The Annual Trip to the Ice-rink: A Seasonal Cause of Wrist Trauma in Irish Hospitals

Fractures of the distal radius are a common orthopaedic presentation in Irish emergency departments. As a nation, Irish people tend to ice-skate seasonally with a peak of interest seen during the Winter months in temporary ice-rinks. This case series describes winter ice-skating as a significant cause of wrist fractures in the younger patient, including five cases of distal radius fractures, four of which ultimately required internal fixation, under general anaesthesia, over a single weekend in the month of December. Despite all five patients being amateur ice-skaters, all denied ever having taken ice-skating lessons. This demonstrates the dangers of wrist trauma in the inexperienced or beginner ice-skaters on temporary ice-rinks; the seasonal morbidity suffered as a result.


Introduction
Fractures of the distal radius are common presentations in the western world, accounting for over 16% of orthopaedic trauma presentations in emergency departments [1]. Nearly two-thirds of all distal radius fractures are reported to occur following low-velocity trauma in the elderly, osteoporotic patient. Such wrist fractures are reported to correlate with significant morbidity [2]. However, in younger patients, sporting injuries are reported to the leading cause of distal radius fractures [3].
Due to Ireland's cool temperate oceanic climate, participation in ice-skating is typically only facilitated using non-natural ice-skating rinks. Therefore, peaks of interest in ice-skating are seen in Ireland during the Christmas period with seasonal ranks opening on a temporary basis in December nationwide. Despite the significant morbidity associated with this activity, many amateur Irish ice-skaters elect to ice-skate without having undergone lessons leading to a significant increase in ice-skating related injuries presenting to Irish emergency departments [4]. This case series demonstrates the dangers of wrist trauma associated with seasonal iceskating and the morbidity suffered as a result.

Case 1
A 40-year-old right-hand-dominant lady presented to the emergency department following a fall on an outstretched hand (FOOSH) injury whilst ice-skating. She suffered an extra-articular distal radius fracture with dorsal comminution and angulation to her non-dominant left hand

Case 2
A 53-year-old right-hand-dominant lady presented to the emergency department following a fall backwards whilst holding hands with her friend while ice-skating. She suffered an extraarticular distal radius fracture with dorsal comminution and angulation to her dominant right hand; this had been the contra-lateral hand to that held whilst ice-skating. Following the reduction in the emergency department, she was treated with open reduction and internal fixation using an Angle Stable Distal Radial Plate System (Marquardt Group, Rietheim-Weilheim, Germany).

Case 3
A 36-year-old left-hand-dominant female teacher presented to the emergency department following a fall during her first-time ice-skating. She suffered an intra-articular distal radius fracture with dorsal angulation and severe comminution to her dominant left hand. She

Case 4
A 41-year-old right-hand-dominant lady presented to the emergency department after a FOOSH injury whilst ice-skating. She suffered an intra-articular left distal radius fracture involving a significant portion of the radial styloid. She underwent closed reduction using two 1.6 mm Krischner wires (k-wires). She was neurovascularly intact post-operatively. Her k-wires were removed in the outpatient department at six-weeks with satisfactory fixation.

Case 5
A 37-year-old right-hand-dominant lady presented to the emergency department after falling backwards onto an out-stretched left hand whilst ice-skating. This resulted in an extra-articular left distal radius fracture with dorsal comminution. She was neurovascularly intact. This lady was treated conservatively using a molded cast and followed up in the outpatient fracture clinic thereafter.

Discussion
Distal radius fractures are reported to occur more commonly in elderly, osteoporotic patients [4]. Our case series discusses the intermittent, annual trips to an ice-skating rink as a significant cause of morbidity for the young, active patient. As all five distal radius fractures presented over one weekend in December; this sparked curiosity for the authors. Ice-skating is a seasonal leisure activity in Ireland that accounts for significant trauma, particularly in the month of December [4].
As a nation, ice-skating remains a novelty to the Irish population, which is commonly enjoyed during the Christmas period [4]. Ice-skating injuries, although serious in nature, are thought to represent less than 1% of emergency department referrals during this time period [5]. Due to the sporadic nature of our engagement with the activity, few people elect to receive full iceskating lessons prior to skating in a full-sized ice-rink [6]. Williamson et al. postulated that of those who sustain injuries whilst ice-skating, 75% will be beginners and 92% will never have received formal tuition or lessons [7]. Similarly, Matsumoto et al. reported that of those who suffer distal radius fractures during winter sporting and leisure activities, nearly 95% will never have had formal professional instruction [8].
Significant trauma can occur as a result of ice-skating and serious injuries (including distal radius fractures) related to this activity tend to occur in beginner ice-skaters [9]. Despite the majority of ice-skating injuries occurring in inexperienced or beginner ice-skating, over 40% of advanced ice-skaters will suffer a severe injury on the ice during their lifetime [10]. Of the trauma which occurs, it has been shown that upper limb trauma remains the commonest injury presenting to emergency departments following ice-skating accidents, with studies reporting that distal radius fractures may account for 45%-82% of such presentations [4,11].

Conclusions
This case series demonstrates the risk distal radius fractures in light of our desire to enjoy the hazardous activity of ice-skating on the annual trip to the temporary ice-rink. Furthermore, acknowledgement must be given to the fact that ice-skating lessons may need to be more widely available to newcomers and amateur ice-skaters. This, alongside significant public education, may play a role in the future to reduce the burden on our emergency departments.