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The Cutting Edge: A Deeper Look at Skate Blade Lacerations in Hockey

By Jerome C. Murray, MD, Caitlin C. Chambers, MD

    • Physicians' Corner
    • Industry Insights

Introduction

Ice hockey has an injury profile unlike most sports at the professional level due to the inherent contact, speed and intensity of play. Epidemiological studies assessing hockey injuries are sparce but reveal general injury rates as high as 84 per 1000 hours of gameplay in men’s hockey, and 20 per 1000 hours in women’s hockey1. Across all levels of play, the most common injuries are lacerations, ligament sprains, contusions, fractures and concussions. The source of laceration can be due to skate blades or direct strike by the puck or sticks.

Skate Blade Lacerations in the Media

Skate blade lacerations have recently garnered more attention due to their impact on player safety after the tragic death of former National Hockey League (NHL) player, Adam Johnson. Johnson, 29, died in October 2023 after his neck was cut by the skate blade of an opposing player in an Elite Ice Hockey League game in Sheffield, England. This disaster sent shockwaves through the hockey community, however it was not the first of its nature to happen in the sport. Two well-known NHL neck skate blade lacerations include Clint Malarchuk who suffered an Internal Jugular Vein laceration due to an opposing player’s skate in 1989 and Richard Zednik who had a common carotid artery laceration due to his teammate’s skate in 2008. Both Malarchuk and Zednik underwent emergent vascular repair and ultimately recovered without permanent neurological sequelae. In 2022, a 10th-grade high school player in Connecticut died due to skate laceration after a collision with an opponent’s skate blade. In the same year, NHL player Evander Kane sustained a skate blade laceration to the wrist in a professional hockey game.

The 2019-2020 NHL season saw six skate lacerations in 14 weeks before the season was suspended due to the COVID-19 pandemic. These included three wrist lacerations requiring surgery for transected tendons, nerves, and vasculature; two facial lacerations including an eyelid laceration requiring 90 sutures suffered by Johnny Boychuk of the Islanders, and one leg laceration2. While reportedly extremely rare, these devastating injuries reignited discussions regarding player protection and emergency preparedness.

Skate Blade Laceration Epidemiology

One challenge in defining the issue of skate blade lacerations is the lack of quality data on the subject. Particularly within professional, collegiate, and elite amateur hockey, team medical staff often perform laceration repairs on-site. This can lead to under-reporting within medical record databases that would otherwise capture and track skate blade lacerations. Additionally, lacerations in hockey are not always from skates but can also be due to contact with pucks, sticks, and the ice or boards, complicating tracking of this specific injury subset.

The best study of ice hockey skate blade lacerations to date was published in 2009 utilizing data from a survey sent to all registered USA hockey players. The resultant data from 11,000 hockey players revealed neck lacerations from a skate blade to be rather infrequent at 1.8%, with 61% of neck lacerations needing only bandaging3. The frequency and severity of these injuries are influenced by the speed and intensity of the game as well as the aggressive style of play.

Understanding the epidemiology of these injuries is imperative for the development and maintenance of targeted prevention strategies, player safety protocols, as well as improving rehabilitation protocols, ultimately contributing to the durability and safety of athletes in a physically demanding sport. Publication of additional injury tracking data would be of benefit to better defining this problem in an effort to impact safety-focused changes.

Prevention of Skate Blade Lacerations

Strategies for the prevention of skate laceration injuries in hockey involve a multi-faceted approach that includes special equipment, adjustments to in-game rules, and a vigilant emergency preparedness plan. Of the special equipment discussed, the primary method of prevention for lacerations is the use of materials resistant to sharp blades. Advancements in protective technology have led to the development of cut-resistant clothing (socks, shirts, wrist sleeves) made with the synthetic fibers used in bulletproof vests and shark bite-resistant suits, as well as padded and cut-resistant neck guards to mitigate the risk of lacerations from skate blades. A 2015 study comparing effectiveness of commercially available cut-resistant neck guards on a custom-made neck laceration model found the most effective products to have unique designs in that one had two layers of Kevlar, and the other was the only device to utilize Spectra Guard, a material with a higher modulus of elasticity and tensile strength than Kevlar4. In recent years, many hockey gear manufactures have publicly committed to producing more protective gear, especially neck guards, but comparative data is not yet available regarding efficacy.

Effective August 1, 2024, USA Hockey mandated the use of neck laceration protection for all ice hockey players and officials under the age of 18 in both games and practices 5. Adult hockey players can choose to wear cut-resistant gear, however it is not currently mandated by the NCAA nor most professional leagues including the NHL, Professional Women’s Hockey League (PWHL), American Hockey League, and the East Coast Hockey League. As of October 2023, all three leagues within the Canadian Hockey League as well as the women’s division of Hockey Canada, do require cut-resistant neck guards,

In addition to improvements in protective equipment, in-game adjustments to rules and penalties play a crucial role in improving player safety. Stricter regulations have been implemented in more junior leagues to minimize dangerous play that could increase the risk of sustaining laceration injuries. These changes, such as the penalty rule change in high-school boy’s hockey, aim to influence body-checking and high-sticking, with the goal of reducing the frequency of high-impact collisions and reckless maneuvers that increase the risk of blade-related accidents6. Additionally, enforcing multi-game suspensions for especially risky contact is important in ensuring player attention to safety, such as the seven-game suspension and >$160,000 fine of an Oilers player in February 2020 for intentionally kicking a defenseman while both were down on the ice7.

Even with increasing regulation surrounding physical play, skate blade-related injuries remain a possibility, and a comprehensive emergency action plan is essential for effective injury management. The NHL emergency action plan utilizes a minimum of three physicians (one orthopedist, one primary care, and one emergency medicine physician) at each game, as well as two ambulances and automated external defibrillators (AEDs) at each arena. One, if not all of the team physicians must be up to date in hockey-specific trauma management and/or Advanced Trauma Life Support and Advanced Cardiac Life Support. Teams across collegiate and professional hockey conduct simulated drills to prepare for medical emergencies including skate laceration incidents, ensuring that players and medical staff are equipped to respond swiftly and safely. The NHL Team Physician Society and Professional Hockey Athletic Training Society introduced a neck vascular laceration simulation model at their joint meeting in 2024, allowing medical staff the opportunity to practice management of catastrophic carotid or jugular lacerations. In addition to team medical staff preparedness, having emergency medical services (EMS) on-site is essential for providing immediate care, helping to limit morbidity and mortality associated with delays in treatment. The goal of these preventive measures is to form a comprehensive strategy to safeguard players against the severe consequences of skate laceration injuries.

Treatment of Skate Blade Lacerations

Unfortunately, even despite best efforts at prevention, skate blade lacerations can and do still occur. In fact, 27% of surveyed hockey players who reported suffering a skate blade laceration of the neck were wearing a cut-resistant neck guard at the time of injury 3. This is due in part to the fact that, even with cut-resistant neck guards, there remains an unprotected area of the neck between the guard and helmet, particularly if there is no full facemask or visor (Figure 1)

Figure 1: The white arrow points to the remaining area of exposed neck above a high profile cut-resistant neck guard, leaving vascular structures at risk for injury particularly if no cage or shield is worn.

The management of skate blade lacerations is dependent on the depth of laceration, body region and potential for catastrophic anatomic disruption, as summarized in Table 1. Thankfully, a majority of skate blade lacerations fall into the category of being non-threatening to limb and life.

In the rare instance of laceration to a major blood vessel in the neck, time to initiation of fluid resuscitation and transfusion protocols as well as rapid transfer to a trauma hospital is of the utmost importance. With a mean flow rate through the common carotid artery of 395 mL/min, class IV hemorrhage ( >40% of total blood volume loss) with vital sign instability can be achieved within 5 minutes of laceration of this at-risk vessel 8. Penetrating injuries to cerebrovascular arteries including the common carotid, internal carotid, and vertebral artery, carry a 17% in-hospital stroke risk and 26% in-hospital mortality risk 9.


Table 1: Management of Skate Blade Lacerations


Example



Management
  • Non Life- or Limb-Threatening

Superficial Lacerations

  • Irrigate wound
  • Assess for injury to deeper tissues (neurovascular, musculotendinous)
  • Primary laceration repair with suture, skin glue, or bandages
  • Surgical repair if involvement of deeper tissues
  • Update Tetanus vaccination
Limb Threatening

Arterial or venous laceration of a limb (i.e. femoral artery, popliteal artery, brachial artery, radial artery).

  • Apply tourniquet
  • Can utilize hemostatic gauze if available
  • Immediate EMS transfer to hospital
  • Emergent vascular repair
Life Threatening

Common or internal carotid artery

  • One-finger occlusion of laceration

Avoid completely compressing the vessel due to risk for ischemic stroke

  • Immediate EMS transfer to hospital
  • Maintain laceration occlusion in ambulance
  • Emergent vascular repair

Internal or external jugular vein

  • Pack the wound to tamponade slower bleeding
  • Can utilize hemostatic gauze if available
  • Immediate EMS transfer to hospital
  • Maintain pressure in ambulance
  • Emergent vascular repair

Airway Laceration

  • Secure airway if able
  • Immediate EMS transfer to hospital
  • Emergent surgical exploration and repair

Conclusions

The true incidence of skate blade lacerations in ice hockey is not well established due to challenges in tracking and injury mechanism identification, but regardless of how low the incidence may be, the potential outcomes of this athletic injury are uniquely catastrophic. Prevention of skate blade lacerations depends upon enforcement of rules aimed at avoiding at-risk plays and encouraging use of cut-resistant gear. While more leagues have begun requiring use of cut-resistant neck guards, the highest level of men’s and women’s hockey in the US within the NCAA, NHL, and PWHL lag behind in such efforts. Encouraged use of cut-resistant neck guards as well as gear protecting other at-risk areas such as the wrist and ankles is imperative in reducing the risk of these devastating injuries. In the unfortunate circumstance of a skate laceration compromising a major artery or the airway, on-site EMS and rapid transfer to a trauma hospital can be the determinant between life and death. Medical staff preparedness with emergency action plans, on-ice simulations, and medial pre-game briefs with EMS, home and visiting medical teams can help to ensure processes are familiar prior to a potential emergency.

References

1. Anderson GR, Melugin HP, Stuart MJ. Epidemiology of Injuries in Ice Hockey. Sports Health. 2019;11(6):514-519. doi:10.1177/1941738119849105

2. Reed T. ‘Amazing it doesn’t happen more often’: How NHL players deal with skate cuts.https://www.nytimes.com/athlet.... March 6, 2020.

3. Stuart MJ, Link AA, Smith AM, Krause DA, Sorenson MC, Larson DR. Skate Blade Neck Lacerations: A Survey and Case Follow-up. Clinical Journal of Sport Medicine. 2009;19(6):494. doi:10.1097/JSM.0b013e3181c0aaa4

4. Loyd AM, Berglund L, Twardowski CP, et al. The Most Cut-Resistant Neck Guard for Preventing Lacerations to the Neck. Clinical Journal of Sport Medicine. 2015;25(3):254-259. doi:10.1097/JSM.0000000000000121

5. USA Hockey Congress Approves Requirement For Neck Laceration Protection Starting August 1.https://www.usahockey.com/news....

6. Kriz P, Lockhart G, Staffa S, et al. EFFECT OF PENALTY MINUTE RULE CHANGE ON INJURIES AND GAME DISQUALIFICATION PENALTIES IN HIGH SCHOOL ICE HOCKEY. Orthopaedic Journal of Sports Medicine. 2019;7(3_suppl):2325967119S00021. doi:10.1177/2325967119S00021

7. Wyshynski G. Oilers’ Zack Kassian Suspended 7 Games for Kicking Opponent.; 2020. https://www.espn.com/nhl/story...

8. Ackroyd N, Griffiths K, Appleberg M. Quantitative common carotid artery blood flow: Prediction of internal carotid artery stenosis. 1986;3(6).

9. DiBartolomeo AD, Williams B, Weaver FA, et al. Risk factors for stroke in penetrating cerebrovascular injuries. Journal of Vascular Surgery. 2024;80(4):1064-1070. doi:10.1016/j.jvs.2024.05.061

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