Skiing
and Snowboarding Injuries in the Year 2000
Edward
Heneved, MD, FACEP
This
material was presented at the Wilderness Medical Societyís
Summer Conference and Annual Meeting, August 2000, Park
City, Utah. It has been updated with data from the most
recent winter season. Karl Neumann, Editor, Wilderness Medicine
Letter
Alpine
skiing and snowboarding are very popular winter sports.
In the United States alone, there were over 52 million visitors
to the ski slopes during the 1999-2000 season. This report
will focus on the injuries commonly seen in this population
of skiers and snowboarders. While both activities involve
strapping some kind of board to the feet and sliding down
a snow covered hill, each sport has its unique spectrum
of injuries.
Demographics
According
to the National Ski Areas Association (NSAA), the 1999-00
winter season saw 7.4 million skiers and 3.6 million snowboarders
with a combined total of 52.2 million total ski area visits.
(A skier/snowboarder visit represents one person visiting
a ski area for all or any part of a day or night.) Eighteen
percent of the snowboarders also skied. This calculates
to 10.4 million total on-slope participants. The National
Sporting Goods Association estimates that since 1988 the
number of snowboarders has increased 77%, while the number
of skiers has declined 25%. Skiers tend to be older, average
age 31, and 60% are male. The average snowboarder is younger,
average age 20, and 75% are male. During the 1999-2000 season,
there were 503 total ski areas that operated in the U.S.
(down from 735 in 1983). Of these, only five ski areas did
not allow snowboarding (Aspen Mountain, Colorado; Perfect
North Slopes, Indiana; Taos Ski Valley, New Mexico; Alta
and Deer Valley, Utah).
Injury
Rates
"Medically
significant" injuries are those which require medical
treatment or keep a person from skiing for at least one
day. For every 1000 ski area visits, about three will result
in an injury serious enough to require immediate medical
attention. (By comparison, the injury rate for football
is 810/1,000 participants, while tennis has an incidence
of 30/1,000 players.) In a typical year there are about
135,000 medically significant snow sport injuries in the
U.S. Many studies estimate that up to 40% of all injuries
go unreported. One study calculated there may be as many
as 500,000 skier/snowboarder injuries each year. At this
rate of injury for the average skier who skis 14 days a
year, the individual chance of injury each year is approximately
14%.
Over
the past 27 years, skiing injury rates have declined by
half. However, this rate of injury has not decreased in
the past 12 years. With snowboardingís growing popularity,
the incidence of snowboarding injuries has certainly increased.
The injury rate for the newer sport of snowboarding is more
difficult to determine. This is primarily because skier
and snowboarder days are represented by lift ticket sales
that do not distinguish one from the other. This forces
one to estimate the percentage of each on the mountain.
Most early studies report snowboarders to be injured about
as often as skiers. However, recent studies suggest the
rate for snowboarders may be increasing. A report from Mammoth
and June Mountain (California) ski resorts estimated twice
the injury rate for snowboarders, as did studies from Italy
and Switzerland. A Japanese report showed three-fold increase;
and one from Aspen suggests snowboarders are injured five
times more often. During the 1999-2000 season, first aid
data from one large North Tahoe ski resort recorded its
ski injury rate as 3.2/1000 and the snowboarder injury rate
as 12.7/1000. Tahoe Forest Hospital, in Truckee, California,
the closest emergency department to this area documented
five snowboarders injured for every one skier.
In both
skiing and snowboarding, beginners suffer almost three times
more injuries than the more experienced participants. One
study documented 49% of injured snowboarders were beginners
versus 18% of beginner skiers. First-time snowboarders sustain
a significantly higher incidence of emergent injuries (such
as fracture, concussion, dislocation, lost teeth) necessitating
immediate intervention. Teenagers suffer the highest overall
rate of injury in any one age group. Among skiers, the injury
rate for anterior cruciate ligament (ACL) sprains has more
that tripled since the late 1970s, while the incidence of
every other injury has declined.
Factors
Affecting Injury Rates
Regarding
alpine skiers, the injury rate reduction seen since the
1970s is primarily due to a decrease in ankle sprains and
lower extremity fractures. This is attributed to the improved
grooming of slopes, ski instruction, safety innovations
in ski areas, and improved ski equipment. Other factors
that affect injury rates include snow conditions, visibility,
number of skiers on the slopes, skier fatigue, and the use
of alcohol and other drugs. Most injuries occur between
12 noon and 4 PM. The most critical determinants of injury,
however, are still skier ability, relation of speed to athletic
proficiency, and improper adjustment or poor functioning
of equipment. It has been estimated that 44% of all downhill
ski injuries are due to improper maintenance and adjustment
of equipment. Failure of binding release occurs in 70% of
lower leg fractures and serious knee injuries.
The
raw injury rate in women exceeds that in men. Women are
more likely to sustain upper extremity injuries and are
twice as likely to suffer an ACL sprain. When ability, experience,
and size (weight and height) are taken into consideration,
the overall risk of injury for women in skiing is similar
to men.
Fatalities
During
the past 15 years, there has been an average of 34 deaths
per year among skiers and snowboarders. During 1999-2000
season, 30 fatalities occurred out of the 52.2 million skier/snowboarder
days reported. Twenty-three of the fatalities were skiers
(19 male, 4 female) and seven were snowboarders (6 male,
1 female). This equates to a fatality rate of 0.57 per million
skier/snowboarder visits or 2.88 deaths per million on-slope
participants. Sixty percent of all fatal injuries in skiing
involve head injuries. The most common cause of fatal injury
is classified as "skier lost control, hit tree."
Most fatalities in skiers occur in the same population that
exhibits "high-risk behavior." Victims are predominantly
male (85%), in their late teens to early 20s (70%), possess
better than average experience, go at a high rate of speed
at the margin of an intermediate trail. This is the same
group who sustain 74% of the fatal car crashes and 85% of
all fatal industrial accidents.
By comparison,
in 1999, there were 41,300 deaths in automobile accidents,
17,100 deaths from falls, and 11,000 deaths by poisoning.
During 1998, lightning killed 90 people and there were 130
deaths from tornadoes. The rate 2.88 deaths per million
participants for skiing/snowboarding compares to 31.9 for
scuba diving, 25.9 for swimming, 64.7 for boating, and 21.2
for bicycling.
Catastrophic
Injury
Catastrophic
injury is a nebulous term that has yet to be clearly defined
and is therefore not a real statistic over time. Serious
injuries (coma, paraplegia, and serious head or spinal injury)
occur at a rate of 38 per year. In the 1999-2000 season,
there were 44 serious injuries, 30 were skiers (21 male
and 9 female) and 14 were snowboarders (13 male, 1 female).
The rate of serious injury in 1999-2000 was 0.84 per million
skier/snowboarder visits. There is no credible evidence
that catastrophic injuries are increasing at a statistically
significant rate.
Equipment
Boots.
In the 1960s, the most common injury in skiing (25%) was
a fracture of the lateral malleolus, termed "skierís
ankle." It was seen with low, soft leather boots. Over
the past 25 years, the incidence of tibia and fibula fractures
and of lower extremity equipment-related (LEER) injuries
has been reduced by 72% and 43%, respectively. Todayís ski
boot consists of a hard plastic outer shell and a soft inner
liner which extends to the mid-tibia and allows better control
of the ski. Modern ski boots transmit forces to the knee
and contribute to making sprained knees the most common
injury (25 ,38%) in alpine skiing. The incidence of ACL
sprain (about 25,000 per year in the U.S.) represents 33%
of all knee injuries. Curiously, the left knee is more likely
to be injured than the right. ACL tears account for a quarter
of all medically significant injuries and half the treatment
dollars spent each year.
This
same phenomenon has been reproduced in the evolution of
snowboarderís boots. Soft boots give the snowboarder twice
the risk of ankle injury compared to hard boots. "Snowboarderís
ankle," a fracture of the lateral process of the talus,
is caused by forced dorsiflexion and inversion at the ankle
permitted by softer boots. Hard boots place the snowboarder
at risk for "boot-top" fractures of the tibia
and fibula as well as double the risk for knee injury.
Bindings.
Snowboard bindings are of three general types: (1) soft-boot
bindings employ two or three straps across the boot; (2)
hard-boot (or plate) bindings use wire bales to secure the
heel and toe of the boot; (3) a newer step-in type binding
utilizes hardware affixed to the bottom of either soft (stiff-shank)
or hard-shelled boots and lets the rider "click-in."
Current snowboarding technology utilizes non-releasable
bindings. Two companies, Meyer of Switzerland and Miller
of Utah, have marketed releasable bindings since 1991. However,
the industry has not endorsed this concept. Whether releasable
bindings will reduce or simply change the snowboarderís
likelihood of injury remains a heated controversy. If a
rider were "upside down in a tree well" or trying
to "swim out of an avalanche," releasable bindings
may be beneficial. Obviously, in a release situation, both
bindings would need to release or twisting injuries similar
to those of skiers would result. Eight percent of snowboarder
injuries occur while loading onto or unloading from a ski
lift (while only the lead foot is in the binding).
After
a fall, the current non-releasable system acts as a "sea
anchor" and lessens the distance a snowboarder slides
down the hill. Along with generally slower speed, this shortened
"fall zone" (the area which snowboarders will
probably slide if they fall) partly explains why snowboarders
suffer fewer fatal and catastrophic injuries than skiers.
Snowboard bindings lock both feet in the same plane and
create an entirely different spectrum of injury than seen
in skiing with its independent movement of each leg.
Current
dual-mode alpine ski bindings release in two different directions,
toe rotation and heel lift. Some manufacturers have introduced
toe-up release binding that may affect the "boot-induced"
injury. Unfortunately, criteria for ski bindings have been
based solely on protecting the tibia from injury, using
calculations based on the width of the tibial plateau and
studies of the tibiaís breaking point, not the failure point
of the knee ligaments.
Shape
of Skis and Snowboards. Shaped (formerly called "parabolic")
skis have taken over the alpine ski market. It is not clear
if they will lead to a new type of injury. One 3-year study
suggests there may be an increase in the isolated ACL knee
sprain and possibly an increase in ankle fractures (although
the author speculates the latter is more likely to be an
equipment system failure.) The recent rise in tibial plateau
fractures among skiers is probably more age related than
due to equipment. Entry level skiers show no increase injury
incidence with the new shaped skis while advanced skiers
are injured slightly more often. "Older skiers"
who have learned to constantly face "square down the
fall line" must now learn not to "over turn"
but to "follow their skis." Alpine skiers suffer
rotational injuries as their separate, individual skis catch
inside or outside edges. The length of the ski acts as a
lever arm to the foot and leg, often twisting the knee (which
is meant to be a hinge, not a rotational joint).
Snowboards
also have generous side cuts and are of three general types:
free-style, free riding, and carving. Side-standing snowboarders
get slammed forward when they catch a toe-edge and fall
on the outstretched hand (FOOSH). If riders do not get their
hands out, they impact their shoulders (clavicle fracture,
acromioclavicular separation, or humeral head contusion
or fracture) or their faces (concussions, cervical sprains).
More commonly, snowboarders fall backward as they lose their
heel-edge and suffer wrist impacts, buttock contusions,
axial loading spinal compressions, and occipital head injuries.
Poles."Skierís
thumb," a sprain of the ulnar collateral ligament of
the first metacarpophalangeal joint is the most common injury
of the upper extremity. Since so many go unreported, it
may be the most common injury in alpine skiing. Because
10% of skiers and only 1% of snowboarders report this injury,
it is easy to conclude that the skierís pole grip and strap
contribute to this injury. The ski pole is implicated in
24% of shoulder dislocations by causing the arm to be externally
rotated and forcibly abducted in a fall.
Helmets.
In 1999, the U.S. Consumer Product Safety Commission (CPSC)
formally recommended that skiers and snowboarders wear helmets.
They calculated that doing so would help prevent or reduce
the severity of head injuries from falls and collisions
by 50%. Between 1993 and 1997, CPSC reported the number
of skiing related injuries treated in the emergency room
declined, while the number of skier head injuries remained
constant. During the same period, snowboarding injuries
nearly tripled and their head injuries increased five-fold.
In 1997, there were 17,500 head injuries (3,400 "potentially
serious") associated with skiing and snowboarding.
The CPSC concludes helmet use would prevent 11 deaths per
year. A study from Vermont notes that during the 1998-1999
ski season, 15.5% of all injured skiers used helmets while
32% of those diagnosed with any degree of concussion used
helmets. Also, 35% of fatally injured skiers and snowboarders
wore helmets. The National Ski Areas Association suggests
that helmets afford little protection beyond 12 mph (skiers
typically travel at 25 to 40 mph). They further express
concern that there is no U.S. standard for recreational
helmets and that "consumers not gain a false sense
of security by wearing a helmet."
Wrist
guards. For snowboarders, the wrist is the most common
site of injury, accounting for one quarter of all injuries
and one half of all fractures. Wrist guards have been shown
to be very effective in preventing wrist injuries in in-line
skaters. However, they may transfer the forces more proximal,
leading to mid-shaft forearm fractures, posterior elbow
dislocations, or shoulder injuries. One survey of 21 snowboarders
who had been injured while wearing wrist guards revealed
no wrist injury, but six had shoulder injury and four had
radial shaft fractures. Snowboard instructors advise the
"closed-fist" position for falling. Falling backward
is the mechanism of injury in about 75% of wrist injuries.
Mechanisms
of Injury
Falling.Falling
is the leading cause of skiing (87%) and snowboarding (75%)
injuries. Skiers most commonly fall forward while snowboarders
more often fall backwards.
Jumping.
Unsuccessfully landing jumps is the second most common cause
of snowboarding injury. Snowboarders are injured three times
more frequently jumping than are skiers. Jumping includes
dropping from great heights and getting "big air"
(a.k.a. "hospital air") off moguls or terrain
park mounds. The impacts are associated with head, facial,
spinal, and abdominal injuries.
Collisions
. Collisions account for 10% of all injuries but 67% of
hospital admissions and most of the fatalities. Most commonly
collisions involve a stationary object, but often it is
another person. Contrary to popular myth, skiers are more
likely to hit a snowboard rider than are riders to hit a
skier. Only 1% of injuries to skiers are caused by collisions
with snowboarders while 7.7% of all ski injuries are the
result of skiers running into skiers and only 2.6% of snowboard
accidents are caused by snowboarders running into other
snowboarders.
Overuse
syndromes. Muscle strains and tendinitis are probably
the most common types of injury sustained by skiers. Since
symptoms usually do not declare themselves until the following
day, estimates on the incidence of such problems are inaccurate.
Deep
snow immersion. Avalanches kill by causing massive trauma
or asphyxiation. With deep powder, tree-well immersion deaths
have been recorded in the last 10 years. Three snowboarders
died in separate but nearly identical incidents at Lake
Tahoe ski resorts in a 3-week period in December 1992 ,
January 1993. Each was vertically buried, head down in deep
snow at the base of a tree. Postmortem examinations were
strikingly similar: small facial contusions, marked upper
lobe pulmonary congestion, and frontal lobe brain contusions.
Although cause of death was listed as suffocation, it is
impossible to conclude the contribution of other factors
such as hypothermia, brain injury, head-down position, duration
of immersion, and/or non-releasable bindings, for example.
More skiers die each year from snow immersion injuries than
do snowboarders.
Injury
Patterns
Snowboarders
have an increased rate of head injuries at 10% compared
with skiers at 5%, but skiers are five times more likely
to suffer a fatal head injury. Spinal injury rates are four
times more common among snowboarders (0.04/1000 snowboarding-days
vs. 0.01/1000 skier-days). Similarly snowboarders are twice
as likely to suffer a chest injury (6.1% versus 2.7%) or
a splenic injury (13% vs. 2%) as are skiers.
Almost
one quarter of snowboarding injuries occur during the personís
first experience, and almost one half occur during the first
season. Skill level influences snowboarding injuries. One
study showed wrist injuries predominated (41%) in the beginner
group, shoulder injuries were most common (38%) in the intermediate
group, and head injuries predominated (36%) in the expert
group. Another study reported: beginning snowboarders were
most likely to injure the wrists (30%); low intermediates,
their knees (28%), intermediates, their ankles (17%), and
advanced and experts, their shoulder or clavicle (14%).
Prevention
Preventing
the injury is obviously favorable to treating after the
fact. Several suggestions are intuitive; some are controversial.
Personal
fitness. Get in shape. Regular general fitness and training
will help protect from injury. Avoid drugs and alcohol.
Do not ski/snowboard if you are sick or fatigued. Take time
to acclimatize to altitude (especially over 8,000 feet).
Equipment.
Be sure your equipment is properly maintained, repaired,
or replaced. The majority of lower leg injuries in skiing
are related to the quality and condition of the release
system. Use certified and reputable ski/snowboard shops.
Children need special attention to match equipment to their
size, weight, and ability. Release settings for ski bindings
need to be checked before each season and periodically throughout
the season. Releasable snowboard bindings could reduce the
incidence of ankle injuries but have not been sufficiently
studied or accepted to endorse. A proper technologic study
needs to answer this question. Ski poles grips and straps
should allow the hand to fall free and avoid hyperabducting
the thumb. Avoid strapless saber pole grips, and grasp any
tether with the thumb over the strap. Wrist guards probably
benefit the beginning snowboarder, especially on icy, firm-packed
snow. Helmets can be recommended for novice snowboarders
and all skiers and riders who venture among the trees. The
U.S. Ski Association requires helmets for most competitions
and official training under their sanction. Head protection
gear for all skiers and snowboarders can be considered protective
as long as it is recognized that wearing a helmet does not
confer invincibility or invulnerability to the user.
Instruction.
Professional and certified instructors can significantly
lessen injury rates and severity. Novice snowboarders might
consider the use of poles to lessen wrist and head injuries
while learning. All participants should be taught how to
recover from a loss of control, when recovery is inappropriate,
and how to make a controlled landing. The Vermont ACL Awareness
program has reduced ACL sprains by 75% among participating
ski-patrollers, and by 55% among ski area employees. Snowboarders
should fall with closed fists and try to roll into a fall
like a paratrooper, spreading the force of the fall out
over the body instead of in one place. Those choosing to
jump must know their landing site.
Snow
Conditions. Avoid icy slopes. Do not ski alone in deep
powder. Avoid crowded slopes, particularly at the end of
the day. Be informed about the snow conditions. Dress properly,
in layers. Outer wear should be of a fabric to reduce sliding.
Wear protective eyewear. Be prepared for changeable weather.
Responsibility
Code. Ski and ride within your ability. Watch for skiers
downhill. Look uphill before entering a trail. Move to the
side of the trail when stopping. Use devices to help prevent
runaway equipment. Observe all posted signs and warnings.
Have the ability to load and unload lifts. Practice courteous
ski habits. "Look before you leap" , use caution
when jumping and leaping on the slopes, especially in snowboard
and terrain parks.
Wilderness
Medicine Letter, Volume 19, Number 2, Spring 2002
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