Hyperbaric oxygen therapy (HBOT) may have a benefit in assisting recovery from this condition but there is not adequate research at this time.

Older surfers may suffer facet osteoarthritis, zygapophyseal low back pain (Z-joint LBP) or facet syndrome. Establishing a diagnosis of lumbosacral facet syndrome is difficult because the findings for zygapophyseal synovitis (Z-joint LBP) are nonspecific and correlation between the history and physical examination findings is poor. However, obtaining a detailed history and performing a physical examination help rule out other entities and assist with guiding the examiner in establishing the diagnosis of Z-joint–mediated LBP. Although no single sign or symptom is diagnostic, the combination of the following 7 factors was significantly correlated with pain relief from an intra-articular Z-joint injection: older age, previous history of LBP, normal gait when walking, maximal pain with extension from a fully flexed position, absence of leg pain, absence of muscle spasm and absence of exacerbation with a Valsalva (bearing-down or straining at stool) maneuver. Worse symptoms of LBP are radiculopathy (sciatica) which may be diagnosed by slump testing. Have injured surfer slumped in chair and passively extend one knee at a time. The test is positive if symptoms are worsened. A positive test warrants a specialist referral and MRI. A positive single leg spinal extension test indicates spondylolysis and warrants a bone scan.

Hip Pain

Chronic lumbopelvic-hip instability from surfing causes back, butt and hip pain with a growing amount of hip labral tears related to surfing.

Hip labral tears are classically associated with forced splits injuries (think of maneuvers by hockey goalies). Diagnose clinically with scour test by flexing knee and hip and rotating hip in the socket, looking for pain and feeling for clicks. Send for X-ray to rule out fracture and MR arthrogram to confirm diagnosis. Hip contusions are treated with rest and ice and passive stretching to reduce incidence of myositis ossificans. Forced splits in heavy wave action can dislocate a hip in addition to causing hip labral injury. Urgent reduction, transport and immobilization and radiography are necessary. Reduction often requires two rescuers performing countertraction. Posterior hip dislocations can compress the sciatic nerve and cause "foot drop" and ruin surfing.
With overuse injuries, particularly straining the gluteus medius, the trochanteric bursa can be inflamed.

Knees and Legs:

Errant surfboards can make contact with the calves, thighs or buttocks, creating significant hematoma and bruising. Occasionally, untreated deep contusions will have complication of bone forming in the hematoma zone (myositis ossificans). This diagnosis is heralded by a bruise that is not resolving or by a firm mass within the muscle belly. Imaging should be done to rule out other problems. Early quadriceps contusions may be splinted in 120 degrees of knee flexion to prevent myositis. Oral anti-inflammatory medicines may also help (Sports Injuries: Mechanisms, Prevention and Treatment, LWW, 2001, 568-582). In competitive surfers, most of the knee strains occurred as a result of aggressive turning and aerial maneuvers, which appear to place high stresses on a surfer’s knee. These powerful and acrobatic maneuvers, which score highly in competition, are too difficult for the average surfer to execute and may account for the higher proportion of soft tissue knee injuries observed among competitive surfers than in their recreational counterparts. (Am J Sports Med 2007, 35:1, 113-117).  

Acute knee and ankle, ligament and joint surface injuries can result from a big drop at take-off or from landing aerial maneuvers. When standing up on fast, steep waves, the surfer’s feet can leave the board and then find it again at the bottom of the wave, sometimes fins-up. If the surfer becomes unbalanced for whatever reason, he/she can land off-center, putting excessive rotational or medial/lateral force through knees or ankles.  The bracing company Ossur has recently begun an advertising campaign featuring surfers (and surf models) wearing ACL braces, either due to the increase in popularity of surfing or the knee injuries sustained.

Since surfing and sports medicine is so often about "making the call", the caveat is this: if it hurts and is swollen or unstable get out of the water and seek medical attention. The pivot shift and hyperextesion injury mechanisms of the anterior cruciate ligament (ACL) of the knee can be seen (or felt) with any botched take-off or aerial in surfing. Voluminous swelling (often hemarthrosis) occurs immediately. ACL tears occur as the result of a medially directed force on the lateral aspect of the knee while the foot is flexed and the joint fully extended. With this mechanism of injury, the medial collateral ligament and medial meniscus are also at risk. Females have more ACL injuries than males as seen in many studies and clinical settings. The "dashboard injury" of the posterior cruciate ligament is also highly plausible in a big wipeout situation. Posterolateral instability is urgent: Check recurvatum. If knee goes beyond normal -5 hyperextension or the fibula subluxes, get imaging. (Wheeless Orthopaedics, 2005)

 

Ankle:

Several pros are currently nursing ankle injuries from misjudging the landings on their "airs". However, ankle sprains have not been widely described in surf injury reports but there are several plausible mechanisms including running to and from the ocean in loose or rocky sand. 60-70% of ankle sprains are classified as “minor” (NCAA, 2000). Ground reaction forces of the buoyant surfboard are variable and lessen the potential for severe sprains.  A surfer’s forefoot may be everted during turning predisposing to lateral talar dome osteochondral lesions. These may present as a nonhealing ankle sprain. MRI is diagnostic. The same forefoot eversion may predispose to syndesmotic sprains. Squeezing the leg above the ankle causes pain in this condition. It may be treated conservatively, provided that xrays do not demonstrate ankle mortise widening. Subtalar dislocations are also a distinct possibility. Reduce only if neurovascularly compromised by traction and eversion of the foot and seek urgent medical evaluation. Injuries may be prevented by strength and conditioning programs that include supervised "depth jumps" to increase ankle and knee balance (proprioception).

Foot:

Running on the beach and slamming feet on the reef in the surf environment can cause a host of problems. Turf toe results from traumatic sprain to the plantar capsuloligamentous complex of the great toe from forced dorsiflexion. Sand toe results to the dorsal capsuloligamentous complex from forced plantarflexion. Traumatic dislocations of the first metatarsophalangeal joint occur at the extreme end of this continuum. The small sesamoid bones sometimes prevent reduction in the field. If the sesamoids are themselves separated (rupture of the intersesamoid ligament) or fractured, closed reduction may be possible (Foot Ankle 1980;1:15-21). Subtalar dislocations may occur with forceful landing on the ocean floor in shallow water falls. Eighty percent of these are medial, 20% lateral, 10% open and over half have associated fractures. Closed reduction of this condition can be performed by flexing the knee and forefoot, applying gentle traction and then reversing the deformity while holding the talar head. Contusions of the foot can form hematomas that cause nerve entrapment. Medial heel pain can be caused lateral plantar nerve entrapment and the pain may radiate laterally across the foot when walking or running. Lacerations of the foot are common in rock and reef breaks and when exiting waves on aerial and landing on the fins. See Wound Management section for details on treatment.

Environmental Considerations

Surfing can be defined as a risk sport due to several variables including but not limited to currents, wave force, water aspiration, and collisions with equipment, rocks, coral reefs, and other surfers. It is essential for surfers, both novice and elite, to have a significant base of paddling strength, balance, and general physical fitness in order to meet the demands of an unpredictable oceanic environment and to prevent repetitive motion injuries. (Everline, Strength and Conditioning Journal 2007;29(3)32-40)

 

Drowning: 

The 2002 World Congress on Drowning, held in Amsterdam, experts suggested a new consensus definition for drowning in order to decrease the confusion over the number of terms and definitions (>20) referring to this process:

Drowning is a process resulting in primary respiratory impairment from submersion in a liquid medium. 

The terms wet drowning, dry drowning, active or passive drowning, near drowning, secondary drowning, and silent drowning would be discarded.

Rip currents were reported in 22% of surf beach drownings. Surfboard usage does not prevent drowning. Pre-existing cardiovascular conditions were implicated in 26% of surf-related drownings. (Injury Prevention 2008; 14:62-65). Approximately 20,000 surfers a year will be injured badly enough to require emergency care by analysis of a study documenting ED visits by outdoor sports enthusiasts. (Wilderness and Environmental Medicine, 19:2, June 2008; 91-98) 

Physiology

The initial events upon submersion progressing to death are:  

1. Panic and struggle

2. Breath holding

3. Inhalation and swallowing of water

4. Reflex laryngospasm to protect the airway

5. Intermittent strong inhalations

6. Hypoventilation, hypoxia, hypercapnia,

7. Asphyxia with loss of consciousness

8. Laryngospasm abates, the glottis opens, and water passively enters airways

9. Up to 15% victims may have persistent laryngospasm

10. Cardiopulmonary arrest, pulmonary edema, neurological asphyxia

Most near-drowning victims aspirate 3 to 4 ml/kg of body weight.

22ml/kg is the lethal volume. As little as 2.2 ml/kg decrease Pa02 to 60

mmHg and increases pulmonary shunting. There is little physiological difference between fresh and saltwater drowning. Both cause disruption and washout of surfactant with alteration of surface tension in the lung and alveolar collapse. Microatelectasis results in ventilation/perfusion (V/Q) mismatch, right to left intrapulmonary shunting and hypoxemia which causes hyperventilation. Disruption of lung parenchymal architecture (capillary and alveolar membranes) leads to inflammation and pulmonary edema. Fluid in the lungs leads to pulmonary vasoconstriction and hypertension. In both fresh and salt water, electrolyte changes and volume shifts are rarely large enough to be of clinical significance. 

Clinical Presentation

There is a wide spectrum of clinical presentations for submersion events. Victims may be asymptomatic and appear well, others obtunded, pulseless, and apneic.
 

Treatment by category

The asymptomatic patient: Alert, no respiratory distress, no cough, normal vital signs, and normal chest exam (using “Look, Listen, Feel” field exam). Try to estimate severity of incident, especially the possibility of aspiration. Victims require careful monitoring for onset of hypoxemia secondary to delayed pulmonary changes (edema, atelectasis), usually within 4 hours (California Beach Study). However, clinical signs of pulmonary dysfunction may be delayed for 12 to 24 hours depending on the extent of submersion. If on a remote beach or coastal cruising, head to nearest port as a precaution; if offshore, alert any other vessels in area using a “pan-pan” alert.

The coughing patient-normal exam: Treat as above, but anticipate possible deterioration, and need for evacuation. Observe for persistent cough, tachycardia, tachypnea, dyspnea, pallor, anxiety.

The symptomatic patient: one who requires resuscitation or experiences respiratory distress including: persistent cough, dyspnea, tachypnea, anxiety, and burning chest pain. Signs may include abnormal vital signs, cyanosis, wheezing, rales, frothy sputum, and a variety of neurological states ranging from alert and oriented to combative, stuporous, or comatose. Evacuation and transfer from boat or beach to a hospital is required. While awaiting transport, protection of the airway to insure oxygenation and ventilation is a priority. Most (85%) victims will be vomiting, therefore protect the airway from gastric contents. If available, administer supplemental (100%) oxygen via mask (8-10L/min) by demand valve. Dive boats in the area may have emergency oxygen tanks. Albuterol inhalation is effective for the initial treatment of bronchospasm. Steroids and antibiotics are not indicated. Protect against hypothermia by shielding the victim from the wind, dry the skin and dress them in dry clothing. Wrap them in blankets if available. Maintain patient in horizontal position and splint cervical spine if c-spine injury is likely (usually low incidence). If the patient is conscious and insists on sitting up to ease his breathing and clear the airway, allow him to do so.

 

CPR, started earlier, has a better outcome. Chest compression and mouth-to-mouth ventilation are difficult to perform in the water, are generally ineffective, and delay extrication from the water. If the rescuer is skilled and well trained in this method, rescue breathing is certainly worth trying in the water. With respect to the “new guidelines” (Circulation, August 12, 2008) for CPR, it’s important to note that rescue breathing is especially critical if the cause of cardiac arrest is predominantly due to a respiratory problem such as drowning. Perform CPR on cold water drowning victims (water less than 68ºF) where submersion has been less than one hour. If submersion time is unknown, begin CPR, unless obvious signs of a long submersion are evident. Stop CPR after 30 minutes if VS absent in normothermic victim (“warm and dead”). If possible, perform CPR on cold water drowning victims (water less than 68ºF) until they reach the hospital. If a hospital is not available, and rewarming is not feasible, discontinue within 30 minutes. If person has been submerged in the water of any temperature for more than one hour, resuscitation efforts are usually unsuccessful (Giesbrecht). Do not start CPR if the victim has sustained an obviously fatal injury. The Heimlich maneuver has no role in the resuscitation of submersion victims.” It does place the victim at risk for pulmonary aspiration of gastric contents.

 

Hypothermia

 

Hypothermia is the life-threatening lowering of the body's core temperature due to exposure to cold. Water conducts heat from the body 25 to 30 times faster than air. Make sure you have appropriate wetsuit and other heat retaining clothing when surfing in cold environments and don't overdo exposure to the cold by staying out too long. Recognize warning signs such as euphoria and dizziness. A blanching of fingertips and toes known as Raynaud’s phenomenon may also occur.

We now appreciate that sudden immersion of an unsuited head, neck and face in very cold water (winter surfing in New Jersey) initiates a series of incapacitating reflexes which increase the risk of drowning. Indeed, the most common cause of death from accidental cold-water immersion is drowning, not hypothermia. These deaths occur while the victims are still normothermic. The initial response, which affects breathing, heart function, and muscle strength, is called the Cold-Shock Response. This is a series of reflexes that begin immediately upon sudden cooling of the skin following cold-water immersion. The initial phase of the cold-shock response peaks during the first 30 seconds, and lasts just two to three minutes. Cold water stimulates large inspiratory gasps, followed by rapid and deep breathing. If entry into the water includes complete submersion of the head, the gasp reflex can result in immediate aspiration of water and immediate drowning; uncontrolled hyperventilation can also quickly lead to accidental inhalation of seawater and drowning.  

This rapid and seemingly uncontrollable over-breathing creates a sensation of suffocation and contributes to feelings of panic. Hypocapnia, decrease in cerebral blood flow, and cerebral hypoxia eventually contribute to dizziness, confusion, disorientation, and a decreased level of consciousness. The hyperventilation may be prolonged by the emotional stress of the situation. During the cold shock response, blood pressure, heart rate, and the workload of the heart all increase, making individuals with cardiac disease more susceptible to ventricular fibrillation, cardiac arrest, and myocardial infarction. It is important to realize that this initial phase of the cold-shock response is brief and that actions during this time can vastly improve your chance for survival. If you recognize yourself or another in the throes of cold shock response, it is imperative you try to bring your breathing under control while keeping the head above the water. Try to calm yourself, do not panic, and remember these reflexes will pass. Just keep your head above the water and consciously slow your breathing.

Rescuing Others

Basic rescue principles include getting to the injured surfer while being safe. Keep an eye out for rocks and other hazards. Get about 5 rescue breaths into the victim by laying the victim face-up and perpendicular over the surfboard, grabbing the chin in a pistol-grip fashion and performing mouth-to-mouth or mouth-to-nose resuscitation ensuring that air is entering the lungs by watching the chest rise and fall (Renneker, Sick Surfers, Palo Alto, Bull Publishing, 1993).  Get the surfer on the board using a “rescue roll” technique. Grab by the wetsuit or whatever gives leverage while exercising caution for potential spinal injuries. Advance shoreward with caution Paddle the surfer face-down and out of the water (“airway freeboard”), propped on the nose of the board with you paddling behind.

The New Pollution 

Coastal waters can have high levels of bacteria and other pollutants just after a storm. Waiting a few days is usually a good idea. Also checking for water quality advisories at the beach and online can help you stay healthy. Ocean water is a rich broth of microorganisms. Each organism has its own pathogenicity. Pseudomonas is well known for causing “hot-tub folliculitis” and is also implicated in causing the red raised welts of “wetsuit folliculitis”. These welts often resolve in 7-10 days without antibiotics. This may also be called “wetsuit pimples” (Renneker, Sick Surfers, Palo Alto, Bull Publishing, 1993).

“Red Tide” is a misnomer, often the water is clear or it may be brown, yellow or red, depending on the species of algae. Red tide has nothing to do with the tide. Therefore harmful Algal bloom

(HAB) is the preferred term and is increasing in frequency world-wide. It is commonly associated with fertilizer runoff and warm water temperatures. Often the result is widespread fish kills and death of other marine life such as birds, seals and whales. Aerosolized toxins (Brevitoxin)in the ocean spray or whitewater may cause respiratory problems, conjunctivitis, and rhinitis.

(Nathanson AN, Seafood Toxidromes, Proceedings of First WMS Conference on Travel and Marine Medicine; 2008 Nov 1-4; Maui, HI. Maui, HI: Wilderness Medical Society 2008)

On the east coast of the United States, Pfiesterra algae have been implicated in ciguatera-type illness (tingling in hands and feet) as well as skin lesions, headache and a burning sensation in the skin on contact with water during fish-kill periods (Environ Health Persp 109(suppl 5)p781 2001). Risk appears to be increased near estuaries and river-mouth breaks.

Phototrauma

Solar urticaria (sun bumps) and aquagenic (rare water mediated bumps) are immunologically mediated and itch relentlessly. Cold and cholinergic urticaria are temperature related from cold and intense exercise (or hot wetsuits) respectively (J Allergy Clin Imm 1988;82). Treatment is modification of precipitating factors and antihistamines. 

In response to an alarming increase in skin cancer rates, much work is being done to find causes, identify populations at risk, and appropriately modify behaviors and protective strategies. The causes of nonmelanoma and melanoma skin cancers are multifactorial; however, the evidence implicating ultraviolet radiation as a major factor is mounting. Sunlight consists of four important wavelengths. Two of them, UVA and UVB, are the most harmful because they cause direct cellular trauma and immunologic suppression. Sunburn is a delayed UVB-induced redness in the skin. Sunburn is a delayed prostaglandin-mediated erythema that implies severe damage to DNA in a cumulative fashion. Avoidance recommendations include activity planning strategies and sunscreen use. (Wilderness and Environmental Medicine: Vol. 12, No. 3, pp. 195–200)

An appreciation of skin types is requisite to the understanding of photoprotection principles.

Type 1: never tan, always burn (lightly complected blondes and red heads).

Type 2: frequently burn, may tan after prolonged exposure.

Type 3: burn infrequently and tan easily.

Type 4: rarely burn, tan heavily (Asian, Native American, Latin American descent).

Type 5: darkly complected, darker with exposure (lightly complected African and Indian descent).

Type 6: heaviest pigmentation (darkly complected African descent).

(Arch Dermatol. 1997;133:1146–1158)

It has been written that one in seven Americans will get skin cancer (Renneker, Sick Surfers, Palo Alto, Bull Publishing, 1993). Know how to examine a lesion with ABCD. A for asymmetry: an asymmetric lesion is more likely to be malignant. B for border: a fuzzy or irregular border heralds abnormality. C for color: dark bluish discoloration is abnormal, “black mole” skin cancer has been a term for malignant melanoma (Renneker, Sick Surfers, Palo Alto, Bull Publishing, 1993).. D for diameter: large lesions must be evaluated further.

Collagenomas- Getting Rubbed the Wrong Way

“Surfer’s knots” were common on the knees and feet with knee-paddling surfers. As more surfers are in a prone paddling position with short-board surfing, chest knots and rib knots may arise and become quite disturbing to a surfer not acquainted with fluid filled lumps on the ribs and costal cartilage. They are sometimes painful. They are non-malignant.

Soft Tissue Injuries 

Most common injuries are lacerations. The head, lower leg and foot appear to be the most common injuries, usually caused by contact with the surfer’s own or another surfer’s board or fins, with the ocean floor, or with submerged pilings. Surf safe and know the proper etiquette (do not “snake” and do not “drop-in”) in the lineup to avoid hurting others. Physicians and paramedical personnel, see Wound Management principles below.

Soft-tissue injuries comprise the second-largest category, ranging from contusions to acute strains or sprains to the lumbar and cervical spine, shoulder, knee and ankle. Marine creatures pose a significant risk to surfers in contrast to land-based sports. Knowledge of the dangers is important as is their prevention, evaluation and management.

Marine Animal Bites 

Morey Eels: 

Morey eel injuries can result in bleeding, severe muscle damage and fractures. Moray eel bites are notorious for tendon and nerve damage in hands and feet. For minor bites, gently pull the edges of the skin open and remove embedded teeth either by rinsing or using tweezers. Scrub directly inside the bite with clean gauze or a cloth soaked in clean, fresh water. Press on the wound to stop bleeding. If bleeding persists, or the edges of a wound are jagged or gaping, the victim likely needs stitches. Stop any bleeding with pressure, clean wounds thoroughly. (Thomas, C. All Stings Considered. University of Hawaii. 1997, pp. 20-229)

Bites are notoriously infectious and require broad spectrum gram negative coverage including Vibrio species. It is less likely that they will frequent turbulent surf break areas.

Barracuda: 

Barracudas can sever arteries or veins. In such cases, victims can die rapidly from blood loss. Often, a rescuer can stop bleeding from severed blood vessels by firmly pressing anything handy (swimsuit, towel, hand) directly on the wound. Such pressure usually causes the vessel to clamp down in spasm, and clots begin to form. In the water, however, this procedure can be nearly impossible, especially while helping a victim to shore, or to a boat. In these cases, when bleeding may be fatal, a tourniquet is appropriate. Tying a surfboard leash or dive mask strap around a massively bleeding limb could save a life. (Thomas, C. All Stings Considered. University of Hawaii. 1997, pp. 20-229)

Crocodiles and Caimans:

Crocodiles include all archosaur members of the order Crocodilia: i.e. the true crocodiles, the alligators and caimans. Australian surfer Matthew Goodall was attacked and rolled by a large saltwater crocodile in Indonesia recently. Crocodiles are found in the rivermouth breaks of Costa Rica. Caimans may be found near the Amazon. Bites are notoriously infectious and require broad spectrum gram negative coverage including Vibrio species.

Sharks:

Sharks are mostly marine fish that sometimes swim into freshwater estuaries at rivermouth breaks, with certain species large and voracious. They have a cartilagenous skeleton, placoid scales, 5-7 gill slits on side of head, 1 or more rows of functional teeth. Most attacks in South Africa are at dusk near shore. In U.S. most attacks are off Florida shore. Worldwide, only 50 shark attacks occur per year with 10 deaths. Surfers make up 69% of all shark attack victims whereas SCUBA divers make up 18% (www.flmnh.ufl.edu/fish/Sharks)

 
Sharks most commonly associated with human attacks are:

1. Tiger Shark
2. Great White Shark
3. Gray Reef Shark
4. Bull Shark

   Sutures and Ocean Wounds 

Know the contraindications to suturing or closure

1. Puncture Wound
2. Crush injury
3. Wound involving distal hands or feet

Observe for signs of infection
Most common bacterial organisms are 

1. Staphylococcal Cellulitis
2. Group A Streptococcus Cellulitis (Erysipelas)
3. Vibrio vulnificus (high risk of rapid progression)
4. Treat Cellulitis early if observed and select antibiotics to cover Vibrio Cellulitis– Doxycycline (prophylaxis is usually not indicated)

(Habif (1996) Dermatology, p. 491; Jain (2003) Emerg Med Clin North Am 21(4):1117; Perkins (2004) Am Fam Physician 69(4):885)

Injury prevention measures include:

1. Rubber Guards
   1. Covers surf board nose and fins
   2. SurfCo – endorsed by ISA (www.isasurf.org)
2. Surfing helmet – GATH endorsed by ISA
3. Protective eye glasses – per ASTM standards (see solar injury section)
4. Surfboard leash
   1. Protect other surfers from a loose board
   2. Raises risk of injury to surfer via recoil
   3. Consider longer surf board leash

                                    (Zoltan (2005) Am Fam Physician 71:2313)

4. May use leash to stabilize to board for transport with “towel collar” (surfboard and collar- improvisational only when EMS not available- see cervical spine section) 

Wetsuits, rash guards, gloves and boots may all help prevent abrasions and lacerations but are no guarantee.

Abdominal trauma emergencies:

World champ Martin Potter eviscerated himself at Burliegh Heads during a surf session
Splenic laceration is the most commonly injured internal organ and the most frequent cause of death from blunt trauma in sport. Symptoms may be limited only to shock-like symptoms as wetsuits may obscure the injury. Any perforated skin with viscera protruding should be irrigated and covered with an occlusive dressing. Eviscerated organs should be placed back in the peritoneal cavity before swelling precludes this. Prompt EMS transport to a trauma center is a must.

Urologic-genital trauma emergencies:

Testicular trauma and torsion (twisting of the testicle) are best evaluated by ultrasound in the ED as testicular rupture is a surgical emergency (Journal of Urology 2002; 168(4 Pt 2)1805). There have been cases of the surfboard's nose and fins slicing through wetsuit and scrotum to lacerate testicles and cause urethral meatal injuries. Female forced water douche can cause vaginal lacerations with subsequent endometritis and even salpingitis. This has been documented in the literature occurring in water-skiing injuries. Similar forces in heavy wave action (“surf-douche”) are plausible. Vulvar and urethral injuries also occur from falls onto the surfboard. Flank pain and hematuria (bloody urine) may occur when board, rock or reef forcefully impact at the costovetebral angle in the mid-back where the kidneys rest. 95% of kidney contusions will have some degree of hematuria (bloody urine). All contusions deserve imaging as cortical and caliceal lacerations cannot be ruled out (Journal of Urology 2002;168(6):2575). Hematuria can occur independent of renal trauma after strenuous exercise, however it will manifest simply as dark urine and not grossly bloody. If it is bloody or persists for longer than 48 hours, a full workup is needed to rule out renal cell carcinoma, polycystic kidneys or stones (Clin Sports Med 1992;11:437). The same is true for protein in the urine. Exercise induced proteinuria is common with strenuous activities such as surfing. It should clear after 24-48 hours. 

 

Eyes:

Loose surfboards can gouge out an eye just as easily as lacerate the skin. All efforts should be exhausted to maintain control of a board when paddling out around others. Letting go of a board during paddle-outs is a serious and dangerous faux-pas. If an eye injury occurs, visual acuity, mechanism of injury, tearing, blood-fluid level in the anterior chamber, pain and sensitivity to light (photophobia) are the most important factors in triaging an eye injury (Prim Care 1984;11:161). External examination of bony orbits with finger pressure should be done to rule out fracture. An eyeball that cannot fix gaze may indicate a blowout fracture. A teardrop pupil may indicate a globe rupture. Never place an eyepatch over a suspected ruptured globe as there is risk of retinal detachment. Use a rigid eye shield or improvise with a cup while seeking emergency care (Am Fam Physician 1996;34:137-142). LASIK has not been shown to increase risk of globe rupture from blows to the eye whereas radial keratotomy has been (Int Ophth Clin 2002;43(3):33). Differentiating a simple subconjunctival hemmorhage from a likely ruptured globe is possible with knowledge that subconjunctival hemorrhage will never completely encircle the pupil whereas ruptured globes will and require emergent ophthalmology evaluation (Rhee, Wills Eye Manual, LWW, 1999). Corneal abrasions cause pain and photophobia and copious tearing which can blur vision (Vaughan, General Ophthalmology, A&L, 1999). All surfers should wear eye protection to prevent the above as well as pterygium (discussed below) and especially those that are functionally monocular (best corrected visual acuity less than 20/40 in one eye) (Phys Sports Med 2000;28)

 

Ears:

Surfer's ear (inflamed auditory canal) can be prevented by rinsing ears with vinegar after each surf session. 

The surfer can perforate an eardrum when the external auditory canal experiences a forceful displacement of air towards the tympanic membrane when the ear impacts flat against water. This may be accompanied by dizziness or vertigo as saltwater floods the labrynthine system. Urgent ENT evaluation is recommended. Cauliflower ear is an unlikely complication of ear cartilage impact with a surfboard. Blood accumulation between the auricular cartilage can lead to permanent deformity and is often seen in wrestlers, boxers, mixed martial artists and brawlers. Treatment involves ice and aspirating the blood with an 18-20 gauge needle, followed by either a pressure dressing or suturing buttons on either side of the cartilage to prevent blood accumulation (Phys Sports Med 1998;26(9).

"Surfer's exostosis” is a chronic condition may develop involving bony growths within the external ear canal as a result of cold water, spray and wind rushing in and out of the canal, stimulating the tissues to produce excessive bone growth. This causes a loss in diameter of the ear canal and a consequential decrease in hearing. Ear plugs may slow this phenomenon. Doc's Proplugs are endorsed by the ISA.

Nose: 

Nasal fractures are most likely to occur from an errant surfboard. Seek emergency care after reduction in the field to reduce swelling. Side blows cause simple fractures with opposite side deviation whereas direct blows cause comminuted fractures (Phys Sports Med 1998;26(8)). No surfing for at least a week. Accumulation of blood between septal cartilage and mucosa will cause a bluish bulge on examination of the nose and heralds a septal hematoma. Emergency care is highly recommended. If a kit is present with a skilled operator, drainage with an 18-20 gauge needle, bilateral nasal packing for 5 days and 2 weeks of antibiotics will prevent abcess formation (Phys Sports Med 1998;26(8)).

Mouth and throat: 

Tooth avulsions are dental emergencies. Place the tooth back into position manually as soon as possible and seek immediate dental care. About 90% of avulsed teeth may survive if reimplanted and confirmed of this by a dental expert. A tooth out of socket for more than 2 hours has a dismal chance of survival. (Am Fam Phys 2003;67(3):511). If reimplantation is not possible, place the tooth in the cheek, under the tongue, in Hank's Solution (see medical kit), and less desirably milk or sea water. Tap water is the worst option. Tongue and lip lacerations bleed copiously. Through-and-through lacerations (daylight through the lip) should be repaired at a hospital with antibiotics (see wound management principles). Blunt trauma to the throat, though rare, may cause laryngospasm with choking and panic. Manual jaw thrusting opens the airway (EM Clinics North Am 2003;21:1). Laryngospasms usually relax within a minute but must be evaluated by a medical professional as swelling crescendos for six hours and must be observed for the next forty-eight hours. (Phys Sports Med 2001;29(11)).

The Surfari: General recommendations for Surf Travel Abroad

Traveler’s Diarrhea: Safe food, Safe Water and water purification

Viruses and bacteria cause traveler’s diarrhea. Both iodine tablets and chlorine are effective in the inactivation of viral pathogens in water. Standard field filtration devices are only capable of removing protozoan parasites and bacteria. All tap water used for drinking, brushing teeth, and making ice cubes should be boiled prior to use. Insure that bottled water is uncapped in your presence. Milk should be boiled to insure safety. Powdered and evaporated milk are available and safe. Avoid butter and other dairy products. All meat, poultry and seafood must be well cooked and served while hot. Pork is best avoided. Vegetables should be well cooked and served hot. Salads and mayonnaise are best avoided. Fruits with intact skins should be peeled by you just prior to consumption. Avoid cold buffets, custards, and any frozen dessert. (Forgey, Travel Medicine 101, Proceedings of 1^st WMS Dive, Travel and Marine Medicine Conference, November 2008). 

Chumming and Bumming: Sea Sickness- Causes, Cures, Prevention

Boat trips are the ultimate luxury in destination surfing. The English words nautical and nausea both derive from the old Greek word-root of " boat", and a close association between the two continues to this day. Seasickness is a debilitating condition that can afflict almost anyone, some­times even in relatively mild sea conditions. Its direct effects are temporary and nonfatal, but it may lead to potentially dangerous dehydration and can create a hazardous situation by robbing crew members of the ability—and sometimes the will—to care for self and ship. Some individuals appear to be relatively immune while others, including many commercial fishermen and professional mariners, suffer from it intensely and repeatedly. Aversion to seasickness is a major deterrent to recreational boating, sport fishing, and cruise vacationing. Although fear may be a contributing factor, the condition itself is neither psychological nor “all in the head.” It is a very real physiological response to disturbance of the normal sense of balance, as perceived via the visual, vestibular (inner ear), proprioceptor (peripheral body sensory), and somato­sensory (overall body sensory) systems. Seasickness is largely preventable and is treatable once in progress. Many people with motion sickness susceptibility function comfortably at sea by us­ing good information to apply appropriate behavior and effective medication.Many marine, water sports, and medical writers have offered seasickness advice based on lengthy experience on the water. Some of that advice is confirmed by the research results, while much appears intuitively valid but not clinically tested.  Many sources state that seasickness is the result of dissonance between the vestibular and vision systems that often occurs when persons go below deck or focus their vision on objects inside the cabin. However, if it were caused simply by the difference between what the eye sees and the inner ear experi­ences, it could be prevented or cured simply by keeping the sufferer’s vision focused on the sea outside the boat. Usually this is not the case. Seasickness in most people has two components. One is distress—the sen­sation of malaise, dizziness, and nausea—that results from sensory inputs to the brain. The other is the stomach’s reaction to it, which can be churning, acid overload, and vomiting. People may experience one without the other, but distress in the motion center of the brain seems to trigger a reaction in the stomach. Antacids and stomach folk remedies may ease the unpleasant gastric effects of seasickness, but will not attack the cause. While the genesis of most seasickness is repeated rhythmic motion, espe­cially up and down motion), it is exacerbated by odors, lack of ventilation, fear or apprehension, a sense of lack of control, and substances ingested by the sufferer, including alcohol, acidic drinks such as coffee and cola, and spicy or fatty foods. Even the sight of a vomiting shipmate can trigger nausea.  

Prevention, Diagnosis, and Treatment of Common Infectious Diseases Abroad:

Cholera

In January 1991, epidemic cholera appeared in South America and quickly spread to several countries. A few cases have occurred in the United States among persons who traveled to South America or ate contaminated food brought back by travelers. Predicting how long the epidemic in Latin America will last is difficult. The cholera epidemic in Africa has lasted more than 20 years. In areas with inadequate sanitation, a cholera epidemic cannot be stopped immediately, and there are no signs that the epidemic in the Americas will end soon. Latin American countries that have not yet reported cases are still at risk for cholera in the coming months and years. Major improvements in sewage and water treatment systems are needed in many of these countries to prevent future epidemic cholera. 

Cholera has been very rare in industrialized nations for the last 100 years; however, the disease is still common today in other parts of the world, including the Indian subcontinent and sub-Saharan Africa. Although cholera can be life-threatening, it is easily prevented and treated. In the United States, because of advanced water and sanitation systems, cholera is not a major threat; however, everyone, especially travelers, should be aware of how the disease is transmitted and what can be done to prevent it.

Cholera is an acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae. The infection is often mild or without symptoms, but sometimes it can be severe. Approximately one in 20 infected persons has severe disease characterized by profuse watery diarrhea, vomiting, and leg cramps. In these persons, rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours. A person may get cholera by drinking water or eating food contaminated with the cholera bacterium. In an epidemic, the source of the contamination is usually the feces of an infected person. The disease can spread rapidly in areas with inadequate treatment of sewage and drinking water.

The cholera bacterium may also live in the environment in brackish rivers and coastal waters. Shellfish eaten raw have been a source of cholera, and a few persons in the United States have contracted cholera after eating raw or undercooked shellfish from the Gulf of Mexico. The disease is not likely to spread directly from one person to another; therefore, casual contact with an infected person is not a risk for becoming ill.

In the United States, cholera was prevalent in the 1800s but has been virtually eliminated by modern sewage and water treatment systems. However, as a result of improved transportation, more persons from the United States travel to parts of Latin America, Africa, or Asia where epidemic cholera is occurring. U.S. travelers to areas with epidemic cholera may be exposed to the cholera bacterium. In addition, travelers may bring contaminated seafood back to the United States; foodborne outbreaks have been caused by contaminated seafood brought into this country by travelers.

The risk for cholera is very low for U.S. travelers visiting areas with epidemic cholera. When simple precautions are observed, contracting the disease is unlikely.

All travelers to areas where cholera has occured should observe the following recomendations:

• Drink only water that you have boiled or treated with chlorine or iodine. Other safe beverages include tea and coffee made with boiled water and carbonated, bottled beverages with no ice.
• Eat only foods that have been thoroughly cooked and are still hot, or fruit that you have peeled yourself.
• Avoid undercooked or raw fish or shellfish, including ceviche.
• Make sure all vegetables are cooked -- avoid salads.
• Avoid foods and beverages from street vendors.
• Do not bring perishable seafood back to the United States.
• A simple rule of thumb is:   "Boil it, cook it, peel it, or forget it."

A vaccine for cholera is available; however, it confers only brief and incomplete immunity and is not recommended for travelers. There are no cholera vaccination requirements for entry or exit in any Latin American country or the United States. 

Cholera can be simply and successfully treated by immediate replacement of the fluid and salts lost through diarrhea. Patients can be treated with oral rehydration solution, a prepackaged mixture of sugar and salts to be mixed with water and drunk in large amounts. This solution is used throughout the world to treat diarrhea. Severe cases also require intravenous fluid replacement. With prompt rehydration, fewer than 1% of cholera patients die.

Antibiotics shorten the course and diminish the severity of the illness, but they are not as important as rehydration. Persons who develop severe diarrhea and vomiting in countries where cholera occurs should seek medical attention promptly.

 

Dengue Fever

Dengue (DF) and dengue hemorrhagic fever (DHF) are caused by one of four closely related, but antigenically distinct, virus serotypes (DEN-1, DEN-2, DEN-3, and DEN-4), of the genus Flavivirus. Infection with one of these serotypes provides immunity to only that serotype for life, so persons living in a dengue-endemic area can have more than one dengue infection during their lifetime. DF and DHF are primarily diseases of tropical and sub tropical areas, and the four different dengue serotypes are maintained in a cycle that involves humans and the Aedes mosquito. However, Aedes aegypti, a domestic, day-biting mosquito that prefers to feed on humans, is the most common Aedes species. Infections produce a spectrum of clinical illness ranging from a nonspecific viral syndrome to severe and fatal hemorrhagic disease. Important risk factors for DHF include the strain of the infecting virus, as well as the age, and especially the prior dengue infection history of the patient.

The first reported epidemics of DF occurred in 1779-1780 in Asia, Africa, and North America.  The near simultaneous occurrence of outbreaks on three continents indicates that these viruses and their mosquito vector have had a worldwide distribution in the tropics for more than 200 years. During most of this time, DF was considered a mild, nonfatal disease of visitors to the tropics. Generally, there were long intervals (10-40 years) between major epidemics, mainly because the introduction of a new serotype in a susceptible population occurred only if viruses and their mosquito vector could survive the slow transport between population centers by sailing vessels.

A pandemic of dengue began in Southeast Asia after World War II and has spread around the globe since then.  Epidemics caused by multiple serotypes (hyper-endemicity) are more frequent, the geographic distribution of dengue viruses and their mosquito vectors has expanded, and DHF has emerged in the Pacific region and the Americas. In Southeast Asia, epidemic DHF first appeared in the 1950s, but by 1975 it had become a frequent cause of hospitalization and death among children in many countries in that region.

No dengue vaccine is available. Recently, however, attenuated candidate vaccine viruses have been developed.  Efficacy trials in human volunteers have yet to be initiated.  Research is also being conducted to develop second-generation recombinant vaccine viruses. Therefore, an effective dengue vaccine for public use will not be available for 5 to 10 years.

Prospects for reversing the recent trend of increased epidemic activity and geographic expansion of dengue are not promising. New dengue virus strains and serotypes will likely continue to be introduced into many areas where the population densities of Ae. aegypti are at high levels. With no new mosquito control technology available, in recent years public health authorities have emphasized disease prevention and mosquito control through community efforts to reduce larval breeding sources.

 

Hepatitis 

Viral hepatitis is inflammation of the liver caused by a virus. Several different viruses, named the hepatitis A, B, C, D, and E viruses, cause viral hepatitis.

All hepatitis viruses can cause acute, or short-term, viral hepatitis. The hepatitis B, C, and D viruses can also cause chronic hepatitis, in which the infection is prolonged, sometimes lifelong. Chronic hepatitis can lead to cirrhosis, liver failure, and liver cancer. Hepatitis C and D is mostly not a risk for travelers unless injection drug users or receiving blood transfusion.

Researchers are looking for other viruses that may cause hepatitis, but none have been identified with certainty. Other viruses that less often affect the liver include cytomegalovirus; Epstein-Barr virus, also called infectious mononucleosis; herpesvirus; parvovirus; and adenovirus.

Symptoms include

• jaundice, which causes a yellowing of the skin and eyes
• fatigue
• abdominal pain
• loss of appetite
• nausea
• vomiting
• diarrhea
• low grade fever
• headache

However, some people do not have symptoms.

Hepatitis A is spread primarily through food or water contaminated by feces from an infected person. Rarely, it spreads through contact with infected blood.

People most likely to get hepatitis A are

• international travelers, particularly those traveling to developing countries
• people who live with or have sex with an infected person
• people living in areas where children are not routinely vaccinated against hepatitis A, where outbreaks are more likely
• day care children and employees, during outbreaks
• men who have sex with men
• users of illicit drugs

 

The hepatitis A vaccine offers immunity to adults and children older than age 1. The Centers for Disease Control and Prevention recommends routine hepatitis A vaccination for children aged 12 to 23 months and for adults who are at high risk for infection. Treatment with immune globulin can provide short-term immunity to hepatitis A when given before exposure or within 2 weeks of exposure to the virus. Avoiding tap water when traveling internationally and practicing good hygiene and sanitation also help prevent hepatitis A. 

Hepatitis A usually resolves on its own over several weeks.

Hepatitis B is spread through contact with infected blood, through sex with an infected person, and from mother to child during childbirth, whether the delivery is vaginal or via cesarean section.

People most likely to get hepatitis B are

• people who live with or have sexual contact with an infected person
• men who have sex with men
• people who have multiple sex partners
• injection drug users
• immigrants and children of immigrants from areas with high rates of hepatitis B
• infants born to infected mothers
• health care workers
• hemodialysis patients
• people who received a transfusion of blood or blood products before 1987, when better tests to screen blood donors were developed
• international travelers

The hepatitis B vaccine offers the best protection. All infants and unvaccinated children, adolescents, and at-risk adults should be vaccinated. For people who have not been vaccinated, reducing exposure to the virus can help prevent hepatitis B. Reducing exposure means using latex condoms, which may lower the risk of transmission; not sharing drug needles; and not sharing personal items such as toothbrushes, razors, and nail clippers with an infected person.

Drugs approved for the treatment of chronic hepatitis B include alpha interferon and pegylated (PEG) interferon, which slow the replication of the virus in the body and also boost the immune system, and the antiviral drugs lamivudine, adefovir dipivoxil, entecavir, and telbivudine. Other drugs are also being evaluated. Infants born to infected mothers should receive hepatitis B immune globulin and the hepatitis B vaccine within 12 hours of birth to help prevent infection.

People who develop acute hepatitis B are generally not treated with antiviral drugs because, depending on their age at infection, the disease often resolves on its own. Infected newborns are most likely to progress to chronic hepatitis B, but by young adulthood, most people with acute infection recover spontaneously. Severe acute hepatitis B can be treated with an antiviral drug such as lamivudine.

 

Malaria 

Malaria is a serious and sometimes fatal disease caused by a parasite that commonly infects a certain type of mosquito which feeds on humans. People who get malaria are typically very sick with high fevers, shaking chills, and flu-like illness. Four kinds of malaria parasites can infect humans: Plasmodium falciparum, P. vivax, P. ovale, and P. malariae. Infection with P. falciparum, if not promptly treated, may lead to death. Although malaria can be a deadly disease, illness and death from malaria can usually be prevented.

About 1,300 cases of malaria are diagnosed in the United States each year. The vast majority of cases in the United States are in travelers and immigrants returning from malaria-risk areas, many from sub-Saharan Africa and South Aisa.

The World Health Organization estimates that each year 300-500 million cases of malaria occur and more than 1 million people die of malaria, especially in developing countries. Most deaths occur in young children. For example, in Africa, a child dies from malaria every 30 seconds. Because malaria causes so much illness and death, the disease is a great drain on many national economies. Since many countries with malaria are already among the poorer nations, the disease maintains a vicious cycle of disease and poverty.

Usually, people get malaria by being bitten by an infective female Anopheles mosquito. Only Anopheles mosquitoes can transmit malaria and they must have been infected through a previous blood meal taken on an infected person. When a mosquito bites an infected person, a small amount of blood is taken in which contains microscopic malaria parasites. About 1 week later, when the mosquito takes its next blood meal, these parasites mix with the mosquito's saliva and are injected into the person being bitten.

Because the malaria parasite is found in red blood cells of an infected person, malaria can also be transmitted through blood transfusion, organ transplant, or the shared use of needles or syringes contaminated with blood. Malaria is not spread from person to person like a cold or the flu, and it cannot be sexually transmitted. You cannot get malaria from casual contact with malaria-infected people, such as sitting next to someone who has malaria.

Plasmodium falciparum causes severe and life-threatening malaria; this parasite is very common in many countries in Africa south of the Sahara desert. People who are heavily exposed to the bites of mosquitoes infected with P. falciparum are most at risk of dying from malaria. People who have little or no immunity to malaria, such as young children and pregnant women; or travelers coming from areas with no malaria, are more likely to become very sick and die. Poor people living in rural areas who lack knowledge, money, or access to health care are at greater risk for this disease.

Typhoid 

Typhoid fever is a life-threatening illness caused by the bacterium Salmonella Typhi. In the United States about 400 cases occur each year, and 75% of these are acquired while traveling internationally. Typhoid fever is still common in the developing world, where it affects about 21.5 million persons each year.

Typhoid fever can be prevented and can usually be treated with antibiotics. If you are planning to travel outside the United States, you should know about typhoid fever and what steps you can take to protect yourself.

Salmonella Typhi lives only in humans. Persons with typhoid fever carry the bacteria in their bloodstream and intestinal tract. In addition, a small number of persons, called carriers , recover from typhoid fever but continue to carry the bacteria. Both ill persons and carriers shed S. Typhi in their feces (stool).

You can get typhoid fever if you eat food or drink beverages that have been handled by a person who is shedding S. Typhi or if sewage contaminated with S. Typhi bacteria gets into the water you use for drinking or washing food. Therefore, typhoid fever is more common in areas of the world where handwashing is less frequent and water is likely to be contaminated with sewage.

Once S. Typhi bacteria are eaten or drunk, they multiply and spread into the bloodstream. The body reacts with fever and other signs and symptoms.

Typhoid fever is common in most parts of the world except in industrialized regions such as the United States, Canada, western Europe, Australia, and Japan. Therefore, if you are traveling to the developing world, you should consider taking precautions. Over the past 10 years, travelers from the United States to Asia, Africa, and Latin America have been especially at risk. 

Two basic actions can protect you from typhoid fever:

1. Avoid risky foods and drinks.
2. Get vaccinated against typhoid fever.

It may surprise you, but watching what you eat and drink when you travel is as important as being vaccinated. This is because the vaccines are not completely effective. Avoiding risky foods will also help protect you from other illnesses, including travelers' diarrhea, cholera, dysentery, and
hepatitis A.

"Boil it, cook it, peel it, or forget it"

If you are traveling to a country where typhoid is common, you should consider being vaccinated against typhoid. Visit a doctor or travel clinic to discuss your vaccination options.

Remember that you will need to complete your vaccination at least 1 week before you travel so that the vaccine has time to take effect. Typhoid vaccines lose effectiveness after several years; if you were vaccinated in the past, check with your doctor to see if it is time for a booster vaccination. Taking antibiotics will not prevent typhoid fever; they only help treat it.

Persons with typhoid fever usually have a sustained fever as high as 103° to 104° F (39° to 40° C). They may also feel weak, or have stomach pains, headache, or loss of appetite. In some cases, patients have a rash of flat, rose-colored spots. The only way to know for sure if an illness is typhoid fever is to have samples of stool or blood tested for the presence of S. Typhi . 

If you suspect you have typhoid fever, see a doctor immediately. If you are traveling in a foreign country, you can usually call the U.S. consulate for a list of recommended doctors.

You will probably be given an antibiotic to treat the disease. Three commonly prescribed antibiotics are ampicillin, trimethoprim-sulfamethoxazole, and ciprofloxacin. Persons given antibiotics usually begin to feel better within 2 to 3 days, and deaths rarely occur. However, persons who do not get treatment may continue to have fever for weeks or months, and as many as 20% may die from complications of the infection.

Even if your symptoms seem to go away, you may still be carrying S. Typhi . If so, the illness could return, or you could pass the disease to other people. In fact, if you work at a job where you handle food or care for small children, you may be barred legally from going back to work until a doctor has determined that you no longer carry any typhoid bacteria.

If you are being treated for typhoid fever, it is important to do the following:
Keep taking the prescribed antibiotics for as long as the doctor has asked you to take them. Wash your hands carefully with soap and water after using the bathroom, and do not prepare or serve food for other people. This will lower the chance that you will pass the infection on to someone else. Have your doctor perform a series of stool cultures to ensure that no S. Typhi bacteria remain in your body.

 

Yellow Fever

Yellow fever is a viral disease that is transmitted to humans through the bite of infected mosquitoes. Illness ranges in severity from an influenza-like syndrome to severe hepatitis and hemorrhagic fever. Yellow fever virus (YFV) is maintained in nature by mosquito-borne transmission between nonhuman primates. Transmission by mosquitoes from one human to another occurs during epidemics of “urban yellow fever.”

The disease occurs only in sub-Saharan Africa and tropical South America where it is endemic and intermittently epidemic. Areas considered endemic for yellow fever have evidence of yellow fever transmission to humans and/or its potential, due to the presence of both a competent vector and YFV in nonhuman primates. In Africa, where most cases are reported, a variety of mosquitoes transmit the virus. The case-fatality rate of yellow fever in Africa is highly variable but approximates 20%. Infants and children are at greatest risk of severe disease. In South America, yellow fever occurs most frequently in young men who are exposed through their work to mosquito vectors in forested or transitional areas of Bolivia, Brazil, Colombia, Ecuador, Venezuela, Guyana, French Guiana, and Peru.

A traveler’s risk of acquiring yellow fever is determined by various factors, including immunization status, location of travel, season, duration of exposure, occupational and recreational activities while traveling, and the local rate of virus transmission at the time of travel. Although reported cases of human disease are the principal indicator of disease risk, case reports may be absent because of a high level of immunity in the population (e.g., due to vaccination campaigns), or because cases are not detected by local surveillance systems (1). Only a small proportion of yellow fever cases is recognized and officially reported because the involved areas are often remote and lack specific diagnostic capabilities.

During inter-epidemic periods, low-level transmission may not be detected by public health surveillance. Such inter-epidemic conditions may last years or even decades in certain countries or regions. This “epidemiologic silence” does not equate to absence of risk and should not lead to travel without the protection provided by vaccination. Surveys in rural West Africa during “silent” periods have estimated an annual incidence of yellow fever of 1.1-2.4 cases per 1,000 persons and 0.2-0.5 deaths per 1,000 persons. YFV transmission in rural West Africa is seasonal, with elevated risk during the 2-4 months that the rainy season ends and the dry season begins (usually July-October); therefore, the annual incidence reflects incidence during a transmission season of 2-4 months.

The incidence of yellow fever in South America is lower than that in Africa because the mosquitoes that transmit the virus between monkeys in the forest canopy do not often come in contact with humans and because immunity in the indigenous human population is high. Urban epidemic transmission has not occurred in South America for many years, although the risk of introduction of the virus into towns and cities is ever present. For travelers, the risks of illness and death due to yellow fever are probably 10 times greater in rural West Africa than in South America; the risk varies greatly according to specific location and season. In West Africa, virus transmission is highest during the late rainy and early dry seasons (July-October). In Brazil, the risk of infection is highest during the rainy season (January-March)

Travelers to areas with yellow fever transmission should take precautions against exposure to mosquitoes. Staying in air-conditioned or well-screened quarters and wearing long-sleeved shirts and long pants will help prevent mosquito bites. Insect repellents containing DEET or picaridin should be used on exposed skin and reapplied as directed on the label. Permethrin-containing repellents should be applied to clothing. Yellow fever is preventable by a relatively safe, effective vaccine. For all eligible persons, a single injection of 0.5 mL of reconstituted vaccine should be administered subcutaneously.

 

 

Feel free to email me at boardsportsdoc@yahoo.com.

Snowboarding Injuries Supplement

Compared with injuries resulting from traditional alpine skiing, snowboarding injuries occur more frequently in the upper extremities and ankles and less frequently in the knees.  (AFP 1999; 59:1) With the rise in popularity of snowboarding there has been a change in the injury pattern of these winter sports participants as compared with skiing and there has been the recognition of an ankle injury (fracture of the lateral process of the talus) that is specific to and only occurs in snowboarding. (Br J Sports Med 2000; 34:79) Risk of injury may be lowered by using protective equipment, such as a helmet and wrist guards (AFP 1999; 59:1)

 

Snowboarding has a slightly higher potential for upper extremity injuries than skiing, but it may be safer on the knees. There is an increased rate of foot and ankle injuries associated with snowboarding. The lead foot has twice the number of injuries than the back foot. One study showed that the hybrid or “mid-stiffness” boots were the safest style of boots. There may be more high-energy injuries such as femur fractures, high-speed injuries and injuries caused by getting “big air.”

(American Orthopaedic Society for Sports Medicine 2008, www.sportsmed.org)

 

Prepare for the season and get in shape.

Get your equipment checked at a certified shop. 

Warm up before riding and stretch afterward.

Don’t ride while intoxicated. 

Wear a helmet

(AOSSM 2008)

 

According to a 1999 report by the U.S. Consumer Product Safety Commission, head injuries represent approximately 14 % of all skiing and snowboarding injuries. The majority of severe snowboarding head injuries were caused by the “opposite-edge phenomenon” where the snowboarder falls backward and contacts the occiput. The use of a helmet reduced substantially the linear accelerations and head injury criterion associated with head-to-ground contact on hard, icy snow and during the simulated tree contact. Also, the neck loads were reduced modestly with helmet use.  (JASTM 2006; 3:4)

The Colorado Snowboard Injury Survey collected information from over 7000 snowboard injuries. Their findings indicated that snowboarders wearing wrist guards were half as likely to injure their wrists than those not wearing guards. Wrist guards reduce the risk of wrist injuries among snowboarders. For every 50 snowboarders who were a wrist guard, one wrist injury will be averted.
(Clin J Sport Med. 2007 Mar;17(2):145-50) 

Big Air and Spinal Injuries

Over a ten year study period, 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, which are more severe stages of spinal injury. (AJSM 2008)

Snow Immersion Deaths

Kizer et al (Phys Sportsmed 1994;22(12):49-61) and Shealy reported that non-avalanche related snow immersion deaths in ski area tree-wells (NARSIDs) are a particular hazard for snowboarders. In a recent US study that spanned about the same time frame as this investigation, Shealy reported more snowboarders than Alpine skiers among tree-well fatalities. (Shealy JE: Modalities of death, snowboarding and skiing differences; 1991/92 through 1997/98. Presented at 13th International Congress on Ski Trauma and Skiing Safety, May 2-8, 1999, Breuil Cervenia, Italy).

It is advisable to stock and keep inventory of first aid and medical supplies for any off-piste snowboarding expedition. Wilderness, Outdoor Emergency Care and Sportsmedicine skills are useful in evaluating and managing snowboarding injuries in the field. Plan accordingly with the length of time and distance spent away from established civilian medical care.