Helmet use is associated with higher Injury Severity Scores in alpine skiers and snowboarders evaluated at a Level I trauma center

Traumatic Brain Injury in Alpine Winter Sports: Comparison of Two Case Series from a Swiss Trauma Center 30 Years Apart

BACKGROUND

 Between 3 and 15% of winter sports-related injuries are related to head injuries, which are the primary cause of mortality and disability among skiers. Despite the widespread adoption of helmets in winter sports, which has reduced the incidence of direct head injury, there is a paradoxical trend of an increasing number of individuals wearing helmets sustaining diffuse axonal injuries (DAI), which can result in severe neurologic sequelae.

METHODS

 We retrospectively reviewed 100 cases collected by the senior author of this work from 13 full winter seasons during the period from 1981 to 1993 and compared them with 17 patients admitted during the more shortened 2019 to 2020 ski season due to COVID-19. All data analyzed come from a single institution. Population characteristics, mechanism of injury, helmet use, need for surgical treatment, diagnosis, and outcome were collected. Descriptive statistics were used to compare the two databases.

RESULTS

 From February 1981 to January 2020, most skiers with head injuries were men (76% for the 1981-1993 and 85% for 2020). The proportion of patients aged over 50 increased from <20% in 1981 to 65% in 2020 (p < 0.01), with a median age of 60 years (range: 22-83 years). Low- to medium-velocity injuries were identified in 76% (13) of cases during the 2019 to 2020 season against 38% (28/74) during the 1981 to 1993 seasons (p < 0.01). All injured patients during the 2020 season wore a helmet, whereas none of the patients between 1981 and 1993 wore one (p < 0.01). DAI was observed in six cases (35%) for the 2019 to 2020 season against nine cases (9%) for the 1981 to 1993 season (p < 0.01). Thirty-four percent (34) of patients during the 1981 to 1993 seasons and 18% (3) of patients during the 2019 to 2020 season suffered skeletal fractures (p = 0.02). Among the 100 patients of the 1981 to 1993 seasons, 13 (13%) died against 1 (6%) from the recent season during care at the hospital (p = 0.15). Neurosurgical intervention was performed in 30 (30%) and 2 (12%) patients for the 1981 to 1993 and 2019 to 2020 seasons, respectively (p = 0.003). Neuropsychological sequelae were reported in 17% (7/42) of patients from the 1981 to 1993 seasons and cognitive evaluation before discharge detected significant impairments in 24% (4/17) of the patients from the 2019 to 2020 season (p = 0.29).

CONCLUSION

 Helmet use among skiers sustaining head trauma has increased from none in the period from 1981 to 1993 to 100% during the 2019 to 2020 season, resulting in a reduction in the number of skull fractures and deaths. However, our observations suggest a marked shift in the type of intracranial injuries sustained, including a rise in the number of skiers experiencing DAI, sometimes with severe neurologic outcomes. The reasons for this paradoxical trend can only be speculated upon, leading to the question of whether the perceived benefits of helmet use in winter sports are actually misinterpreted.

Pelvic ring injuries after alpine ski and snowboard accidents

PURPOSE

The purpose of this study was to analyze the patient/injury characteristics and associated hospital course of patients sustaining traumatic pelvic ring injuries after alpine ski and snowboard accidents at a level one trauma center in the Rocky Mountain region.

METHODS

Patient/injury characteristics were obtained from patients presenting with pelvic ring injuries after alpine ski (n = 55) and snowboard (n = 9) accidents. Characteristics and outcomes analyzed included mechanism of injury, pelvic ring classification (Young-Burgess and Tile), hospital admission, physical therapy (PT) clearance, ambulation, length of stay, inpatient morphine milligram equivalents (MME), and discharges to rehabilitation facility.

RESULTS

Snowboarders were more often younger, male, tobacco/substance users, and more likely to be injured by a fall from height than skiers. There were no differences in injury classification or hospital course outcomes between alpine sports. Most common injuries included lateral compression type 1 (LC1) injuries (37.5%), isolated pubic ramus fractures (31.3%), and isolated iliac wing fractures (15.6%). LC1 injuries were unstable in 50% of cases and associated with increased admissions (proportional difference: 47.5%, CI: 23.8-64.5%, p = 0.0002), longer time to PT clearance (median difference(MD): 1.0 day, CI: 0-2.0, p = 0.03), longer LOS (MD: 2.0, CI: 0-2.0, p = 0.02), and increased inpatient MMEs (MD: 197.9 MME, CI: 30.0-420.0, p = 0.02), as compared to other pelvic ring injuries.

CONCLUSION

The majority of pelvic ring injuries from alpine ski and snowboard accidents were LC1 injuries, half of which were unstable, resulting in longer hospital stays, time to PT clearance/ambulation, and opioid use.

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.

Geriatric Snowmobile Trauma: Longer Courses After Similar Injuries

BACKGROUND

Snowmobiling is a popular activity that leads to geriatric trauma admissions; however, this unique trauma population is not well characterized. We aimed to compare the injury burden and outcomes for geriatric versus nongeriatric adults injured riding snowmobiles.

MATERIALS AND METHODS

A retrospective cohort study was performed using the National Trauma Databank comparing nongeriatric (18-64) and geriatric adults (≥65) presenting after snowmobile-related trauma at level 1 and 2 trauma centers from 2011 to 2015. Demographic, admission, injury, and outcome data were collected and compared. A multivariate logistic regression model assessed for risk factors associated with severe injury (Injury Severity Score >15). Analysis was also performed using chi square, analysis of variance, and Kruskal-Wallis testing.

RESULTS

A total of 2471 adult patients with snowmobile trauma were identified; 122 (4.9%) were geriatric. Rates of severe injury (Injury Severity Score >15) were similar between groups, 27.5% in geriatric patients and 22.5% in nongeriatric adults (P = 0.2). Geriatric patients experienced higher rates of lower extremity injury (50.4 versus 40.3%, P = 0.03), neck injury (4.1 versus 1.4%, P = 0.02), and severe spine injury (20.6 versus 7.0%, P = 0.004). Geriatric patients had longer hospitalizations (5 versus 3 d, P < 0.0001), rates of discharge to a facility (36.8% versus 12%, P < 0.0001), and higher mortality (4.1 versus 0.6%, P < 0.0001). Geriatric age did not independently increase the risk for severe injury.

CONCLUSIONS

Geriatric age was not a significant predictor of severe injury after snowmobile trauma; however, geriatric patients suffered unique injuries, had longer hospitalizations, had higher rates of discharge to a facility, and had higher mortality. Tailored geriatric care may improve outcomes in this unique sport-related trauma population.

Impact Performance Comparison of Advanced Snow Sport Helmets with Dedicated Rotation-Damping Systems

Rotational acceleration of the head is a principal cause of concussion and traumatic brain injury. Several rotation-damping systems for helmets have been introduced to better protect the brain from rotational forces. But these systems have not been evaluated in snow sport helmets. This study investigated two snow sport helmets with different rotation-damping systems, termed MIPS and WaveCel, in comparison to a standard snow sport helmet without a rotation-damping system. Impact performance was evaluated by vertical drops of a helmeted Hybrid III head and neck onto an oblique anvil. Six impact conditions were tested, comprising two impact speeds of 4.8 and 6.2 m/s, and three impact locations. Helmet performance was quantified in terms of the linear and rotational kinematics, and the predicted probability of concussion. Both rotation-damping systems significantly reduced rotational acceleration under all six impact conditions compared to the standard helmet, but their effect on linear acceleration was less consistent. The highest probability of concussion for the standard helmet was 89%, while helmets with MIPS and WaveCel systems exhibited a maximal probability of concussion of 67 and 7%, respectively. In conclusion, rotation-damping systems of advanced snow sport helmets can significantly reduce rotational head acceleration and the associated concussion risk.

Geriatric Skiers: Active But Still at Risk, a National Trauma Data Bank Study

BACKGROUND

Downhill skiing accounts for a large portion of geriatric sport-related trauma. We assessed the national burden of geriatric versus nongeriatric ski trauma.

MATERIALS AND METHODS

Adults presenting to level 1/2 trauma centers after ski-associated injuries from 2011 to 2015 were identified from the National Trauma Data Bank by ICD-9 code. We compared demographics, injury patterns, and outcomes between geriatric (age ≥65 y) and nongeriatric adult skiers (age 18-64 y). A multiple regression analysis assessed for risk factors associated with severe injury (Injury Severity Score >15).

RESULTS

We identified 3255 adult ski trauma patients, and 16.7% (543) were geriatric. Mean ages for nongeriatric versus geriatric skiers were 40.8 and 72.1 y, respectively. Geriatric skiers more often suffered head (36.7 versus 24.3%, P < 0.0001), severe head (abbreviated injury scale score >3, 49.0 versus 31.5%, P < 0.0001) and thorax injuries (22.2 versus 18.1%, P = 0.03) as compared with nongeriatric skiers. Geriatric skiers were also more often admitted to the ICU (26.5 versus 14.9%, P < 0.0001), discharged to a facility (26.7 versus 11.6%, P < 0.0001), and suffered higher mortality rates (1.3 versus 0.4%, P = 0.004). Independent risk factors for severe injury included being male (OR: 1.68, CI: 1.22-2.31), helmeted (OR: 1.41, CI: 1.07-1.85), and having comorbidities (OR: 1.37, CI: 1.05-1.80). Geriatric age was not independently associated with severe injury.

CONCLUSIONS

At level 1/2 trauma centers, geriatric age in ski trauma victims was associated with unique injury patterns, higher acuity, increased rates of facility care at discharge, and higher mortality as compared with nongeriatric skiers. Our findings indicate the need for specialized care after high impact geriatric ski trauma.

Head injury and helmet usage trends for alpine skiers and snowboarders in western Canada during the decade 2008-9 to 2017-18

OBJECTIVES

This research explores snowsport head injury trends in western Canadian resorts over the decade 2008-2018.

DESIGN

Ecological study.

METHODS

Head-injury and participation data on alpine skiing and snowboarding (snowsports) was provided by the Canada West Ski Areas Association (CWSAA) for 2008-2018. Injury reports from the ski patrol of 52 western Canadian resorts were analysed. 29 resorts were included where there was both injury and participation data for at least 8 out of 10 seasons, resulting in analysis of 10,371 reports. Data was imported into SPSS 24 for analysis using descriptive statistics, chi-squared analysis, odds ratios and linear regression.

RESULTS

Over the decade: the head injury rate was 0.205 injuries per thousand skier days. Head injuries were 9-10% of all injuries, significantly lower for skiers (8.3%) than snowboarders (10.9%). There were no significant differences in helmet-usage rates of injured and non-injured populations. 80.6% of injured participants wore a helmet, those wearing a helmet were 8% more likely to report a head injury than those not wearing a helmet. There was little variation in the proportion of head injuries reported as concussion, but a 50% reduction in ambulance or helicopter transport, a head-injury severity proxy. There was a significant relationship between the proportion of snowsport participants who were snowboarders and the head-injury rate.

CONCLUSIONS

Head injuries remain a rare event. There has been a decline in the severity of reported head injuries which may be a function of a decline in the proportion of snowboarders in snowsports.