Head injury trends and helmet use in skiers and snowboarders in Western Canada, 2008-2009 to 2012-2013: an ecological study

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.

Global research trends in skiing from 1974 to 2023: A bibliometric analysis

This study analyzes 1643 documents related to skiing from 1974 to 2023 using the Web of Science Core Collection database, employing CiteSpace and VOSviewer for quantitative analysis. Findings reveal a growing literature output, with the past five years contributing to 36.2 % of publications. Norway leads in total publications and collaboration intensity, with the University of Salzburg and the Norwegian University of Science and Technology as prominent institutions. The research spans a wide range of disciplines such as Sport Sciences, Physiology, etc., and interdisciplinary intersections with engineering, computer science, etc. have become a future research trend. The research focuses on the analysis of skiers' sports performance, the analysis of skiing-induced sports injuries, the biomechanical analysis of skiers' postures, and the analysis of skiing-induced respiratory diseases. The study highlights the evolution of research focus from skiing injuries to injury prevention and sports performance enhancement. This comprehensive overview aids scholars in understanding skiing research hotspots and future trends efficiently.

Characteristics of Fatal Accidents due to Exogenous Causes at Ski Resorts in Japan Over the Past 13 Years: A Retrospective Descriptive Study

INTRODUCTION

The characteristics of ski- and snowboard-related fatalities at Japanese ski resorts remain unknown. We aimed to analyze the characteristics of this in the current study.

METHODS

Using the Ski Resort Injury Report data for the 13-y period between the 2011-12 and 2022-23 seasons, we described the characteristics of fatal accidents due to exogenous causes.

RESULTS

Eighty-four subjects (48 skiers and 36 snowboarders) were analyzed. Males accounted for 73 cases of all 84 fatalities (86.9%), including 44 skiers (91.7%) and 29 snowboarders (80.6%). Skiers aged ≥50 y and snowboarders aged 20-35 y had the highest number of fatal accidents (32 and 18 cases, respectively). Regarding location, 26 fatal accidents occurred on slopes, and 58 occurred out of slopes (skiers, 11 and 37 cases; snowboarders, 15 and 21 cases, respectively). Among skiers, head and neck trauma accounted for the cause of death in 13 cases (27.1%) and asphyxiation in 11 cases (22.9%). Among snowboarders, head and neck trauma accounted for the cause of death in 14 cases (38.9%) and asphyxiation in 14 cases (38.9%).

CONCLUSIONS

Males, particularly those aged ≥50 among skiers and 20-35 among snowboarders, should be wary of the potential for injuries to the head, neck, and airway when skiing or snowboarding. In this study, traumatic deaths from crashing into trees and asphyxiation from deep snow immersion accidents accounted for approximately half of fatal ski accidents in Japan.

[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.

Collisions with another person while skiing and snowboarding: A 13-year national registry analysis

INTRODUCTION

Interindividual collisions while skiing or snowboarding occur regularly, they can be associated with severe injuries.

OBJECTIVE

To elucidate causes of accidents, injury patterns and potential risk factors for injury severity in interindividual collisions of skiers and snowboarders.

MATERIAL AND METHODS

Retrospective analysis of the Austrian Registry for Mountain Accidents within a 13-year timeframe (2005-2018) with regard to on- or off-piste collisions of skiers and snowboarders.

RESULTS

A total of 30,503 collisions, involving 52,430 (85.9%) skiers and 8,576 (14.1%) snowboarders were analysed. Denominators are lacking, since total numbers of skiers and snowboarders were not available. Compared to skiers, snowboarders were younger (23 vs. 42 years; p<0.001), predominantly male (77.4% vs. 61.0%; p<0.001) and less often severely injured (46.8% vs. 26.2%; p<0.001). Most accidents occurred on slopes (>95%). Collisions involving two snowboarders occurred proportionally more often in terrain parks (4.1% of 1,664 injured snowboarders; p<0.001) and while one victim was standing or sitting (9.7%; p<0.001). Contusions/strains/sprains were most prevalent (>23%), as were head injuries (>12%). In skiers, chest, shoulder, hip, thigh and knee injuries occurred more often, leading to fractures, dislocations, concussions and internal injuries more frequently. In snowboarders, spine/back, elbow, forearm, wrist and lower leg injuries were more prevalent. Female gender and standing or sitting prior to the accident was a risk factor for being more severely injured in collisions involving i) two skiers (OR: 4.02 (3.79-4.26) and 3.91 (3.26-4.68)), ii) a skier and a snowboarder (OR: 4.50 (3.95-5.14) and 11.49 (8.04-16.41)) or iii) two snowboarders (OR: 2.85 (2.12-3.84) and 12.47 (6.17-25.20)). Wearing a helmet increased the risk when two skiers collided (OR: 1.10 (1.03-1.17)). In skier vs. snowboarder collisions, the skier had a higher risk of being injured more severely (OR: 7.93 (6.98-9.01)).

CONCLUSIONS

In interindividual collisions of skiers and snowboarders, injury patterns and preceding causes differ substantially. Skiers are more likely to be severely injured. Awareness of an increased risk of injury should be raised particularly while standing or sitting on the slope.

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.

Motives for the Use or Not of Protective Equipment for the Recreational Practice of Skiing and Snowboarding in Spanish Winter Stations

The objective of this research was to analyze the motives for using or not using protections by recreational ski and snowboard athletes, specifically regarding gender and age in the winter resorts of Sierra Nevada and Alto Campoo (Spain). A total of 520 users participated in Sierra Nevada (n = 306 (58,8%)) and Alto Campoo (n = 214 (42.2%)); 257 of them were men (49.4%) and 263 (50.6%) were women; from 6 to 50 years old; classified by 4 stages of development (Childhood (n = 106 (20.4%); Teenagers (n = 110 (21.2%); Young adults (n = 101 (19.4%); Adults (n = 203 (39.0%)). For the data collection an ad hoc questionnaire was used (socio-demographic data, use/no use of protection, motives for the use). The data revealed that 76.5% used protections equipment, with the women being more likely to use protective equipment than men. Regarding age, young adults and adults were the ones using less protection. In relation to the motives of using protective equipment, security was the main motive for using it, while the reason to avoid using it was, most of the time, discomfort. Additionally, the childhood and teenager groups were the ones who reported, as motivation, family obligation, showing the importance of the influence of the parents.

Gender differences in snowboarding accidents in Austria: a 2005-2018 registry analysis

OBJECTIVES

To elucidate gender differences in snowboarding accidents.

DESIGN

Retrospective registry analysis within the Austrian National Registry of Mountain Accidents.

SETTING

Snowboard-related emergencies between November 2005 and October 2018.

PARTICIPANTS

All injured snowboarders with documented injury severity and gender (3536 men; 2155 women).

PRIMARY AND SECONDARY OUTCOME MEASURES

Gender-specific analysis of emergency characteristics and injury patterns.

RESULTS

Over time, the number of mild, severe and fatal injuries per season decreased in men but not in women. Accidents most frequently were interindividual collisions (>80%) and occurred when heading downhill on a slope. Men more often suffered injuries to the shoulder (15.1% vs 9.2%) and chest (6.8% vs 4.4%), were involved in accidents caused by falling (12.9% vs 9.6%) or obstacle impact (4.3% vs 1.5%), while on slopes with higher difficulty levels (red: 42.6% vs 39.9%; black: 4.2% vs 2.5%), while snowboarding in a park (4.8% vs 2.1%) and under the influence of alcohol (1.6% vs 0.5%). Women more often sustained injuries to the back (10.2% vs 13.1%) and pelvis (2.9% vs 4.2%), on easier slopes (blue: 46.1% vs 52.4%) and while standing or sitting (11.0% vs 15.8%). Mild injuries were more frequent in women (48.6% vs 56.4%), severe and fatal injuries in men (36.0% vs 29.7% and 0.9% vs 0.4%). Male gender, age and the use of a helmet were risk factors for the combined outcome of severe or fatal injuries (OR (99% CI): 1.22 (1.00 to 1.48), 1.02 (1.02 to 1.03) and 1.31 (1.05 to 1.63)). When wearing a helmet, the relative risk (RR) for severe injuries increased while that for mild injuries decreased in male snowboarders only (RR (95% CI): 1.21 (1.09 to 1.34) and 0.88 (0.83 to 0.95)).

CONCLUSIONS

Snowboard injuries are proportionally increasing in women and the observed injury patterns and emergency characteristics differ substantially from those of men. Further gender-specific research in snowboard-related injuries should be encouraged.

TRIAL REGISTRATION NUMBER

NCT03755050.

Protections in the Recreational Practice of Ski and Snowboard-An Age and Gender Discussion? A Case Study in Spain

The objective of this research was to evaluate the protections taken by ski and snowboard recreational athletes of the winter stations Sierra Nevada and Alto Campoo (Spain), regarding gender, age, and practiced sport. A total of 520 users participated, Sierra Nevada (n = 306 (58.8%)); Alto Campoo (n = 214 (42.2%)), 257 of them were men (49.4%) and 263 (50.6%) were women, from 6 to 64 years old, classified by 4 stages of development (Childhood (n = 106 (20.4%)); Teenagers (n = 110 (21.2%)); Youth (n = 101 (19.4%)); Adults (n = 203 (39.0%))). For the data collection, an Ad Hoc questionnaire was used (Socio-demographic data, use/no use of protection). The data revealed that 23.5% of the participants did not use any protection. Regarding the development stage, 1% of the children did not use any protection, neither did 3.1% of the teenagers, 6.7% of the youth, or 12.7% of the adults (p < 0.001). Regarding gender, a total of 17.1% of men did not use protection, and regarding women, 6.3% of them did not use it (p < 0.001). In relation to the practiced sport, 15.8% of the skiers did not use it against 7.7% of the snowboarders (p = 0.006). The use of protection for the practice in winter sports is not enough to reduce the injury risk in these sports and, in the worst cases, fatal accidents.

Helmet Fit Assessment and Concussion Risk in Youth Ice Hockey Players: A Nested Case-Control Study

CONTEXT

Injury surveillance has shown that concussions are the most common injury in youth ice hockey. Research examining the criteria for ensuring the correct fit of protective equipment and its potential relationship with concussion risk is very limited.

OBJECTIVE

To evaluate the association between helmet fit and the odds of experiencing a concussion among youth ice hockey players.

DESIGN

Nested case-control within a cohort study.

SETTING

Calgary, Alberta, Canada.

PATIENTS OR OTHER PARTICIPANTS

Data were collected for 72 concussed, 41 nonconcussion-injured, and 62 uninjured ice hockey players aged 11 to 18 years.

MAIN OUTCOME MEASURE(S)

Helmet-fit assessments were conducted across players and encompassed helmet specifications, condition, certification, and criteria measuring helmet fit. Using a validated injury-surveillance system, we identified participants as players with suspected concussions or physician-diagnosed concussions or both. One control group comprised players who sustained nonconcussion injuries, and a second control group comprised uninjured players. Helmet-fit criteria (maximum score = 16) were assessed for the concussed players and compared with each of the 2 control groups. The primary outcome was dichotomous (>1 helmet-fit criteria missing versus 0 or 1 criterion missing). Logistic and conditional logistic regression were used to investigate the effect of helmet fit on the odds of concussion.

RESULTS

The primary analysis (54 pairs matched for age, sex, and level of play) suggested that inadequate helmet fit (>1 criterion missing) resulted in greater odds of sustaining a concussion when comparing concussed and uninjured players (odds ratio [OR] = 2.67 [95% CI = 1.04, 6.81], P = .040). However, a secondary unmatched analysis involving all participants indicated no significant association between helmet fit and the odds of sustaining a concussion when we compared concussed players with nonconcussion-injured players (OR = 0.98 [0.43, 2.24], P = .961) or uninjured players (OR = 1.66 [0.90, 3.05], P = .103).

CONCLUSIONS

Inadequate helmet fit may affect the odds of sustaining a concussion in youth ice hockey players. Future investigators should continue to evaluate this relationship in larger samples to inform helmet-fit recommendations.

Injury trends in alpine skiing and a snowboarding over the decade 2008-09 to 2017-18

OBJECTIVES

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

DESIGN

Ecological study.

METHODS

Injury and participation data on alpine skiing and snowboarding was provided by the Canada West Ski Areas Association for 2008-2018. Inclusion criteria were met by 29 of 52 resorts, resulting in the analysis of 107,540 injury reports via SPSS 24, using descriptive statistics and chi-squared analysis.

RESULTS

Over the decade: there was a gradual decline in the injury rate, averaging 2.24 injuries per 1000 skier days. Male snowboarders accounted for 1/3 of all injured participants, females were 42% of all. Day-ticket holders were the most injured of all customer-types, with most injuries occurring as the result of falls on marked, green/easiest terrain. For skiers, injuries to lower limbs, and especially knees, were most common. For snowboarders, upper limb injuries, especially wrists, were most common. 12.8% of the injured population required emergency transport. Advanced slopes/terrain had the highest proportion requiring emergency transport. Fewer skiers experienced head injuries than snowboarders. Snowboarders experienced a higher proportion of serious injuries.

CONCLUSIONS

Snowsport injuries are relatively rare when compared to other sports. Skiers were most prone to knee injuries and snowboarders to wrist injuries. Emergency transport was proportionally needed more from advanced slopes/terrain. Further research is needed into why and how participants make decisions around risk. Future injury prevention strategies should be evaluated in light of potential risk factors such as, social determinants of injury, fall mechanisms, changing participation patterns, age, snowsport discipline, and legal cannabis use.

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.

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.

The King-Devick test is not sensitive to self-reported history of concussion but is affected by English language skill

OBJECTIVES

Head injuries, including concussion, are a concern in many sports. Current validated concussion assessment protocols such are problematic with suggestions that an oculomotor examination, such as the King-Devick (K-D) test, could be included. This research explores the role of the K-D test in snowsport concussion research.

DESIGN

Experienced snowsport participants were recruited through a western Canadian resort (n=75).

METHODS

Participants completed a questionnaire that included their history of prior serious head impacts and were assessed via the computer-based K-D test in English.

RESULTS

Of the 75 participants, 23 (69%) reported at least one previous serious head impact. English was the not primary language for seven participants. Independent sample t-tests revealed: significant differences in the K-D average saccade scores for those who had broken their helmets, with or without a serious head injury (̄x¯=171.23, SD=12.9) and those who had not broken a helmet (̄x¯=186.61, SD=20.18; t (70)=-2.53, p=.014, twotailed) and significant differences in the K-D time for those whose native language is English (̄x¯=47.9, SD=6.3) and those where English was not their first language (̄x¯=53.3, SD=7.4; t(73)=.48, p=.04), but no significant difference for their saccade velocities: English (̄x¯=183.64, SD=20.0) versus those where English is a second or third language (̄x¯=188.44, SD=20.1; t(70)=-.56, p=.576).

CONCLUSIONS

For subjects whose first language is not English, such as in many snowsport resorts, the K-D test may need to be conducted in a person's native language to provide a valid assessment based upon the time to complete the task.

Snowsport experience, expertise, lower limb injury and somatosensory ability

OBJECTIVES

Previous research demonstrates that a history of ankle injuries increases the risk of overall future injuries, and that somatosensory scores are correlated to sport performance. This research explores the relationship between lower limb somatosensory scores in snowsport participants and ankle injury history; and the relationship between lower limb somatosensory scores and Instructor qualification.

DESIGN AND METHODS

Experienced snowsport participants who were recruited through a western Canadian snowsport school completed a questionnaire that included their ankle injury history, the Identification of Functional Ankle Instability (idFAI), the Cumberland Ankle Instability Tool (CAIT), and their current instructor qualification level, as a proxy for sport performance. Lower limb somatosensory was assessed using the active movement extent discrimination assessment (AMEDA) method.

RESULTS

Of the 75 participants, 55% reported at least one previous ankle injury. An independent sample t-test did not show any significant difference in somatosensory scores of those with an ankle injury history (x¯=.66, SD=.05) or not (x¯=.66, SD=.05). Nor was there any difference between those with a functionally unstable ankle (i.e. CAIT<24 and idFAI>11) and all others [x¯=.66, SD=.04 cf. x¯=.66, SD=.05; t(67)=.54, p=.78]. An ANOVA exploring the relationship between Instructor Qualification and somatosensory scores was significant at p<.05 [F(4, 68)=4.0, p=.006].

CONCLUSIONS

The results did not reveal any significant difference in perceived functional instability and somatosensory scores, which contrasts with previous research. The sport performance finding is consistent with previous work examining the relationship between somatosensory scores and sport performances. Further research is needed to explore if the dynamic snowsport working environment impacts ankle instability and somatosensory scores.