Risk factors associated with alpine skiing injuries in children. A case-control study

Effectiveness of an injury prevention video on risky behaviours in youth snow sports: A randomized controlled trial

Objectives

Ski and snowboard-related injuries are common among Canadian youth. Analyzing the role of risky behaviours that contribute to injury risk is essential for gaining an understanding of injury prevention opportunities. The objective was to determine if rates of risky behaviour seen at the ski hill were lower for children and adolescents exposed to an educational injury prevention video.

Methods

This single-blinded cluster randomized controlled trial included students (ages 7-16) from 18 Calgary schools who were enrolled in novice levelled school-sanctioned ski and snowboard programs. Consenting schools were randomly assigned to the intervention or control. The control group followed standard preparation including watching a general ski hill orientation video that was created by the ski hill. The intervention group viewed the intervention video focussed on injury prevention. The Risky Behaviour and Actions Assessment Tool was used by blinded research assistants to observe and record students' risky behaviours at an Alberta ski hill.

Results

In total, 407 observations estimated the rate of risky behaviour. The overall rate of risky behaviour was 23.31/100 person runs in the control group and 22.95/100 person runs in the intervention group. The most commonly observed risky behaviours in both groups were skiing too close to other skiers/snowboarders and near collision with an object/person.

Conclusions

Both groups showed similar rates of risky behaviour and demonstrated the same most common type of behaviour. Practical applications: future work should focus on mitigating common risky behaviours.

Level of Overestimation Among Dutch Recreational Skiers: Unskilled Tourists in the Mountains

OBJECTIVE

To examine the level of overestimation (LO), associated factors, and identify the group of severe overestimators, among recreational skiers.

DESIGN

Cross-sectional observational study.

SETTING

An intermediate difficulty slope in an artificial snow indoor ski hall, and one in the mountains (Flachau, Austria).

PARTICIPANTS

Dutch recreational skiers.

INDEPENDENT VARIABLES

Participants were asked to rate themselves (SRSS, self-reported skill score). While skiing downhill they were objectively evaluated by 2 expert assessors (OSS, observed skill score). Potential associated factors and predictors for severe overestimation were assessed by a questionnaire.

MAIN OUTCOME MEASURES

The LO, calculated by subtracting the OSS from the SRSS, was categorized into "no," "mild," and "severe." Potential differences between these groups were analyzed, and regression analyses were performed to identify the factors associated with severe overestimation. To construct a profile of severe overestimators, the dataset was stratified based on 3 variables.

RESULTS

Overestimation was largely present (79.8%), and was severe in 32%. The LO decreased toward the more skilled skiers. Severe overestimators were mainly male, skied the least hours per day, were more avoidant, and showed the highest proportions of beginners and slightly advanced skiers. The profile of "severe overestimator" is characterized by physically unprepared males, avoidant for certain weather circumstances.

CONCLUSIONS

Overestimation among recreational Dutch skiers is largely present, particularly among physically unprepared males, avoidant of certain snow and weather conditions. These features may function as a proxy to identify "severe overestimators" in comparable populations. Preventive strategies should focus to increase awareness particularly among these subjects.

Estimating skills level in recreational skiing: Development and validation of a practical multidimensional instrument

Skiing and snowboarding are both popular recreational alpine sports, with substantial injury risk of variable severity. Although skills level has repeatedly been associated with injury risk, a validated measure to accurately estimate the actual skills level without objective assessment is missing. This study aimed to develop a practical validated instrument, to better estimate the actual skills level of recreational skiers, based on the criteria of the Dutch Skiing Federation (DSF), and covering five different skill domains. A sample of Dutch recreational skiers (n = 84) was asked to fill in a questionnaire reflecting seven, a priori chosen predictors by expert opinion, to ski downhill and to be objectively evaluated by expert assessors. The instrument was developed to have a multidimensional character and was validated according to the TRIPOD guideline (Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis). The sample reported an overall incorrect self-reported estimation of their skills, compared with the observed skill score. The instrument showed good calibration and underwent multiple validation methods. The estimated skills score showed to be closer to the observed scores, than self-reportage. Our study provides a practical, multidimensional, and validated instrument to estimate the actual skills level. It proved to better reflect the actual skills levels compared with self-reportage among recreational skiers.

Skiing and snowboarding related deep laceration injuries. A five-season cross-sectional analysis from a level-1 trauma centre in the Swiss Alps

OBJECTIVES

Lacerations comprise 5.6-33.6% of skiing/snowboarding related injuries. This study aimed to investigate the mechanism of injury and the location of these lacerations and propose preventive measures.

METHODS

After our state ethics committee approval, we retrospectively reviewed the medical records and surgical protocols of 46 patients (mean age (±SD) 34.6 (±15.3); 71.4% men) treated for severe skiing/snowboarding lacerations at our level-1 trauma centre between 2016 and 2021. Patients were asked to answer a questionnaire on their skiing experience, equipment used and the circumstances of the accident.

RESULTS

Lacerations around the hip, thigh, and knee accounted for 94%. The latter was the most common location (45%). Although 91.3% of patients wore appropriate clothing and full standard protection equipment, it did not offer any extra-resistance against skiing/snowboarding's edges. Skiers were more affected (91.3%) than snowboarders (8.7%). The most common mechanism of injury was inadvertent release of the bindings (52.2%), followed by insufficient ski level for the slope (21.7%) and collisions (17.4%). Long-term trends demonstrated an increasing incidence.

CONCLUSION

Identification of body areas at risk and the mechanisms of injury were the most significant findings of this work. These data encourage the development of specific injury prevention programs as the occurrence of these lesions tended to increase over the last few years. To reduce their incidence, we propose skiers to have their bindings regularly adjusted and manufacturers to develop cut-resistant skiwear.

LEVEL OF EVIDENCE

IV.

A Comparison of ACL Injury Risk, Ski Geometry and Standing Height Parameters between Skiers with Rented and with Owned Skis

to evaluate if ACL injuries are associated with recreational skiers using rented skis and whether individual factors, ski geometry parameters and standing heights differ between skiers who rented or owned skis. A retrospective questionnaire-based, case-control study of ACL-injured and uninjured recreational skiers was conducted during six winter seasons. Age, sex, body height, body weight, nationality, ownership of skis, skill level, risk-taking behavior, ski length, side-cut radius, widths of the tip, waist, and tail, and the standing heights at the front and rear components of the ski binding were assessed. Additionally, ratios between ski widths and a standing height ratio were calculated. Altogether, 1780 skiers (48.9% females) with a mean age of 39.2 ± 13.0 years participated, of whom 22.0% sustained an ACL injury and 32.3% rented skis. ACL injury risk was significantly associated with rented skis (OR 3.2, 95% CI 2.5-4.0). Compared to skiers using own skis, participants who rented skis were more likely female, smaller and lighter, tourists, less skilled and more cautious. In comparison to owned skis, rented skis showed significantly lower mean values in ski length, side-cut radius, ski widths, and for the three ski widths ratios. Additionally, standing heights were significantly lower while standing height ratio was higher for rented skis. Beside individual factors, equipment-related factors should be considered when renting skis in order to reduce ACL injury risk.

Gender Differences in Postural Stability among 13-Year-Old Alpine Skiers

This experiment examined changes in body sway after Wingate test (WAnT) in 19 adolescents practicing alpine skiing, subjected to the same type of training load for 4–5 years (10 girls and nine boys). The postural examinations were performed with eyes open (EO), eyes closed (EC), and sway reverenced vision (SRV) in the medial-lateral (ML) and anterior-posterior (AP) planes. The displacement of center of foot pressure (CoP), range of sway (RS), mean sway velocity (MV), way length, and surface area were measured in bipedal upright stance before and after the WAnT to assess the influence of fatigue on postural balance. There were no significant differences in WAnT parameters between girls and boys. Relative peak power (RPP), relative total work (RWtot) were (girls vs. boys) 8.89 ± 0.70 vs. 9.57 ± 1.22 W/kg, p < 0.05 and 227.91 ± 14.98 vs. 243.22 ± 30.24 W/kg, p < 0.05 respectively. The fatigue index (FI) was also on similar level in both genders; however, blood lactate concentration (BLa) was significantly higher in boys (10.35 ± 1.16 mM) than in girls (8.67 ± 1.35 mM) p = 0.007. In the EO examination, statistically significant differences between resting and fatigue conditions in the whole group and after the division into girls and boys were found. In fatigue conditions, significant gender differences were noted for measurements in the ML plane (sway path and RS) and RS in the AP plane. Comparison of the three conditions shows differences between EO vs. EC and SRV in AP plane measured parameters, and for RS in ML plane in rest condition in girls. The strong correlations between FI and CoP parameters mainly in ML plane in the whole group for all examination conditions were noted. By genders, mainly RS in ML plane strongly correlates with FI (r > 0.7). No correlation was found between BLa and CoP parameters (p > 0.06). The presented results indicate that subjecting adolescents of both genders to the same training may reduce gender differences in the postural balance ability at rest but not in fatigue conditions and that girls are significantly superior in postural balance in the ML plane than boys. It was also shown that too little or too much information may be destructive to postural balance in young adolescents.

Is ski boot sole abrasion a potential ACL injury risk factor for male and female recreational skiers?

Objectives

To evaluate the potential impact of ski boot sole abrasion on the ACL injury risk of recreational skiers.

Methods

During the past two winter seasons 2016/17 and 2017/18, this retrospective case‐control study was conducted in one Austrian ski area. Among a cohort of 148 ACL‐injured (51.4% females) and 455 uninjured recreational skiers (43.3% females), age, sex, height, weight, and self‐reported skill level were collected by questionnaire, ski length and sidecut radius were notated and sole abrasion of the toe and heel piece of the ski boot was measured using a digital caliper.

Results

ACL‐injured skiers showed a higher proportion of female (51.4% vs 43.3%, P < 0.001) and less skilled skiers (48.6% vs 20.9%, P < 0.001), and ski length to height ratio was higher (94.7 ± 3.7 vs 93.8 ± 5.0%, P = 0.019) compared to uninjured skiers. ACL‐injured skiers used ski boots of greater abrasion at the toe (4.8 ± 1.8 vs 2.4 ± 2.5 mm, P < 0.001) and heel piece (5.4 ± 1.8 vs 3.3 ± 2.3 mm, P < 0.001) compared to controls. Multivariate regression analysis revealed, beside female sex (OR 6.0, 95% CI, 3.1‐11.5, P < 0.001), lower skill level (OR 3.2, 95% CI, 1.9‐5.4, P < 0.001) and ski length to height ratio (OR 1.1, 95% CI, 1.0‐1.2, P < 0.001), sole abrasion at the toe (OR 1.8, 95% CI, 1.5‐2.1, P < 0.001) and heel piece (OR 1.4, 95% CI, 1.2‐1.6, P < 0.001) to be independently associated with an ACL injury among recreational alpine skiers.

Conclusions

Based on the underlying findings, ski boot sole abrasion was found to be an independent risk factor and may contribute to an increased ACL injury risk.

Ski and snowboard school programs: Injury surveillance and risk factors for grade-specific injury

The objective of our study was to evaluate incidence rates and profile of school program ski and snowboard-related injuries by school grade group using a historical cohort design. Injuries were identified via Accident Report Forms completed by ski patrollers. Severe injury was defined as those with ambulance evacuation or recommending patient transport to hospital. Poisson regression analysis was used to examine the school grade group-specific injury rates adjusting for risk factors (sex, activity, ability, and socioeconomic status) and accounting for the effect of clustering by school. Forty of 107 (37%) injuries reported were severe. Adolescents (grades 7-12) had higher crude injury rates (91 of 10 000 student-days) than children (grades 1-3: 25 of 10 000 student-days; grades 4-6: 65 of 10 000 student-days). Those in grades 1-3 had no severe injuries. Although the rate of injury was lower in grades 1-3, there were no statistically significant grade group differences in adjusted analyses. Snowboarders had a higher rate of injury compared with skiers, while higher ability level was protective. Participants in grades 1-3 had the lowest crude and adjusted injury rates. Students in grades 7-12 had the highest rate of overall and severe injuries. These results will inform evidence-based guidelines for school ski/snowboard program participation by school-aged children.

Three-dimensional lower extremity joint loading in a carved ski and snowboard turn: a pilot study

A large number of injuries to the lower extremity occur in skiing and snowboarding. Due to the difficulty of collecting 3D kinematic and kinetic data with high accuracy, a possible relationship between injury statistic and joint loading has not been studied. Therefore, the purpose of the current study was to compare ankle and knee joint loading at the steering leg between carved ski and snowboard turns. Kinetic data were collected using mobile force plates mounted under the toe and heel part of the binding on skies or snowboard (KISTLER). Kinematic data were collected with five synchronized, panning, tilting, and zooming cameras. An extended version of the Yeadon model was applied to calculate inertial properties of the segments. Ankle and knee joint forces and moments were calculated using inverse dynamic analysis. Results showed higher forces along the longitudinal axis in skiing and similar forces for skiing and snowboarding in anterior-posterior and mediolateral direction. Joint moments were consistently greater during a snowboard turn, but more fluctuations were observed in skiing. Hence, when comparing joint loading between carved ski and snowboard turns, one should differentiate between forces and moments, including the direction of forces and moments and the turn phase.

Incidence of Recreational Alpine Skiing and Snowboarding Injuries: Six Years Experience in the Largest Ski Resort in Finland

BACKGROUND AND AIMS

The aim of this study was to provide information on incidences and severity of recreational alpine skiing and snowboarding injuries in Northern Finland and to discuss possible preventive measures to reduce the number and severity of injuries in the future.

MATERIALS AND METHODS

This retrospective study consists of all injured skiers and snowboarders in the Levi Ski Resort during the 2006-2012 winter seasons. The Levi Ski Resort has a SKIDATA® system which records automatically every ski-lift run taking place. The emergency system of the resort registers the data (conditions during the injury, patient characteristics, and observed and/or suspected injuries) of all injured persons they meet. The severity of injury is defined by the needed level of care: Grade 1 (treated by the emergency system with no need for further referral), Grade 2 (referral to the local primacy care clinic), Grade 3 (transfer to hospital by ambulance), and Grade 4 (transfer to tertiary care by helicopter).

RESULTS

During the 6-year study period, there were 29,576.132 lift runs and 2911 injuries were met by the emergency system, resulting in the average injury incidence of 0.98 injuries per 10,000 lift runs. Vice versa, the average number of the ski-lift rides needed to generate one injury was 10,160. The knee injuries of the skiers constituted almost one-third of all cases, whereas snowboarders sustained more injuries to the upper limb and axial areas.

CONCLUSION

Skiing and snowboarding are related to a relatively high risk of injury. The most common injuries affect the knee in skiers and the upper extremity, especially the wrist, in snowboarders. A continuous and systematic review of injuries is needed to monitor the effects of changes made in terms of the safety.

Alpine skiing injuries in Finland - a two-year retrospective study based on a questionnaire among Ski racers

Background

Alpine skiing is one of the most popular winter sports in the world. Nevertheless, it has always been associated with a high risk of injury. There are however, only a few studies that have examined the risk of injury of competitive skiers, especially of the junior ski racers.

Methods

The inclusion criterion was an injury in alpine skiing resulting in a pause in training longer than one week. Athletes of all ages were included. The study period was from the start of the season of 2008–2009 to end of the season of 2009–2010 (two years).

Results

The average annual number of ski racers in Finland was 661. There were 61 injuries (36 males with a median age of 14 years, 25 females with a median age of 14) fulfilling the inclusion criteria. Ligamentous knee injury was the most frequent (17) and lower leg fracture the second common (16) injury, respectively. There was a female dominance in the ACL injuries. Only one major abdominal injury and no major head injuries were observed. The overall training pause was 26 weeks after the ACL injury and 17 weeks after the lower leg fracture, respectively.

Conclusion

The most common and most disabling injuries affect the knee and the lower leg. The high number of lower leg and ACL injuries is alarming. A continuous and careful monitoring of injuries needs to be established to assess this trend. A systematic review of injuries is the appropriate way to monitor the effects of changes made in terms of safety. The present retrospective two-year pilot study forms a base for a continuous alpine ski injury survey in Finland.

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.

Factors affecting injury severity among recreational skiers and snowboarders: an epidemiology study

Different results have been reported for skiing and snowboarding injuries worldwide. Few studies consider the injury severity score (ISS) for the evaluation of differences among injured skiers-snowboarders. The aim of this study is to identify possible risk factors that affect the severity of skiing and snowboarding injuries in three winter seasons (2002-2005) in South Tyrol. For every injured skier or snowboarder referred to our emergency department in three consecutive seasons, the following data were collected: date of birth, gender, self-declared technical skills level, place of residence (local/non-local), as well as the date, time, and place of the accident. Type of injury and ISS were retrospectively assigned. Data concerning the snowfall in the last 24 h, average snow level, and outdoor air temperature values were obtained from four weather stations that were located inside the ski resorts. A multiple linear regression model was used to evaluate the association between ISS and potential determinants. In the analyzed seasons, 2,511 injured skiers and 843 injured snowboarders were evaluated at our emergency department. There was a significant change in the ISS value for subjects with different self-reported skills levels (P < 0.001). Men and non-local residents experienced more severe injuries than women and local residents, respectively (P < 0.013, P < 0.001). The ISS was higher for people aged over 60 (P < 0.001). Snowfalls brought about a decrease in accident severity (P = 0.009). The severity of the injuries increases with age. Prevention and information programs should be targeted to people who are at high risk of severe injury. A 24-h fresh snowfall seems to reduce the severity of injuries. Very little is known about snow conditions and winter sports injury. Further studies are needed to explore this field.

Myths concerning alpine skiing injuries

There are many commonly discussed myths about ski safety that are propagated by industry, physicians, and skiers. Through a review of the literature concerning 12 such topics, this article demonstrates that the following are untrue: (1) Broken legs have been traded for blown-out knees. (2) If you know your DIN (a slang term for release indicator value), you can adjust your own bindings. (3) Toe and heel piece settings must be the same to function properly. (4) Formal ski instruction will make you safer. (5) Very short skis do not need release bindings. (6) Spending a lot of money on children's equipment is not worth the cost. (7) Children need plenty of room in ski boots for their growing feet. (8) If you think you are going to fall, just relax. (9) Exercise can prevent skiing injuries. (10) Lower release settings can reduce the risk of anterior cruciate ligament injury. (11) Buying new ski equipment is safer than renting. (12) Skiing is among the most dangerous of activities. It is important for the skiing public, physicians, and all those interested in improving skiing safety to verify the measures they advocate. The statements analyzed here are simply untrue and have the potential to cause harm if taken as fact by those exposed to these unsupported opinions.

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.

Skimboard injuries

BACKGROUND

Skimboarding is a recreational activity performed in shallow water in a beach setting.

METHODS

We reviewed patient records from our emergency department for a 52-month period and identified 79 patients with skimboard-related injuries.

RESULTS

Mean age of patients was 15.2 years; 73.4% presented with a fracture. Lower-extremity fractures were found 63.8% of the time, and upper extremity were found 36.2%. Distal radius fractures were the most common (61.9%) upper-extremity fracture, and ankle fractures were the most common (83.8%) lower-extremity fracture. The prevalence of fractures sustained while skimboarding was compared with that of other published series of recreational activities, including trampoline injuries, and was found to be higher.

CONCLUSIONS

Skimboarding is a sport in which injuries occur by the sudden deceleration of the board as it transitions from water to land or from falls into shallow water. The lower-extremity fracture prevalence is much higher than in similar sports such as skateboarding and surfing. The prevalence of fracture is also higher than that found in trampoline-related injury reports.

Self-estimation of ability among skiers and snowboarders in alpine skiing resorts

Skiing ability is thought to be an important risk factor for injuries, but the best method to classify skiing ability is not known. The objective of this study was to validate five different questions designed to self-report skiing ability for ski injury surveillance. To this end 512 alpine skiers, Telemark skiers, snowboarders and skiboarders were asked to selfestimate their skiing ability using five different questions based on skiing skill, piste difficulty, turning technique, skiing experience and falling frequency, each with four categories. The participants then made a test run to test their skiing ability. Observed and self-reported skiing ability were compared using kappa statistics. The correlation between observed and self-reported skiing ability was low to fair, with kappa values of 0.34 for skiing skill), 0.33 for piste difficulty, 0.38 for turning technique, 0.26 for experience and 0.16 for falling frequency. However, the sensitivity and specificity for each of the questionnaires in discriminating between individuals in the poorest skiing ability category on the test and the rest of the group was relatively good (skiing skill: sensitivity 75%, specificity 91%; piste difficulty 68, 96%; turning technique 75, 91%; experience 75, 90%; falling frequency 61, 97%). The results show that the capacity to self-assess skiing ability is limited, but estimation based upon turning technique or skiing skill seem to be best methods for epidemiological studies on injuries in snow sports.

Downhill Ski Injuries in Children and Adolescents

Downhill skiing is considered to be an enjoyable activity for children and adolescents, but it is not without its risks and injuries. Injury rates now range between 3.9 and 9.1 injuries per 1000 skier days, and there has been a well documented increase in the number of trauma cases and fatalities associated with this sport. Head and neck injuries are considered the primary cause of fatal injuries and constitute 11-20% of total injuries among children and adolescents. Cranial trauma is responsible for up to 54% of total hospital injuries and 67% of all fatalities, whereas thoracoabdominal and spine injuries comprise 4-10% of fatalities. Furthermore, there has been an increase in the proportion of upper extremity trauma with acromioclavicular dislocations, and clavicle and humeral fractures accounting for the majority (22-79%) of the injuries. However, the most common and potentially serious injuries in children and adolescents are those to the lower extremity, with knee sprains and anterior cruciate ligament tears accounting for up to 47.7% of total injuries. Knee sprains and grade III ligament trauma associated with lower leg fractures account for 39-77% of ski injuries in this young population. Approximately 15% of downhill skiing injuries among children and adolescents are caused by musculoskeletal immaturity. Other factors include excessive fatigue, age, level of experience, and inappropriate or improperly adjusted equipment. Collisions and falls constitute a significant portion (up to 76%) of trauma, and are commonly associated with excessive speed, adverse slope conditions, overconfidence leading to carelessness, and behavioural patterns within and among gender. The type and severity of injuries are typically functions of biomechanical efficiency, skiing velocity or slope conditions; however, a multiplicative array of intrinsic and extrinsic factors may simultaneously be involved. Despite extensive efforts to provide a comprehensive picture of the aetiology of injury, limitations have hampered reporting. These limitations include age and injury awareness, data collection challenges, lack of uniformity in the definition or delineation of age classification and lack of knowledge of predisposing factors prior to injury. Since skill level is the primary impetus in minimising ski injuries, formal instruction focusing on strategies such as collision avoidance and helmet use, fall training minimising lower extremity trauma, altering ski technique and avoiding behaviours that lead to excessive risk are, therefore, highly recommended. Skiing equipment should be outfitted to match the young skier's height, weight, level of experience, boot size and slope conditions. Additionally, particular attention should be paid to slope management (i.e. overcrowding, trail and obstacle marker upkeep) and minimising any opportunity for excessive speed where children are present. Whether increases in knowledge, education and technology will reduce predisposition to injury among this population remains to be seen. As with all high-risk sports, the answer may lie in increased wisdom and responsibility of both the skier and the parent to ensure an adequate level of ability, self-control and simply common sense as they venture out on the slopes.

Injuries among elite snowboarders (FIS Snowboard World Cup)

BACKGROUND

Although snowboarding is already established as an Olympic sport, it is still a developing sport, with new disciplines, more demanding snow installations, and spectacular tricks. A recent study on subjects at Norwegian national elite level showed that injury risk is high and that injuries among competitive snowboarders differ from those seen in recreational snowboarders, with fewer wrist injuries and more knee and back injuries.

OBJECTIVE

To describe the incidence and type of injuries among female and male snowboarders at international elite level.

METHOD

At the last race of the Fédération Internationale de Ski Snowboard World Cup, acute injuries resulting in missed participation and overuse injuries influencing performance, were recorded during a retrospective interview (91% response rate). The registration period was from April 2002 (end of season) until March 2003. Exposure was recorded as the number of runs in all disciplines, and the incidence was calculated as number of injuries per 1000 runs.

RESULTS

The 258 athletes interviewed reported 3193 competition days (n = 46 879 runs) in all disciplines. In total, 135 acute injuries were recorded; 62 (46%) during competition in the official disciplines. Of the 135 acute injuries, the most common injury locations were knee (n = 24; 18%), shoulder (n = 18; 13%), back (n = 17; 13%), and wrist (n = 11; 8%). The overall incidence during competition was 1.3 (95% confidence interval 1.0 to 1.7) injuries per 1000 runs; 2.3 (0.9 to 3.8) for big air (n = 10), 1.9 (1.1 to 2.8) for halfpipe (n = 21), 2.1 (1.2 to 3.0) for snowboard cross (n = 20), 0.6 (0.2 to 1.0) for parallel giant slalom (n = 8), and 0.3 (0.0 to 0.7) for parallel slalom (n = 3). The severity of injuries was graded based on time loss (27% lost >21 days) and score on the Abbreviated Injury Scale (AIS) (38% AIS 1, 61% AIS 2 and 1% AIS 3). There were 122 overuse injuries, 38 (31%) of these to the knee.

CONCLUSION

The injury risk for big air, snowboard cross, and halfpipe disciplines is high, while that for the snowboard slalom disciplines is lower. The injury pattern is different from recreational athletes, with a greater share of knee injuries and fewer wrist injuries. Compared with national level, the injury risk appears to be lower at World Cup level.

Effect of trail design and grooming on the incidence of injuries at alpine ski areas

OBJECTIVES

To identify the conditions at certain sites on slopes known as black spots for injury.

METHOD

In the Hafjell and Voss alpine ski areas in Norway, 1410 skiing injuries were recorded from December 1990 through the 1996 season. In Hafjell, 183 of these injuries were plotted on an area map during the two first seasons. Similarly, in Voss, 214 injuries were plotted on an area map for two seasons. During the last three seasons in Hafjell, 835 ski injuries were related to 6712 snow grooming hours and 6,829,084 lift journeys.

RESULTS

The mean injury rate was 2.2 injuries per 1000 skier days, and the mean injury severity score (ISS) was 3.1. Accumulations of injuries at three sites (black spots) were recorded on the Hafjell area map. These injuries represented 40% of all injuries in the alpine area (p<0.05). Seven injury accumulation sites were recorded on the alpine area map of Voss, representing 22% of the total injuries (p>0.05). Grooming of the slopes was rated poor for the 49% of injuries that occurred at the sites of injury concentration and significantly different (27%) from injuries that occurred at random in Hafjell. The corresponding values in Voss were 50% and 25% respectively. Grooming hours appeared to be inversely proportional to the number of injuries: R = -0.99 (p<0.02). The mean ISS declined significantly in Hafjell over the observation period (p<0.001).

CONCLUSION

Inappropriate trail design and slope grooming seem to result in an accumulation of injuries at certain sites. Modification in construction and maintenance of the courses may reduce the number of injuries and mean ISS.

Injuries among competitive snowboarders at the national elite level

BACKGROUND

Little is known about injury risk or the pattern of injuries among competitive snowboarders.

PURPOSE

To describe the incidence and pattern of injuries among female and male snowboard athletes at the highest national level.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

This study consists of 2 parts: prospective registration of injuries at snowboarding national cup events and the national championships during the 2002 season, as well as a retrospective interview of the participants during the national championships in March 2002. All injuries that resulted in missed participation were recorded. Exposure was recorded as the number of runs in all disciplines.

RESULTS

In the prospective study, the competition incidence was 4.0 +/- 0.7 injuries per 1000 runs (n = 32 injuries). Back (22%), knee (16%), and hand/wrist injuries (9%) were the most common. The incidence for the different disciplines was 14.2 +/- 5.3 per 1000 runs for big jump, 6.1 +/- 1.8 for snowboardcross, 3.1 +/- 0.9 for halfpipe, and 1.9 +/- 1.9 for giant slalom. The retrospective interview (n = 163 athletes, 83% response) revealed 84 acute time-loss injuries during the season; knee (16%), back (13%), head (13%), and hand/wrist injuries (12%) were the 4 most common injury types. The overall competition incidence was 3.4 +/- 0.6 injuries per 1000 runs (6.6 +/- 3.0 for big jump, 5.8 +/- 1.7 for snowboardcross, 2.1 +/- 0.7 for halfpipe, and 6.6 +/- 4.7 for giant slalom). No injury was recorded in parallel slalom in either study.

CONCLUSION

The incidence of injuries is high among competitive snowboarders at the elite national level. The injury pattern is different from the panorama seen among less experienced athletes, with fewer wrist injuries and more knee injuries.

Skiing- and Snowboarding-Related Injuries Treated in U.S. Emergency Departments, 2002

BACKGROUND

This study aims to describe the characteristics of skiing- and snowboarding-related injuries treated in U.S. emergency departments (EDs).

METHODS

Skiing- and snowboarding-related injuries collected by the National Electronic Injury Surveillance System in 2002 were analyzed. Data regarding skiing and snowboarding participation were used to calculate injury rates by age group and activity (skiing versus snowboarding).

RESULTS

An estimated 77,300 (95% CI = 11,600-143,000) skiing- and 62,000 (95% CI = 32,800-91,200) snowboarding-related injuries were treated in U.S. hospital EDs in 2002. Wrist injuries (17.9%) and arm injuries (16.6%) among snowboarders and knee injuries (22.7%) among skiers were the most common injuries. The age groups that have the highest skiing-related injury rates were the 55-64 years (29.0 per 1,000 participants), the 65+ years (21.7 per 1,000 participants), and the 45-54 years (15.5 per 1,000 participants). The age groups that have the highest snowboarding-related injuries were the 10-13 years (15.9 per 1,000 participants), the 14-17 years (15.0 per 1,000 participants), and the 18-24 years (13.5 per 1,000 participants). Traumatic brain injury (TBI) rates were higher among older skiers, 55-64 years (2.15 per 1,000 participants), and younger skiers, 10-13 years (1.69 per 1,000 participants).

CONCLUSIONS

Our study is the first to demonstrate that older skiers are at highest risk for injury. Adolescents are at highest risk for snowboarding-related injury. Prevention of TBI should be a top injury control priority among skiers and snowboarders.

Quality of information on risk factors reported by ski patrols

OBJECTIVE

To determine the reliability of reporting of information on risk factors from a standard accident report form used by ski patrols and a follow up mail questionnaire or telephone interview among injured skiers and snowboarders.

SETTING

19 ski areas in the Canadian province of Quebec between November 2001 and April 2002.

PARTICIPANTS

4377 injured skiers and snowboarders seen by the ski patrol, who completed a follow up mail questionnaire or telephone interview.

MAIN OUTCOME MEASURES

Kappa and weighted kappa statistics were used to measure the chance corrected agreement for self reported ability, age, skiing time on day of injury, lessons, type of practice, use of helmet at time of injury, and hill difficulty.

RESULTS

The kappa value for helmet use at the time of injury was 0.88 (95% confidence interval 0.87 to 0.90) and for other risk factors ranged from 0.45 (skiing time on day of injury) to 0.98 (age). Few differences were seen in reporting by body region of injury. Reporting consistency was lower for respondents who completed telephone interviews compared with those who completed mail questionnaires and those who responded more than four months after the injury.

CONCLUSIONS

Moderate to almost perfect agreement, depending on the risk factor, exists between ski patrols' accident report forms and follow up information. Ski patrol reports can be a reliable and readily available source of information on risk factors for skiing and snowboarding.

Downhill skiing injury fatalities among children

OBJECTIVE

Young skiers are at increased risk for injury, however, epidemiological data on skiing related fatal injuries among child skiers are scarce. This study aimed to provide information needed to develop injury control and prevention programs.

DESIGN AND SETTING

Study subjects came from Colorado, USA and were identified using a death certificate based surveillance system. Fatal injuries were limited to events that occurred at established commercial ski resorts in Colorado, and subjects were classified as child skiers (0-17 years) or adult skiers (> or =18 years).

MAIN OUTCOME MEASURE

Type and external cause, time, and week day of injury, gender and residency of the decedents.

RESULTS

During the study period from 1980-2001, 149 fatal injuries associated with downhill skiing were identified; 21 (14.1%) occurred among child skiers aged < or =17 years. The age of the youngest decedent was 7 years. In females the proportion of fatal injuries among child skiers was nearly three times that of adults. Traumatic brain injuries were the leading cause of death (67% of all deaths) among children, while multiple internal injuries and traumatic brain injuries accounted for almost equal proportions of fatal injuries among adults. Collision was the leading external mechanism of fatal injuries, accounting for more than two thirds of fatal injuries in both child and adult skiers.

CONCLUSIONS

Traumatic brain injury was the leading cause and collision was the leading external injury mechanism of fatal injuries associated with downhill skiing among child skiers. This underscores the importance of brain injury prevention strategies, including the use of ski helmets and prevention of collisions on ski slopes.

Injuries Among Skiers and Snowboarders in Quebec

BACKGROUND

Snow sports such as skiing and snowboarding are recognized as hazardous, but population-based injury rates or specific risk factors have been difficult to estimate as a result of a lack of complete data for both numerator and denominator.

METHODS

We used data from 3 surveys to estimate the number of participants and annual number of outings in Quebec by age, sex, activity, and calendar year. Injuries reported by ski patrollers were used to estimate injury rates among skiers and snowboarders for the head and neck, trunk, upper extremity, and lower extremity.

RESULTS

Head-neck and trunk injury rates increased over time from 1995-1996 to 1999-2000. There was a steady increase in the rate of injury with younger age for all body regions. The rate of head-neck injury was 50% higher in snowboarders than in skiers (adjusted rate ratio [ARR] = 1.5; 95% confidence interval = 1.3-1.8). Women and girls had a lower rate of head-neck injury (0.73; 0.62-0.87). Snowboarders were twice as likely as skiers to have injuries of the trunk (2.1; 1.7-2.6), and more than 3 times as likely to have injuries of the upper extremities (3.4; 2.9-4.1). Snowboarders had a lower rate of injury only of the lower extremities (0.79; 0.66-0.95). Snowboarder collision-related injury rates increased substantially over time.

CONCLUSIONS

Except for lower extremity injuries, snowboarders have a higher rate of injuries than skiers. Furthermore, collision-related injury rates have increased over time for snowboarders. Targeted injury prevention strategies in this group seem justified.

Helmet rental practices at United States ski areas: a national survey

OBJECTIVES

Studies have shown that head injuries are the leading cause of death on ski slopes. Statistics on helmet rental practices at ski areas across the United States have never been reported. This study sought to determine the prevalence of United States ski areas offering helmet rental during the 2002-03 ski season. Secondarily it sought to analyze the relationships of geographic region and size of ski area with helmet rental availability and to gather information on ski helmet rental cost to the consumer.

METHODS

and setting: A stratified cross sectional telephone survey of a sample of 331 United States ski area onsite rental shops during February 2003.

RESULTS

Altogether 50% of ski areas offered helmet rental with significant variation in the prevalence of helmet rental among ski areas of differing regions and sizes (p<0.01). A majority of Northeastern (57%), Western (63%), and Rocky Mountain (71%) ski areas rented helmets, whereas a minority of Southern (37%) and Midwestern (23%) ski areas rented helmets. Twenty five percent of the smallest ski areas (< or =50 acres) rented helmets compared with 74% of the largest ski areas (> or =501 acres).

CONCLUSIONS

United States ski area helmet rental practices vary by region of the country and ski area size. Winter sports participants interested in wearing protective headgear should be aware of the helmet rental practices at the ski area in which they plan to visit and consider helmet purchase if they visit mainly smaller ski areas or areas within the South or Midwest.

Increased injury risk among first-day skiers, snowboarders, and skiboarders

BACKGROUND

Inexperience predisposes skiers, snowboarders, and skiboarders to a higher risk of injury.

HYPOTHESIS

Individuals on their very 1st day's experience of skiing, snowboarding, or skiboarding are at greater risk of injury.

STUDY DESIGN

Case control study.

METHODS

All individuals injured at the three largest ski areas in Scotland during the three winter seasons 1999-2000 through 2001-2002 were included. First-day participants were identified. Individual demographic details and snow sports-related parameters were recorded. Control data were collected from uninjured individuals. Factors associated with injury were explored in univariate and multivariate analyses.

RESULTS

First-day participants were overrepresented in the injured population by a factor of 2.2. Participant age younger than 17 years or older than 26 years, snowboarding, taking professional instruction, and the use of rented or borrowed gear were all independently associated with increased injury risk among 1st-day participants.

CONCLUSIONS

First-day participants are at increased risk of injury. Several independent risk factors for injury have been identified.

CLINICAL RELEVANCE

First-day participants should be targeted in any future educational programs with emphasis on gear selection, use of protective gear, and the risks of exceeding the limits of their ability.

Effect of helmet wear on the incidence of head/face and cervical spine injuries in young skiers and snowboarders

PURPOSE

To evaluate whether helmets increase the incidence and/or severity of cervical spine injury; decrease the incidence of head injury; and/or increase the incidence of collisions (as a reflection of adverse effects on peripheral vision and/or auditory acuity) among young skiers and snowboarders.

METHODS

During one ski season (1998-99) at a world class ski resort, all young skiers and snowboarders (<13 years of age) presenting with head, face, or neck injury to the one central medical facility at the base of the mountain were identified. On presentation to the clinic, subjects or their parents completed a questionnaire reviewing their use of helmets and circumstances surrounding the injury event. Physicians documented the site and severity of injury, investigations, and disposition of each patient. Concurrently, counts were made at the entry to the ski area of the number of skiers and snowboarders wearing helmets.

RESULTS

Seventy children were evaluated at the clinic following ski/snowboard related head, neck, and face injuries. Fourteen did not require investigation or treatment. Of the remaining 56, 17 (30%) were wearing helmets and 39 (70%) were not. No serious neck injury occurred in either group. Using helmet-use data from the hill, among those under 13 years of age, failure to wear a helmet increased the risk of head, neck, or face injury (relative risk (RR) 2.24, 95% confidence interval (CI) 1.23 to 4.12). When corrected for activity, RR was 1.77 and 95% CI 0.98 to 3.19. There was no significant difference in the odds ratio for collisions. The two groups may have been different in terms of various relevant characteristics not evaluated. No separate analysis of catastrophic injuries was possible.

CONCLUSION

This study suggests that, in skiers and snowboarders under 13 years of age, helmet use does not increase the incidence of cervical spine injury and does reduce the incidence of head injury requiring investigation and/or treatment.

Alpine ski injuries and their prevention

Alpine skiing is a popular sport with significant risk of injury. Since the 1970s, injury rates have dropped from approximately 5 to 8 per 1000 skier-days to about 2 to 3 per 1000 skier-days. The nature of the injuries has also been transformed over the same period. Lower leg injuries are becoming less common while the incidence of knee sprains and upper extremity injuries is becoming more common. Much of this change can be attributed to advancements in binding technology, which effectively reduces lower leg injury, but does not adequately address the issue of knee sprains. Along with design, binding adjustment and maintenance are important preventative factors. Poorly adjusted bindings have been correlated with increased injury rates. Upper extremity injuries constitute approximately one-third of skiing injuries, with ulnar collateral ligament sprains and shoulder injuries being the most common. Strategies to prevent these include proper poling technique and avoidance of non-detachable ski pole retention devices. Spinal injuries in skiers have been traditionally much less common than in snowboarders, but this disparity is likely to diminish with the recent trend of incorporating snowboarding moves into skiing. Strategies to help reduce these injuries include promoting the development of terrain parks and focussing on proper technique during such moves. Head injuries have been increasing in incidence over recent decades and account for more than half of skiing-related deaths. The issue of ski helmets remains controversial while evidence for their efficacy remains under debate. There is no evidence to demonstrate that traditional ski instruction reduces injury frequency. More specific programmes focussed on injury prevention techniques are effective. The question of pre-season conditioning to prevent injuries needs further research to demonstrate efficacy.

Snow sports injuries in Scotland: a case-control study

OBJECTIVES

To examine the incidence and patterns of snow sports injuries at the three largest commercial ski areas in Scotland and to identify factors associated with injury risk.

METHODS

A prospective case-control study of all injured people at Cairngorm, Glenshee, and Nevis Range ski areas during the 1999-2000 winter season. Personal details, snow sports related variables, diagnosis, and treatment were recorded. Control data were collected at random from uninjured people at all three areas. Random counts were performed to analyse the composition of the on slope population.

RESULTS

A total of 732 injuries were recorded in 674 people. Control data were collected from 336 people. The injury rate for the study was 3.7 injuries per 1000 skier days. Alpine skiers comprised 67% of the on slope population, snowboarders 26%, skiboarders 4%, and telemark skiers 2%. Lower limb injuries and sprains were the commonest injuries in alpine skiers and skiboarders. Snowboarders sustained more injuries to the upper limb and axial areas. Skiboarders and snowboarders had a higher incidence of fractures. After adjustment for other variables, three factors were all independently associated with injury: snowboarding (odds ratio (OR) 4.07, 95% confidence interval (CI) 1.65 to 10.08), alpine skiing (OR 3.82, CI 1.6 to 9.13), and age <16 years (OR 1.9, CI 1.14 to 3.17). More than five days of experience in the current season and at least one week of experience in total had a protective effect against injury.

CONCLUSIONS

Despite a change in the composition of the alpine population at Scottish ski areas, the overall rate and pattern of injury are similar to those reported previously in comparable studies. Several factors are associated with an increased risk of injury and should be targeted in future injury prevention campaigns.