An analysis of head injuries among skiers and snowboarders

An Epidemiologic Comparison of Injuries to Skiers and Snowboarders Treated at United States Emergency Departments, 2000-2019

Skiing and snowboarding are popular competitive and recreational sports that can be associated with significant injury. Previous studies of skiing and snowboarding injuries have been conducted, but studies evaluating injury types and patterns over long periods of time are needed to drive effective injury prevention efforts. We hypothesized that injury patterns would differ among snowboarders and skiers and that the number of injuries remained constant over time. This is a retrospective study of patients presenting with skiing or snowboarding injuries to the United States emergency departments from 2000 to 2019. A total of 34,720 injured skiers (48.0%) and snowboarders (52.0%) presented to US emergency departments over a 20-year period, representing an estimated 1,620,576 injuries nationwide. There is a decreasing trend of the number of injuries over the study period (p=0.012). Males represented the majority (65.7%) of injuries. Skiers were older than snowboarders (mean 30.1 vs. 20.0 years; p<0.001) and patients aged<18 represented more snowboarding (57.0%) than skiing (43.0%) injuries (p<0.001). Common diagnoses included fractures (33.0%) and sprains/strains (26.9%). Snowboarders primarily presented with upper extremity injuries, meanwhile, skiers primarily presented with lower extremity injuries. Most patients (93.2%), were treated and discharged from the emergency departments. Understanding the epidemiology of injuries presenting to emergency departments can help guide prehospital care and medical coverage allocation for resorts and event organizers, as well as identifying areas for targeted injury prevention efforts.

Self-reported concussion history among midwestern skiers and snowboarders

Aim

To assess the rate of self-reported concussion in midwestern skiers and snowboarders.

Patients

Recreational skiers and snowboarders between the ages of 14 and 69 years during a single winter ski season (2020-2021) at a ski area in Wisconsin, USA.

Methods

Survey study.

Results

Among this survey population (n = 161), 9.32 and 19.25% reported one or more diagnosed concussion and suspected concussion respectively as a result of a skiing- or snowboarding-related incident. Skiers and snowboarders that self-identified as advanced, those who utilized terrain park features, and those that participated in freestyle competition had significantly higher self-reported rates of concussion.

Conclusion

Self-reported concussion history indicates a concussion prevalence that is higher than expected based on previous studies. Participants reported significantly more suspected concussions than diagnosed concussions, indicating a possible issue with underreporting in this population.

[Traumatic brain injuries in winter sports : An overview based on the winter sports skiing, snowboarding and ice hockey]

In winter sports, skiers, snowboarders and ice hockey players have the highest risk of traumatic brain injuries (TBI). In skiing/snowboarding severe TBIs are of concern; in ice hockey, repetitive minor TBIs are frequent. The main causes of TBI in recreational skiing are collisions with trees; in professionals falls due to technical or tactical mistakes are the main causes. In ice hockey 10-15% of all injuries are due to a sports-related concussion (SRC), mostly caused by player-opponent contact. The pathomechanism in TBI is a combination of rotational and linear acceleration during head impact, which causes a diffuse axonal injury. Long-term complications such as neurodegenerative diseases and functional deficits are of relevance. Prevention by wearing helmets is effective, but less effective in TBI/SRC than in focal injuries.

Imaging Review of Alpine Ski Injuries

Skiing is a continuously evolving winter sport, responsible for a considerable number of musculoskeletal injuries. Specific injury patterns and mechanisms in the upper and lower extremities, head, and spine are influenced by skier expertise and skill, position during injury, and environmental conditions. Predilection for certain joints and injury patterns have changed over time, largely due to technological advancements in equipment, increased awareness campaigns, and preventive protocols. Knowledge and understanding of these trends and developments can aid the radiologist to reach a timely and accurate diagnosis, thereby guiding clinical management and potentially reducing the overall incidence of debilitation and death.

Efficacy of Helmet Use on Head Injury Reduction in Snow Sports: A Critically Appraised Topic

Context: Review articles published in 2010 concluded that there was strong evidence to support the use of helmets as a way to decrease the risk of sustaining a head injury during snow sport participation. However, new research published over the last decade on this relationship warrants revisiting this primary injury prevention approach. Clinical Question: What is the effect of helmet use on the occurrence of head injuries in snow sports? Clinical Bottom Line: The results from the included studies did not consistently find a reduction in head injury occurrence with helmet use in snow sports. Rather, the collective findings were more supportive of a neutral relationship between helmet use and head injuries. Therefore, these heterogeneous findings indicate there is SORT Level B evidence to support the use of helmets as a primary head injury prevention approach in snow sports. Future initiatives should acknowledge the multifaceted nature of injury occurrence and seek to educate the public more clearly on the limitations of helmet use during skiing and snowboarding.

A Perennial Threat: A Case Series of Tree-Related Neurotrauma

Background

Despite their devastating nature, injuries due to tree-related- traumas are sparsely reported in the literature. Over the last several years, the incidence of tree-related traumatic injuries presenting to our level one trauma center, in Westchester, New York, has been concerning. The present study was undertaken to evaluate the clinical presentation, injury pattern, and outcomes of tree-related neurotrauma at our institution. In addition, we describe the injury pattern and medical management of several relevant cases of tree-related neurotrauma.

Methods

We conducted a retrospective analysis of tree-related neurotrauma over a five-year period from January of 2014 to March of 2019 at Westchester Medical Center (WMC) and Maria Fareri Children’s Hospital, a level one trauma center. Patients presenting with neurotrauma that necessitated neurosurgical care were eligible for inclusion in this case series. Tree-related injury was defined as any trauma that was sustained as a direct result of collision with a tree.

Results

We identified 21 patients who sustained tree-related trauma. The cohort age ranged from 15 to 68 (mean=38 years). Injuries included seven skull fractures, four cases of subdural hematoma (SDH), six cases of intracranial hemorrhagic contusion, 14 spinal fractures, three cases of epidural hematoma (EDH), one case of spinal cord contusion, three vascular injuries, one case of dural laceration, and one case of pneumocephalus, with several patients suffering multiple injuries. Of the 21 patients, seven were female, and 12 were injured when their motor vehicle struck a tree. All but four patients were taken to the operating room for neurosurgical treatment, and nine of 21 patients were taken emergently to the operating room upon arrival.

Conclusion

The potential for serious head injuries with long-term neurologic sequelae exists with tree-related trauma. Clinicians should be advised of the challenging management of injuries secondary to tree-related trauma, and a greater emphasis should be placed on raising awareness of these accidental, but devastating injuries. Finally, a great majority of these injuries can be prevented or reduced in severity through helmet use and by adhering to safety guidelines.

Examining ski area padding for head and neck injury mitigation

OBJECTIVES

The injury mitigation capabilities of foam, ski-area padding was examined for headfirst impacts.

DESIGN AND METHODS

A custom-made pendulum impactor system was constructed using an instrumented, partial 50th-percentile-male Hybrid-III anthropomorphic testing device (ATD). For each test, the ATD was raised 1.0m, released, and swung into a 20-cm diameter wooden pole. Test trials were conducted with the wooden pole covered by ski area padding (five conditions of various foam types and thicknesses) or unpadded. Linear (linear acceleration and HIC₁₅) and angular (angular velocity, angular acceleration, and BrIC) kinematics were examined and used to estimate the likelihood of severe brain injury. Cervical spine loads were compared to the injury assessment reference values for serious injury. Further tests were conducted to examine the changes produced by the addition of a snowsport helmet.

RESULTS

38 test trials were recorded with a mean (±sd) impact speed of 4.2 (±0.03) m/s. Head, resultant linear acceleration, HIC₁₅, and associated injury likelihoods were tempered by ski area padding at the impact speed tested. Ski area padding did not reduce brain injury likelihood from rotational kinematics (p>0.05 for all comparisons) or reduce the cervical spine compression below injury assessment reference values. The addition of a helmet did not reduce significantly the likelihoods of brain or cervical spine injury.

CONCLUSIONS

At the impact speed tested, ski area padding provided limited impact protection for the head (for linear kinematics) but did not protect against severe brain injuries due to rotational kinematics or serious cervical spine injuries.

Skiing and snowboarding head injury: A retrospective centre-based study and implications for helmet test standards

BACKGROUND

Head injury occurs in up to 47% of skiing or snowboarding injuries and is the predominant cause of death in these sports. In most existing literature reporting injury type and prevalence, head injury mechanisms are underreported. Thus, protective equipment design relies on safety evaluation test protocols that are likely oversimplified. This study aims to characterize severity and mechanism of head injuries suffered while skiing and snowboarding in a form appropriate to supplement existing helmet evaluation methods.

METHODS

A 6-year, multicentre, retrospective clinical record review used emergency databases from two major trauma centres and Coroner's reports to identify relevant cases which indicated head impact. Records were investigated to understand the relationships between helmet use, injury type and severity, and injury mechanism. Descriptive statistics and odds ratios aided interpretation of the data.

FINDINGS

The snow sport head injury database included 766 cases. "Simple fall", "jump impact" and "impact with object" were the most common injury mechanisms while concussion was observed to be the most common injury type. Compared to "edge catch", moderate or serious head injury was more common for "fall from height" (OR = 4.69; 95% CI = 1.44-16.23; P = 0.05), "jump impact" (OR = 3.18; 95% CI = 1.48-7.26; P = 0.01) and "impact with object" (OR = 2.44; 95% CI = 1.14-5.56; P = 0.05). Occipital head impact was associated with increased odds of concussion (OR = 7.46; 95% CI = 4.55-12.56; P = 0.001).

INTERPRETATION

Snow sport head injury mechanisms are complex and cannot be represented through a single impact scenario. By relating clinical data to injury mechanism, improved evaluation methods for protective measures and ultimately better protection can be achieved.

Modeling and simulation of the impact behavior of soft polymeric-foam-based back protectors for winter sports

OBJECTIVES

Winter sports are high-energy outdoor activities involving high velocities and acrobatic maneuvers, thus raising safety concerns. Specific studies on the impact mechanics of back protectors are very limited. In this study analytical and numerical models are developed to rationalize results of impact experiments and propose new design procedures for this kind of equipment.

DESIGN

Different soft-shell solutions currently available on the market are compared. In particular, the role of dynamic material constitutive properties and of environmental temperature (which affects mainly material stiffness) on energy absorption capability are evaluated.

METHODS

Starting from dynamic mechanical-thermal characterization of the closed-cell polymeric foams constituting the protectors, we exploited analytical modeling and Finite Element Method simulations to interpret experimental data from drop weight impact test and to characterize protectors at different temperatures and after multiple impacts.

RESULTS

The temperature and frequency dependent properties of these materials characterize their impact behavior. Modeling results are in good agreement with impact tests. Results demonstrate how ergonomic soft-shell solution provides an advantage with respect to traditional hard-shell in terms of impact protection. Moreover, it can maintain nearly unaltered its protective properties after multiple impacts on the same point.

CONCLUSIONS

The coupled analytical-simulation approach here presented could be extensively used to predict the impact behavior of such equipment, starting from material characterization, allowing to save costs and time for physical prototyping and tests for design and optimization.

Impact of wearing a helmet on the risk of hospitalization and intracranial haemorrhage after a sports injury

BACKGROUND

Despite their reported protective effect against the occurrence of head injuries, helmets are still used inconsistently in sports in which they are optional. We aimed to assess the impact of helmet use on the risk of hospitalization and intracranial haemorrhage for trauma occurring during sport activities.

METHODS

Retrospective cohort of all patients who presented themselves, over an 18-month period, at the emergency department of a tertiary trauma centre for an injury sustained in a sport or leisure activity where the use of a helmet is optional. Impact of helmet use was assessed using multivariable regression analyses (relative risks, RR).

RESULTS

Among the 1,022 patients included in the study, half were cyclists and 40% were skiers or snowboarders. A total of 40 % of patients wore a helmet at the time of injury, 18% had a head injury, 16% were hospitalized and 13% of patients with a head injury had an intracranial haemorrhage. Among all patients, no association was observed between hospital admission and helmet use. However, helmet use in patients with a head injury was associated with significant reductions in the risks of hospitalization (RR 0.41 [95% CI: 0.22-0.76]) and intracranial haemorrhage (RR 0.28 [95% CI: 0.11-0.71]).

CONCLUSIONS

Results suggest that, in recreational athletes who sustain a head injury, helmet use is associated with a reduced risk of hospitalization (all sports) and intracranial haemorrhage (cyclists).

Injury patterns and risk factors for orthopaedic trauma from snowboarding and skiing: a national perspective

PURPOSE

Alpine skiing and snowboarding are both popular winter sports that can be associated with significant orthopaedic injuries. However, there is a lack of nationally representative injury data for the two sports.

METHODS

The National Trauma Data Bank was queried for patients presenting to emergency departments due to injuries sustained from skiing and snowboarding during 2011 and 2012. Patient demographics, comorbidities, and injury patterns were tabulated and compared between skiing and snowboarding. Risk factors for increased injury severity score and lack of helmet use were identified using multivariate logistic regression.

RESULTS

Of the 6055 patients identified, 55.2 % were skiers. Sixty-one percent had fractures. Lower extremity fractures were the most common injury and occurred more often in skiers (p < 0.001). Upper extremity fractures were more common in snowboarders, particularly distal radius fractures (p < 0.001). On multivariate analysis, increased injury severity was independently associated with age 18-29, 60-69, 70+, male sex, a positive blood test for alcohol, a positive blood test for an illegal substance, and wearing a helmet. Lack of helmet use was associated with age 18-29, 30-39, smoking, a positive drug test for an illegal substance, and snowboarding.

CONCLUSIONS

Young adults, the elderly, and those using substances were shown to be at greater risk of increased injury severity and lack of helmet use. The results of this study can be used clinically to guide the initial assessment of these individuals following injury, as well as for targeting preventive measures and education.

LEVEL OF EVIDENCE

Prognostic Level III.

Head injury mechanisms in FIS World Cup alpine and freestyle skiers and snowboarders

Introduction

Head injuries represent a concern in skiing and snowboarding, with traumatic brain injuries being the most common cause of death.

Aim

To describe the mechanisms of head and face injuries among World Cup alpine and freestyle skiers and snowboarders.

Methods

We performed a qualitative analysis of videos obtained of head and face injuries reported through the International Ski Federation Injury Surveillance System during 10 World Cup seasons (2006–2016). We analysed 57 head impact injury videos (alpine n=29, snowboard n=13, freestyle n=15), first independently and subsequently in a consensus meeting.

Results

During the crash sequence, most athletes (84%) impacted the snow with the skis or board first, followed by the upper or lower extremities, buttocks/pelvis, back and, finally, the head. Alpine skiers had sideways (45%) and backwards pitching falls (35%), with impacts to the rear (38%) and side (35%) of the helmet. Freestyle skiers and snowboarders had backwards pitching falls (snowboard 77%, freestyle 53%), mainly with impacts to the rear of the helmet (snowboard 69%, freestyle 40%). There were three helmet ejections among alpine skiers (10% of cases), and 41% of alpine skiing injuries occurred due to inappropriate gate contact prior to falling. Athletes had one (47%) or two (28%) head impacts, and the first impact was the most severe (71%). Head impacts were mainly on snow (83%) on a downward slope (63%).

Conclusion

This study has identified several characteristics of the mechanisms of head injuries, which may be addressed to reduce risk.

Head Injuries in Urban Environment Skiing and Snowboarding: A Retrospective Study on Injury Severity and Injury Mechanisms

Background and Aim:

During the last decade urban skiing and snowboarding has gained a lot of popularity. In urban skiing/snowboarding riders try to balance on handrails and jump off buildings. Previous studies in skiing and snowboarding accidents have mostly been conducted at hospitals located close to alpine terrain with big ski resort areas. The aim of this study is to evaluate the types and severity of traumatic brain injuries occurring in small, suburban hills and in urban environment, and to characterize injury patterns to find out the specific mechanisms of injuries behind.

Materials and Methods:

This study included all patients admitted to the Helsinki University Hospital Trauma Unit from 2006 to 2015 with a head injury (ICD 10 S06-S07) from skiing or snowboarding accidents in Helsinki capital area. Head injuries that did not require a CT-scan, and injuries older than 24 hours were excluded from this study.

Results:

There were a total of 72 patients that met the inclusion criteria Mean length of stay in hospital was 2.95 days. According to the AIS classification, 30% had moderate, 14% had severe, and 10% had critical head injuries. Patients who got injured in terrain parks or on streets where more likely to be admitted to ICU than those injured on slopes. Based on GOS score at discharge, 78% were classified as having a good recovery from the injury, 13% had a moderate disability, 5% had a severe disability and 3% of the injuries were fatal. There were no statistically significant differences in decreased GOS between the accident sites.

Conclusion:

Head injuries occurring in small suburban hills and in urban environments can be serious and potentially fatal. The profile and severity of skiing injuries in urban environments and small, suburban hills is comparable to those on alpine terrain.

Epidemiology of Snow Skiing- Versus Snowboarding-Related Concussions Presenting to the Emergency Department in the United States from 2010 to 2014

OBJECTIVES

To examine the trend of concussions in skiers and snowboarders from 2010 to 2014; and to quantify and compare the incidence of concussions injuries in skiers and snowboarders who presented to emergency departments in the United States in 2014.

DESIGN

Cross-sectional study of concussions in skiers and snowboarders who were evaluated in emergency departments in the United States.

MAIN OUTCOMES MEASURE

Incidence of concussions.

RESULTS

The trend of the annual incidence of concussions for skiers and snowboarders remained stable from 2010 to 2014. An estimated total of 5388 skiing-related concussions and 5558 snowboarding-related concussions presented to emergency departments in the United States between January 1st, 2014, and December 31st, 2014. This represented an incidence of 16.9 concussions per 1 000 000 person-years for skiers and 17.4 concussions per 1 000 000 person-years for snowboarders. The incidence of concussions in the pediatric and young adult population of skiers was significantly higher than the incidence in the adult population. Similarly, the incidence of concussions in the pediatric and young adult population of snowboarders was significantly higher than the incidence in the adult population. The incidence of concussions was significantly higher in males compared with females in both skiing and snowboarding.

CONCLUSIONS

The incidence of concussions from 2010 to 2014 plateaued in both skiers and snowboarders. Pediatric and young adult skiers and snowboarders had significantly higher incidences of concussion than the adult population. In contrast to the higher incidence of concussions in females in several sports including ice hockey, soccer, and basketball, the incidence of concussions was higher in males compared with females in both skiing and snowboarding.

Trends in sports-related concussion diagnoses in the USA: a population-based analysis using a private-payor database

OBJECTIVE

To describe recent epidemiological trends in concussion diagnosis within the United States (US) population.

METHODS

We conducted a retrospective review of PearlDiver, a private-payor insurance database. Our search included International Classification of Disease, Ninth Revision codes for sports-related concussions spanning 2010 through 2014. Overall study population included patients aged 5 to 39 with subgroup analysis performed on Cohort A (Youth), children and adolescents aged 5 to 19, and Cohort B (Adults), adults aged 20 to 39. Incidence was defined as the number of individuals diagnosed normalized to the number of patients in the database for each demographic.

RESULTS

Our search returned 1,599 patients diagnosed during the study period. The average (±SD) annual rate was 4.14 ± 1.42 per 100,000 patients for the overall population. Youth patients were diagnosed at a mean annual rate of 3.78 ± 1.30 versus 0.36 ± 0.16 per 100,000 in Adults. Concussion normalized incidence significantly increased from 2.47 to 3.87 per 100,000 patients (57%) in the Youth cohort (p = 0.048). In Adults, rate grew from 0.34 to 0.44 per 100,000 patients (29%) but was not statistically significant (p = 0.077). Four-year compound annual growth rates for Youth and Adults were 26.3% and 20.4%, respectively. Youth patients comprised 1,422/1,599 (90.18%) of all concussion diagnoses and were predominantly male (75%). Adults also constituted 138/1,599 (8.63%) of the sample and were also largely male (80%). Midwestern states had highest diagnostic rates (Cohort A:19 per 100,000 and Cohort B:1.8 per 100,000). Both cohorts had the most total diagnoses made in the fourth quarter followed by the second quarter.

CONCLUSION

Sports-related concussion diagnostic rates have grown significantly in the youth population. Quarterly, regional and gender distributions appear consistent with participation in concussion-prone sports. Utilization of individualized and multifaceted approaches are recommended to advance diagnosis, assessment and management of concussions in the U.S.

Effectiveness of a nationwide intervention to increase helmet use in Dutch skiers and snowboarders: an observational cohort study

OBJECTIVE

Helmet use in Dutch recreational skiers and snowboarders (DRSS) remains low. This study evaluated the effects of exposure to a nationwide intervention on relevant determinants of helmet use and helmet use in DRSS.

METHODS

The intervention mapping protocol was used to develop an in-season intervention programme targeted at adult DRSS. A prospective single-cohort study was conducted to evaluate the impact of intervention exposure on determinants of helmet use (ie, knowledge about head injury risk and preventive measures, risk perception, attitudes to head injury risk and helmet use and intention to helmet use) and self-reported helmet use. A random sample of 363 DRSS from an existing panel participated in this study. Data were collected using online questionnaires before and immediately after the 2010/2011 intervention season. In a separate sample of 363 DRSS, intervention reach was assessed after the 2010/2011 season.

RESULTS

Overall, no significant associations were found between intervention exposure and the determinants of helmet use. However, subgroup analyses revealed intervention effects on risk perception and knowledge in specific subpopulations. Intervention exposure had a significant, positive effect on helmet use in DRSS (β=0.23; 95% CI 0.017 to 0.44). Subgroup analyses revealed that this effect was found in: (1) skiers, (2) female DRSS, (3) young skiers and (4) intermediate skiers. Overall, intervention reach was 28.1%, with differences found between skiers and snowboarders.

CONCLUSIONS

Exposure to a nationwide intervention programme was associated with increased self-reported helmet use in DRSS. Differences were found in intervention effectiveness and reach between subpopulations. These differences must be taken into account when developing and evaluating future interventions.

Helmet use and injury severity among pediatric skiers and snowboarders in Colorado

INTRODUCTION

Skiing and snowboarding are popular winter recreational activities that are commonly associated with orthopedic type injuries. Unbeknownst to most parents, however, are the significant but poorly described risks for head, cervical spine and solid organ injuries. Although helmet use is not mandated for skiers and snowboarders outside of resort sponsored activities, we hypothesized that helmet use is associated with a lower risk of severe head injury, shorter ICU stay and shorter hospital length of stay.

METHODS

The trauma registry at a level I pediatric trauma center in the state of Colorado was queried for children ages 3-17years, who sustained an injury while skiing or snowboarding from 1/1/1999 to 12/31/2014. Injury severity was assessed by Abbreviated Injury Severity (AIS) score, injury severity score (ISS) and admission location. Head injury was broadly defined as any trauma to the body above the lower border of the mandible. Regression analysis was used to test associations of variables with injury severity.

RESULTS

549 children sustained snow sport related injuries during the 16year study period. The mean patient age was11±3years, most were male (74%) and the majority were Colorado residents (54%). The overall median ISS was 9 (IQR 4-9) and 78 children (14%) were admitted to the ICU. Colorado residents were nearly twice as likely to be wearing a helmet at the time of injury, compared to visitors from out-of-state (adjusted OR 1.86, 95% CI 1.24-2.76, p=0.002). In a multivariate analysis injury severity was significantly associated with injury while skiing (p=0.026), helmet use (p=0.0416), and sustaining a head injury (p<0.0001). In a separate multivariate analysis ICU admission was associated with head injury (p<0.0001) and wearing a helmet (p=0.0257); however, those wearing a helmet and admitted to the ICU had significantly lower ISS (p=0.007) and head AIS (p=0.011) scores than those who were not wearing a helmet at the time of injury.

CONCLUSION

Visitors from out of state were less likely to be wearing a helmet when injured and more likely to be severely injured, suggesting Colorado residents have a better understanding of the benefits of helmet usage. Helmeted skiers and snowboarders who were admitted to the ICU had significantly lower ISS and head AIS scores than those who were not helmeted. Pediatric skiers, snowboarders and their parents should be educated on the significant risks associated with these activities and the benefits of helmet usage.

LEVEL OF EVIDENCE

III.

Helmets for Skiers and Snowboarders: An Injury Prevention Program

The authors' Level I trauma center has advocated the use of ski helmets for several years and in 1998, undertook a social-marketing campaign and a helmet loaner program to increase helmet use among skiers and snowboarders. The loaner program's effect on helmet acceptance was measured by comparing helmet acceptance in participating rental stores with acceptance in nonparticipating stores during 3 years. For the 1998-1999 season, 13.8% of renters in the participating stores accepted a helmet compared to 1.38% in the nonparticipating stores (p < .01); for 2000-2001, 33.5% to 3.93% (p < .01); and for 2001-2002, 30.3% to 4.48% (p < .01). The authors believe that efforts to increase helmet use—by increasing education and public awareness and decreasing barriers, such as through helmet loaner programs or routinely including helmets in rental packages—have significant potential to decrease the incidence and severity of brain injuries from skiing and/or snowboarding accidents in Colorado.

Head injury predictors in sports trauma--a state-of-the-art review

Head injuries occur in a great variety of sports. Many of these have been associated with neurological injuries, affecting the central nervous system. Some examples are motorsports, cycling, skiing, horse riding, mountaineering and most contact sports such as football, ice and field hockey, soccer, lacrosse, etc. The outcome of head impacts in these sports can be very severe. The worst-case scenarios of permanent disability or even death are possibilities. Over recent decades, many In recent decades, a great number of head injury criteria and respective thresholds have been proposed. However, the available information is much dispersed and a consensus has still not been achieved regarding the best injury criteria or even their thresholds. This review paper gives a thorough overview of the work carried out by the scientific community in the field of impact biomechanics about head injuries sustained during sports activity. The main goal is to review the head injury criteria, as well as their thresholds. Several are reviewed, from the predictors based on kinematics to the ones based on human tissue thresholds. In this work, we start to briefly introduce the head injuries and their mechanisms commonly seen as a result of head trauma in sports. Then, we present and summarize the head injury criteria and their respective thresholds.

A human factors approach to snowsport safety: Novel research on pediatric participants' behaviors and head injury risk

OBJECTIVE

This study applied a human factors approach to snowsport resort systems to contribute to the understanding of the incidence and severity of pediatric snowsport head accelerations.

BACKGROUND

Previous research indicates low magnitude head accelerations are common among snowsport participants. This study adds to the knowledge of snowsport safety by measuring aspects of participants' snowsport behavior and linking this with head acceleration data.

METHOD

School-aged students (n = 107) wore telemetry-fitted helmets and Global Positioning System (GPS) devices during snowsport activity. Data was collected over 159 sessions (total hours 701). Head accelerations recorded by the telemetry units were compared with GPS-generated data.

RESULTS

This study found speeds attained normally exceed the testing rating for which helmets are designed; lower rates of head accelerations compared to earlier studies and that when head accelerations did occur they were generally below the threshold for concussions.

CONCLUSION

Pediatric snowsport head accelerations are rare and are generally of low magnitude. Those most at risk of a head acceleration >40 g were male snowboarders. Given the recorded speeds in first time participants, increased targeting of novice snowsport participants to encourage education about the use of protective equipment, including helmets, is warranted. Post event recall was not a good indicator of having experienced a head impact. Consideration should be given to raising the standard design speed testing for snowsport helmet protective devices to reflect actual snowsport behaviors.

Concussion Among Youth Skiers and Snowboarders: A Review of the National Trauma Data Bank From 2009 to 2010

OBJECTIVE

There are limited data regarding concussion among youth skiers and snowboarders. The objective of this study was to examine the frequency of concussion among helmeted and unhelmeted youth skiers and snowboarders presenting to trauma centers.

METHODS

Subjects 18 years or younger with a ski- or snowboard-related injury were studied using data from the National Trauma Data Bank from 2009 to 2010. We further selected those with head/neck injuries and stratified based on helmet status. Concussive injuries were identified from International Classification of Diseases, 9th Revision codes. Severity analysis was based on the Glasgow Coma Scale and Injury Severity Score.

RESULTS

A total of 1001 subjects met inclusion criteria with 678 subjects having documented helmet status. Subjects 12 years or younger were more likely to use helmets compared to 13-18 year-olds (odds ratio, 2.21; 95% confidence interval [95% CI], 1.52-3.21). Skiers were more likely to use helmets compared to snowboarders (odds ratios, 1.60; 95% CI, 1.16-2.19). Snowboarders had a greater likelihood of concussion (estimated-β, 2.1; 95% CI, 1.48-2.85) after adjusting for helmet status and age. There was no significant difference in the frequency of concussion among helmeted compared to unhelmeted subjects. Imputing missing values for helmets status had no effect on outcome for concussion. We found no difference in injury severity among helmeted compared to unhelmeted subjects.

CONCLUSIONS

Among youth skiers and snowboarders who present to trauma centers with a head injury, the likelihood of that injury involving a concussion was not associated with helmet use.

Sledding injuries a practice-based study is it time to raise awareness?

BACKGROUND

The purpose of this review is to describe our practice-based incidence of sledding injuries in children.

METHODS

An 8-year (2003-2011) retrospective review of all hospitalized children (<18 years) from a level one pediatric trauma center due to sledding injuries was performed. Demographic, injury severity score (ISS), hospital stay, ICU stay, and discharge status were analyzed and compared to all other trauma hospitalizations.

RESULTS

Fifty-two children were hospitalized from sledding injuries. There were 34 males and 18 females with an average age of 10.1 ± 3.7 years. Impact with a tree was the most common mechanism of injury in 33/52 (63.5 %). Strikingly 20 (37 %) patients suffered a head injury with average ISS scores of 13.21 ± 2.30 and 70 % of them were admitted to the ICU. Three children had permanent disability including cognitive impairment and two others required long-term hospitalization rehabilitation. Other injuries included fractures (17), solid organs (10), chest trauma (1), and vertebral fractures (3).

CONCLUSIONS

Sledding was a significant component of hospitalized children during winter months. 30 % suffered significant head inquires and nearly 10 % had permanent disabilities. Injury control strategies ensuring safe environments away from trees, and head protection should be publicized.

An evidence-based review: efficacy of safety helmets in the reduction of head injuries in recreational skiers and snowboarders

BACKGROUND

Approximately 600,000 ski- and snowboarding-related injuries occur in North America each year, with head injuries accounting for up to 20% of all injuries. Currently, there are no major institutional recommendations regarding helmet use for skiers and snowboaders in the United States, in part owing to previous conflicting evidence regarding their efficacy. The objective of this review was to evaluate existing evidence on the efficacy of safety helmets during skiing and snowboarding, particularly in regard to head injuries, neck and cervical spine injuries, and risk compensation behaviors. These data will then be used for potential recommendations regarding helmet use during alpine winter sports.

METHODS

The PubMed, Cochrane Library, and EMBASE databases were searched using the search string helmet OR head protective devices AND (skiing OR snowboarding OR skier OR snowboarder) for articles on human participants of all ages published between January 1980 and April 2011. The search yielded 83, 0, and 96 results in PubMed, Cochrane Library, and EMBASE, respectively. Studies published in English describing the analysis of original data on helmet use in relation to outcomes of interest, including death, head injury, severity of head injury, neck or cervical spine injury, and risk compensation behavior, were selected. Sixteen published studies met a priori inclusion criteria and were reviewed in detail by authors.

RESULTS

Level I recommendation is that all recreational skiers and snowboarders should wear safety helmets to reduce the incidence and severity of head injury during these sports. Level II recommendation/observation is that helmets do not seem to increase risk compensation behavior, neck injuries, or cervical spine injuries among skiers and snowboarders. Policies and interventions to increase helmet use should be promoted to reduce mortality and head injury among skiers and snowboarders.

CONCLUSION

Safety helmets clearly decrease the risk and severity of head injuries in skiing and snowboarding and do not seem to increase the risk of neck injury, cervical spine injury, or risk compensation behavior. Helmets are strongly recommended during recreational skiing and snowboarding.

Skiing and snowboarding injury prevention

Skiing and snowboarding are popular recreational and competitive sport activities for children and youth. Injuries associated with both activities are frequent and can be serious. There is new evidence documenting the benefit of wearing helmets while skiing and snowboarding, as well as data refuting suggestions that helmet use may increase the risk of neck injury. There is also evidence to support using wrist guards while snowboarding. There is poor uptake of effective preventive measures such as protective equipment use and related policy. Physicians should have the information required to counsel children, youth and families regarding safer snow sport participation, including helmet use, wearing wrist guards for snowboarding, training and supervision, the importance of proper equipment fitting and binding adjustment, sun safety and avoiding substance use while on the slopes.

Implications of parental influence on child/adolescent helmet use in snow sports

OBJECTIVE

The main objective of this study was to assess the influencing factors in participants who do not use a helmet while skiing or snowboarding in the youth population.

DESIGN

Cross-sectional survey.

SETTING

The 2006-2007 and 2007-2008 ski seasons at the Crested Butte Mountain Resort.

PARTICIPANTS

Children and adolescents between the ages of 6 to 17 years and their parents were enrolled in the study. Two hundred six children/adolescents participated.

INDEPENDENT VARIABLES

Independent variables included age, gender, parental helmet use, ski/snowboard helmet past protection, and child/adolescent reason for wearing/not wearing helmet.

MAIN OUTCOME MEASURES

Dependent variables included child/adolescent helmet use.

RESULTS

Fifty-one percent were male and 49% were female. One hundred seventy-one (83%) reported that they wear a ski/snowboard helmet, and 35 (17%) reported that they did not wear a ski/snowboard helmet. There was a significant relationship between parental helmet use and child helmet use (P ≤ 0.0001). Of the 171 children/adolescents who reported wearing a helmet, 124 (72.5%) reported that wearing a helmet protected them in an accident. Of the 171 children/adolescents who reported wearing a helmet, 87.7% said that safety was the reason for wearing a helmet. The most common reason for not wearing a ski/snowboard helmet was comfort.

CONCLUSIONS

Parent's helmet-wearing behavior was strongly associated with the child/adolescent's helmet-wearing behavior. The results demonstrate the overwhelming influence parental helmet use has on their child/adolescent's decision to wear a helmet.

Impact of a ski helmet mandatory on helmet use on Austrian ski slopes

BACKGROUND

A helmet mandatory for people younger than 16 years was implemented in most Austrian provinces in the winter season 2009/2010. The objective of this study was to evaluate the impact of a ski helmet mandatory on age-dependent helmet use.

METHODS

We compared helmet use in people aged 15 years or less and older than 15 years of Austrian provinces with and without helmet mandatory between the 2008/2009 (n=16,342) and 2009/2010 (n=32,011) winter seasons.

RESULTS

Helmet use in people aged 15 years or less in the 2009/2010 season increased by 16.2% in provinces with helmet mandatory and decreased by 2.1% in provinces without helmet mandatory (all p<0.001), respectively. However, provinces with and without helmet mandatory did not differ regarding mean helmet use in people aged 15 years or less (92.2% vs. 92.8%, p=0.506) in the 2009/2010 season. Helmet use in people older than 15 years in the 2009/2010 season had increased by 11.7% in provinces with helmet mandatory and by 17.9% in provinces without helmet mandatory (all p<0.001), respectively. Helmet use in people older than 15 years was lower in provinces with helmet mandatory compared with provinces without mandatory (63.1% vs. 68.1%, p<0.001) in the 2009/2010 season.

CONCLUSION

A helmet mandatory for people aged 15 years or less may increase helmet use in involved age groups when helmet use is relatively low. However, public discussions and preventive helmet campaigns based on sound theories of health behavior change may also induce increases in helmet use in skiers aged older than 15 years without helmet mandatory.

The epidemiology of sport-related concussion

Concussions and head injuries may never be completely eliminated from sports. However, with better data comes an improved understanding of the types of actions and activities that typically result in concussions. With this knowledge can come improved techniques and rule changes to minimize the rate and severity of concussions in sports. This article identifies the factors that affect concussion rate.

Helmet use and reduction in skull fractures in skiers and snowboarders admitted to the hospital

OBJECT

Helmet use has been associated with fewer hospital visits among injured skiers and snowboarders, but there remains no evidence that helmets alter the intracranial injury patterns. The authors hypothesized that helmet use among skiers and snowboarders reduces the incidence of head injury as defined by findings on head CT scans.

METHODS

The authors performed a retrospective review of head-injured skiers and snowboarders at 2 Level I trauma centers in New England over a 6-year period. The primary outcome of interest was intracranial injury evident on CT scans. Secondary outcomes included the following: need for a neurosurgical procedure, presence of spine injury, need for ICU admission, length of stay, discharge location, and death.

RESULTS

Of the 57 children identified who sustained a head injury while skiing or snowboarding, 33.3% were wearing a helmet at the time of injury. Of the helmeted patients, 5.3% sustained a calvarial fracture compared with 36.8% of the unhelmeted patients (p = 0.009). Although there was a favorable trend, there was no significant difference in the incidence of epidural hematoma, subdural hematoma, intraparenchymal hemorrhage, subarachnoid hemorrhage, or contusion in helmeted and unhelmeted patients. With regard to secondary outcomes, there were no significant differences between the 2 groups in percentage of patients requiring neurosurgical intervention, percentage requiring admission to an ICU, total length of stay, or percentage discharged home. There was no difference in the incidence of cervical spine injury. There was 1 death in an unhelmeted patient, and there were no deaths among helmeted patients.

CONCLUSIONS

Among hospitalized children who sustained a head injury while skiing or snowboarding, a significantly lower number of patients suffered a skull fracture if they were wearing helmets at the time of the injury.

Helmet use in winter sport activities--attitude and opinion of neurosurgeons and non-traumatic-brain-injury-educated persons

PURPOSE

During the last winter season, some fatal sport injuries with severe traumatic brain injury (TBI) prompted major discussions about protective helmet use. Although ski helmets reportedly lead to a 60% decrease of risk to incur TBI, little is known about the distribution of helmet users and which factors are crucial for the decision to wear a helmet. Especially, it is unknown whether knowledge or experience concerning TBI in winter sports influences the use of helmets, as well as the attitude and opinion of people.

METHODS

Since treatment of TBI is a major field in neurosurgery, 55 neurosurgical departments (NS) in Germany, Switzerland and Austria were addressed and asked to answer anonymous questionnaires. A "non-trauma-educated" control cohort (NTP) was interviewed in ski resorts in Austria as well as sports equipment stores in Germany.

RESULTS

Questionnaires were returned by 465 NS and 546 NTP. Half of NS and NTP wore helmets in winter sports. Although some interviewees showed cognitive dissonant behaviour, experience in TBI after ski or snowboard accidents significantly affected the decision to wear helmets. After the fatal ski accidents, and increased media coverage 15.4% NS and 13.2% NTP bought their helmet. Furthermore, incidence of helmet use in children was correlated with the actual use and disposition of their parents to make the use of helmet compulsory.

CONCLUSIONS

This study indicates that brain-trauma education affects ones attitude and opinion concerning protective helmet use in winter sports. However, without neglecting educational measures, emotional arguments should be added in the promotion of helmets to make them a popular integral part of winter sport outfits.

Helmets and mouth guards: the role of personal equipment in preventing sport-related concussions

Millions of athletes in the United States experience concussions annually. Although helmets and mouth guards have decreased the risk of catastrophic head injuries, their protective effects on concussions are less clear. This article evaluates the current literature on the effect of equipment on concussions. Understanding the role that these equipment play in preventing concussions is complicated by many factors, such as selection bias in nonrandomized studies, variations in playing style, and risk compensation in sports with mandatory protective equipment. Improving coach and player education about proper concussion management, encouraging neck-strengthening exercises, and minimizing high-risk impacts may reduce concussions in sports.

Evaluation of skiing and snowboarding injuries sustained in terrain parks versus traditional slopes

This study compares skiing and snowboarding injuries in terrain parks versus slopes at two ski areas, 2000-05. A total of 3953 (26.7%) injuries occurred in terrain parks, predominantly among young male snowboarders. Terrain park injuries were more likely to be severe, involving head (RR 1.31, 95% CI 1.16 to 1.48) or back (RR 1.96, 95% CI 1.67 to 2.29).

Urologic sports injuries in children

Sports participation is an important part of the lives of many children and adolescents. The risk of sustaining a genitourinary injury during sports is low. The published literature suggests that the specific risk to those patients with only one healthy kidney, ovary, or testicle is very low but not zero. Physicians who counsel patients and families about sports participation need to consider many factors: the type of sport, the level of play, the local sports culture, and the relative degree of risk. The published data suggest that major injuries to an ovary during sports are exceedingly rare. Major injuries to a testicle are also unusual. Significant kidney injuries, while uncommon, do occur and not necessarily only in the well-known collision sports.

[Facial perforation trauma: an unusual injury in a skiing accident]

Facial perforation injuries are very rare. We describe a case of a 48-year-old man who sustained a perforation trauma from an 11 cm long wooden tree branch in the middle of the face in a skiing accident. He suffered from additional injuries, such as fractures of the ribs and hand, but was neurologically without pathologic findings and was cardiopulmonary stable.The branch penetrated the head from the sinus maxillaris through the maxilla just missing the internal and external carotid arteries and ending just short of the cervical vertebra. The patient was transported to a center for oral and maxillofacial surgery and underwent several operations.He could return to his normal social and professional life 8 months after the accident.

The effect of helmets on the risk of head and neck injuries among skiers and snowboarders: a meta-analysis

BACKGROUND

The prevention of head injuries in alpine activities has focused on helmets. However, no systematic review has examined the effect of helmets on head and neck injuries among skiers and snowboarders.

METHODS

We searched electronic databases, conference proceedings and reference lists using a combination of the key words "head injury or head trauma," "helmet" and "skiing or snowboarding." We included studies that used a control group; compared skiers or snowboarders with and without helmets; and measured at least one objectively quantified outcome (e.g., head injury, and neck or cervical injury).

RESULTS

We included 10 case-control, 1 case-control/case-crossover and 1 cohort study in our analysis. The pooled odds ratio (OR) indicated that skiers and snowboarders with a helmet were significantly less likely than those without a helmet to have a head injury (OR 0.65, 95% confidence interval [CI] 0.55-0.79). The result was similar for studies that used controls without an injury (OR 0.61, 95% CI 0.36-0.92), those that used controls with an injury other than a head or neck injury (OR 0.63, 95% CI 0.52-0.80) and studies that included children under the age of 13 years (OR 0.41, 95% CI 0.27-0.59). Helmets were not associated with an increased risk of neck injury (OR 0.89, 95% CI 0.72-1.09).

INTERPRETATION

Our findings show that helmets reduce the risk of head injury among skiers and snowboarders with no evidence of an increased risk of neck injury.

Ski patrollers: reluctant role models for helmet use

Ski helmets reduce the risk of traumatic brain injury (TBI), but usage rates are low. Ski patrollers could serve as role models for helmet use, but little is known about their practices and beliefs. A written survey was distributed to ski patrollers attending continuing education conferences. The questions addressed included helmet use rates, prior TBI experiences, perceptions of helmet risks and benefits and willingness to serve as safety role models for the public. To assess predictors of helmet use, odds ratios (OR) were calculated, after adjusting for skiing experience. Ninety-three ski patrollers participated and the main outcome was self-reported helmet use of 100% while patrolling. Helmet use was 23% (95% CI 15-32%). Common reasons for non-use included impaired hearing (35%) and discomfort (29%). Most patrollers believed helmets prevent injuries (90%; 95% CI 84-96%) and that they are safety role models (92%; 95% CI 86-98%). However, many believed helmets encourage recklessness (39%; 95% CI 29-49%) and increase injury risks (16%; 95% CI 7-25%). Three factors predicted 100% helmet use: perceived protection from exposure (OR = 9.68; 95% CI 3.14-29.82) or cold (OR = 5.68; 95% CI 1.27-25.42); and belief that role modelling is an advantage of helmets (OR = 4.06; 95% CI 1.29-12.83). Patrollers who believed helmets encourage recklessness were eight times less likely to wear helmets (OR = 0.13; 95% CI 0.03-0.58). Ski patrollers know helmets reduce serious injury and believe they are role models for the public, but most do not wear helmets regularly. To increase helmet use, manufacturers should address hearing- and comfort-related factors. Education programmes should address the belief that helmets encourage recklessness and stress role modelling as a professional responsibility.

Head injuries in winter sports: downhill skiing, snowboarding, sledding, snowmobiling, ice skating and ice hockey

Winter sports are often associated with high speed, which carries with it the potential for collision. As such, head injuries are among the more commonly encountered injuries in winter-related sporting activities. This article focuses on popular winter sports such as downhill skiing and snowboarding, sledding, snowmobiling, ice skating, and hockey. In virtually all of these activities, the incidence and severity of head injuries can be reduced by the use of appropriate protective headgear.

Advances in the prevention of children's injuries: an examination of four common outdoor activities

PURPOSE OF REVIEW

Injuries remain the leading cause of death for children. Experts in paediatrics and child health have a current interest in promoting children's healthy active living. This review highlights findings from recent literature regarding the prevention of injuries from four common outdoor activities: bicycling, snowboarding and skiing, walking and playground activity.

RECENT FINDINGS

There is sound evidence for the effectiveness of bicycle helmets, the promotion of bicycle helmets at a community level and through physician counselling, and legislation; for the effectiveness of helmets for skiing and snowboarding; for the effectiveness of implementing playground safety standards; and for the effectiveness of modifications to the pedestrian physical environment.

SUMMARY

The science of injury prevention has advanced considerably. The highest level of evidence, including systematic reviews, is now available regarding the effectiveness of protective measures, engineering approaches to the environment and legislation. Healthcare providers caring for children play a leading role in injury prevention through child and family counselling, advocacy and research.