Snow sports are one of the most popular winter activities worldwide, with around 200 million skiers and 70 million snowboarders (12) joined by snowbladers, telemarkers, and cross-country skiers. The injury risk for participants generally is expressed as "injuries per thousand skier days" (IPTSD), and rates of <3 IPTSD for skiers and <4 IPTSD for snowboarders have been quoted (12). Beginners are at higher risk (14). In a large ski area, such as Whistler/Blackcomb, this equates to approximately 2000 injured individuals every season, with injuries that vary according to the snow sport undertaken (19,26).
Continued performance and safety development by ski and snowboard manufacturers has led to huge advances, such as new binding release mechanisms that have been shown to reduce the incidence of anterior cruciate ligament (ACL) rupture among skiers (25). Injury prevention in snow sports is aided, but not confined to, equipment development, with a great deal of responsibility falling on individual snow riders to prepare themselves for the mountains.
This article aims to examine the precautions taken and safety equipment used by skiers and snowboarders attending a medical center at a large ski area.
With more than 8100 skiable acres and more than 200 skiable runs, Whistler/Blackcomb is one of the largest recreational ski resorts in the world. Located in the Coastal Mountains of British Columbia, Canada, Whistler is home to almost 10,000 permanent residents and attracts around 1.4 million visitors every season (17,29). Whistler Medical Centre (WMC) is one of three medical clinics providing a broad range of care to residents and visitors.
Patients attending the Whistler Medical Centre were approached and invited to take part in the study. Sampling took place on every second day over 28 d, providing 14 sample days, and on alternating sample days, morning or afternoon periods were used. There were, therefore, seven mornings and seven afternoons across the sampling period. Individuals were eligible for inclusion if they declared themselves to be a skier or a snowboarder, irrespective of the reason for attending the clinic. Consent was obtained, and then patients were asked to complete a questionnaire that dealt with demographics, details of snow sports participation and skill level, previous or current injuries, and safety equipment used (Appendix).
The results were then accessed, analyzed, and presented using SPSS (Version 15). Categorical variables were assessed using Pearson chi-square and continuous variable using Mann-Whitney U test. The level of statistical significance was set at P < 0.05.
A total of 200 patients were approached, of whom 181 fully completed the assigned questionnaire (Appendix), and 19 either declined or did not return the questionnaire. There were slightly more men (52.5%) than women, with a median age of 27 yr, and most (63.5%) were local residents. As might be expected in a population resident in a ski area, 60% declared themselves to be advanced or expert riders. Skiers were in the majority (52%), while 35% were snowboarders and 13% did both.
Of the population studied, 50.3% had a previous injury for which treatment was required and provided. Injury rates were found to be significantly higher among individuals who do both sports (67%) when compared with pure skiers (49%) and snowboarders (44%) (chi-square test; P < 0.05). In skiers, ACL rupture was the most commonly reported significant injury (20.4%), while snowboarders had more broken wrists (25%).
The majority of respondents were under 35 yr old, and while the age cohort with the most injuries was the 18-24 yr age group, the rate of injuries was highest in the 25-29 yr age group (61%) (Mann-Whitney U test; P < 0.05). The under-18 population constituted 5% of the sampled population, with the youngest being 13 yr. Questionnaires were completed with parental help when required. No injuries were recorded in this subpopulation. Injury rate increased as skill level increased, with experts having a level of previous injuries of 67%, compared with beginners (21%), intermediates (29%), and advanced riders (61%) (chi-square; P = 0.006). Just under half of the local residents in the study group had had a previous injury (55 of 113), but the highest injury rate was found in visitors staying for more than 28 d (65%) (chi-square; P = 0.006).
Table 1 details basic precautions taken by snow riders. Virtually all riders used warm clothing, but use of sun protection was far from universal. Skiers were more likely to undertake fitness training (75% vs 40%, chi-square; P = 0.001), and riders who did both skiing and snowboarding were more likely to take lessons (32% vs 13% for skiers and 11.5% of snowboarders, chi-square; P = 0.02).
Table 2 illustrates widespread use of eye protection and helmets, but other protective equipment was used much less frequently. Use of wrist protectors was highest in riders who both ski and snowboard (27% using most of the time or always). The most common equipment included in the "other" group was a knee brace (17%).
Only a minority of snow riders made any attempt to warm up before or warm down after riding (Figures 1 and 2; Appendix, Charts 1 and 2). Nearly 48% of the sample population believed they were most likely to injure themselves in the late afternoon. The most common reason given for this was fatigue.
This study identified a population of snow sports participants in a major ski resort, in order to identify their experience of snow sports-related injuries and injury prevention, and in particular the use of safety equipment and injury prevention strategies. The group was close to gender equality (52% men) and was young (mean age 30-34 yr). Skiers made up two thirds of the group, snowboarders one third, and, as might be expected in a group where most of whom are resident in a ski resort, the majority were advanced or experts. Previous injuries were common (50% of the group had had a previous injury), while use of even basic risk reduction strategies, such as use of sun protection, was far from universal. Individuals who participated in both skiing and snowboarding had higher injury rates, perhaps reflecting the crossover of an experienced skier to being a beginner snowboarder and vice versa.
Theories regarding the reduction of injury rates in snow sports are numerous and highly dependant on which snow sport is being undertaken. At a basic level, use of eye protection and sunscreens can reduce ultraviolet radiation exposure, reducing skin cancer risk (3). Several studies have been conducted suggesting that the use of wrist guards in snowboarding can reduce the risk of upper limb injury by 35%-50% (12,21). A 1991 study (1) found that snowboarders have a high incidence rate of distal forearm fractures, constituting 16% of all snowboard-related injuries. Preventative measures such as wrist protectors, used in inline skating, may reduce such injuries. In skiing, use of higher boots and more consistent safe-release bindings have reduced rates of tibial fracture and ACL rupture (10).
Some of the most costly injuries associated with snow sports are those affecting head, neck, and spinal cord. There are around 15 head injuries per million skier visits (23,29). The evidence on the value of helmets in preventing more serious injuries is contradictory: one recent study suggested that failure to wear a helmet significantly increased the risk of head, neck, or face injury (19), while other studies suggest that the weight of the helmet may increase the risk of cervical spine injuries, particularly in younger children (18). This however, was only demonstrated in relation to motorcycle helmet use and not in the context of snow sports (11). Notable differences exist between snow sports and motorcycle helmet design, not to mention the obvious variation in modes of injury; therefore, a definitive answer to injury causation in snow sport-related helmet use in young children remains unclear. Other studies have suggested that helmet use may only reduce the risk of minor rather than major head injuries (13). It remains to be seen whether the reduction in risk of serious head injury from helmet use will be offset by those increased risks. Perhaps a cohort study directly comparing head injuries in both the helmet-wearing and nonhelmet-wearing populations would help in definitively addressing the use of such equipment. Neurological injuries also are a recognized cause of morbidity in the snow sport population (8). Prevention programs focusing on safe skiing/snowboarding, collision avoidance, and the promotion of spine protectors have been suggested as prevention methods (7).
The Swiss National Accident Insurance Organization (SUVA) is launching a comprehensive campaign to prevent snow sport accidents by encouraging physical preparation prior to the skiing season and avoidance of a cold start (i.e., warming up) (20). This study is currently ongoing, but similar studies have produced beneficial results when conducted in other sports (2,6,24). Skiers in our series were found to give attention to improving their physical fitness significantly more than snowboarders (P < 0.05), while those who did both sports were found to have taken lessons significantly more than both skiers and snowboarders, reflecting their crossover from competence in one area to being a beginner in another. While professional instruction has not been associated with reduced injury rate (13), when accompanied by the accumulation of significant experience, injury rates have been shown to fall (9). The majority of snow riders in our series made minimal efforts towards warming up or warming down.
In our series, ACL rupture was the most commonly reported significant injury in skiers, while snowboarders recorded more wrist fractures, consistent with similar patterns seen in other studies showing ski injuries most commonly affecting thumb and knee and snowboard injuries most commonly in foot, ankle, and wrist (1,6,26). This varied anatomical injury pattern reflects the fundamental differences in user technique and equipment design. As demonstrated in this study, and others (5,26), the lower limb, especially the knee joint, remains the most commonly reported significant skiing injury, because of differential torque that is generated as skis diverge in a fall. The search for a boot/binding with improved protection against knee injury continues (10), but education of skiers and equipment suppliers in the correct setting of bindings also is important. The ski pole is the culprit in thumb injuries, and again, correct education in use of poles and their straps is essential. Snowboarders, with both feet fixed by nonreleasable bindings to the same board, have a reduced likelihood of sustaining lower limb and knee injuries caused by rotational forces, but are at increased risk of falling to the outstretched hand, resulting in wrist and other upper limb injuries (1,4).
The association with subjective assessments of expertise and injury rate also was significant. The highest injury rate was observed in expert skiers/snowboarders, while the lowest rates were noted to be in beginners. These figures should not be confused with daily incidences or IPTSDs, as they reflect injury risk over a rider's snow-sports career. Previous studies (14,16,27) have shown the increased daily risk of injury to be greater for a beginner, with wrist injuries being reported significantly more (21); however experts have a longer career over which to be exposed to injuries, and were once beginners as well.
The majority of respondents used warm clothing protection (over 92%) and eye protection (86%), but far fewer skiers (65%) and snowboarders (45%) used sun protection. Walkosz et al. found, when such programs were directed at parents and children enrolled in ski and snowboard schools at high-altitude resorts in western North America, more parents at the intervention resorts reported that their child was wearing sunscreen than at the control resorts (28), but this lesson still needs to be pressed home, particularly to snowboarders. Further studies using interventions such as advertising campaigns or providing free sun protection with all lift tickets may perhaps help in emphasizing this point. Certainly within the United States, skin cancer is one of the most common types of cancer, with the primary risk factor being ultraviolet radiation (UVR) exposure. The consensus is that if the skin can be protected from cumulative exposure and severe overexposure (i.e., sunburn) during childhood and adolescence, the overall risk of developing skin cancer in later life can be reduced (28). As previously mentioned, the overall wearing of sunglasses or goggles was high, and rightly so. The association between UV radiation and eye injury is well documented and can be prevented by wearing appropriate sunglasses or goggles (15).
Helmet use has increased steadily over the past 10 yr, and was 54% in our respondents (56% in skiers, 29% in snowboarders), although the evidence on injury prevention/causation is contradictory (13,18). Of our sample population, 62% were advanced/expert snow riders, most of whom were skiers (60%), followed by snowboarders (30%) and crossover individuals (10%). Around 70% of this subpopulation wore helmets most of/all of the time, representing 68% of the total helmet-wearing population. It is therefore clear that helmet use is common among advanced/expert snow riders. It should be noted that skiers constitute almost two thirds of this advanced/expert subpopulation. This likely explains, in part, why at first glance skiers appear to wear helmets more often. In reality it is likely that all snow riders in the advanced/expert population wear helmets equally as often. Although the increased incidence of wrist injuries in snowboarders has been shown (22), only 11% of our snowboarding and 1% of skiing respondents used a wrist guard. It has been suggested that these injuries are more common in beginner snowboarders (16,21,27), while our group's members were more likely to be advanced or expert. Other, more expensive safety items such as avalanche beacons, spine protectors, and medical packs are only carried by a small minority, most likely those that venture away from pisted and patrolled areas. There is no evidence to support the use of hip or knee pads, and these rarely were used in our group.
Of note, the sampled population consisted of every individual presenting to the Whistler Medical Centre, thus ensuring a variety of presenting complaints. Despite this, however, a large percentage of ski-related injuries were noted, likely because of the medical center's location in a ski resort and the fact it was during the peak snow sport season. This raises the question of a potentially injured sample population; therefore, the issue of unavoidable population bias should be acknowledged. It also should be recognized that only individuals with perceived "serious" injuries attended the clinic. It is likely that the number of simple sprains and musculoskeletal injuries were higher; however, these were not addressed in this study.
In this study, based in a medical center in a large ski resort, evidence of previous and recent injuries is common, while use of precautionary and preventive measures is far from universal. Injury reduction strategies should identify areas where there is a strong evidence base and aim to promote use of appropriate safety measures, such as use of wrist guards by beginner snowboarders and use of eye protection and sunscreen by all snow riders. Further research is required to clarify that evidence base in order to allow appropriate recommendations, in particular in reference to use of helmets.
The authors thank Dr. Mike Langran, general practitioner and ski patroller of Aviemore, Scotland, and Dr. Tom Demarco of Whistler Medical Centre, for their assistance in setting up and running the project.
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Appendix: Snap Questionnaire